Fracture dislocations of the cervical spine: a review of 106 conservatively and operatively treated patients

[Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]

BACKGROUND

Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review.

METHODOLOGY

The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR.

RESULTS

A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints.

CONCLUSION

Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.

Immediate Closed Reduction Technique for Cervical Spine Dislocations

STUDY DESIGN

Retrospective study.

PURPOSE

This research aimed to assess the clinical outcomes of patients with traumatic cervical spine dislocation who underwent closed reduction employing our approach.

OVERVIEW OF LITERATURE

Bedside closed reduction is the quickest procedure for repairing traumatic cervical spine dislocations; nevertheless, it also possesses the risk of neurological deterioration.

METHODS

For closed reduction, the patient's head was elevated on a motorized bed, the cervical spine was placed at the midline, traction of 10 kg was applied, the motorized bed was gradually returned to a flat position, the head was lifted off the bed, and the cervical spine was slowly adjusted to a flexed position. The weight of traction was elevated by 5-kg increments until the positional shift was attained. Subsequently, the bed was gradually tilted while traction was applied again to return the cervical spine to the midline position.

RESULTS

Of the 43 cases of cervical spine dislocation, closed reduction was carried out in 40 cases, of which 36 were successful. During repositioning, three patients experienced a temporary worsening of their neck pain and neurological symptoms that enhanced when the cervical spine was flexed. Closed reduction was conducted while the patient was awake; nevertheless, sedation was needed in three cases. Among the 24 patients whose pretreatment paralysis had been characterized by American Spinal Injury Association Impairment Scale (AIS) grades A-C, seven patients (29.2%) demonstrated an enhancement of two or more AIS grades at the last observation.

CONCLUSIONS

Our closed reduction approach safely repaired traumatic cervical spine dislocations.

Does displacement of cervical and thoracolumbar dislocation-translation injuries predict spinal cord injury or recovery?

OBJECTIVE

For patients with cervical and thoracolumbar AO Spine type C injuries, the authors sought to 1) identify whether preoperative vertebral column translation is predictive of a complete spinal cord injury (SCI) and 2) identify whether preoperative or postoperative vertebral column translation is predictive of neurological improvement after surgical decompression.

METHODS

All patients who underwent operative treatment for cervical and thoracolumbar AO Spine type C injuries at the authors' institution between 2006 and 2021 were identified. CT and MRI were utilized to measure vertebral column translation in millimeters prior to and after surgery. A receiver operating characteristic (ROC) curve was generated to predict the probability of sustaining a complete SCI on the basis of the amount of preoperative vertebral column translation. ROC curves were then used to predict the probability of neurological recovery on the basis of preoperative and postoperative vertebral column translation.

RESULTS

ROC analysis of 67 patients identified 6.10 mm (area under the curve [AUC] 0.77, 95% CI 0.650-0.892) of preoperative vertebral column translation as predictive of complete SCI. Additionally, ROC curve analysis found that 10.4 mm (AUC 0.654, 95% CI 0.421-0.887) of preoperative vertebral column translation was strongly predictive of no postoperative neurological improvement. Residual postoperative vertebral column translation after fracture reduction and instrumentation had no predictive value on neurological recovery (AUC 0.408, 95% CI 0.195-0.622).

CONCLUSIONS

For patients with cervical and thoracolumbar AO Spine type C injuries, the amount of preoperative vertebral column translation is highly predictive of complete SCI and the likelihood of postoperative neurological recovery.

Nonoperative Management of Chronically Subluxated Bilateral Cervical Facets with Bony Fusion: A Case Report

CASE

We describe a case of a 65-year-old woman with bilateral chronically subluxated C6 to 7 facets with facet fusion, who presented for care for the first time 1 year after a motor vehicle accident. The patient was minimally symptomatic at the time of her evaluation; thus, nonoperative treatment was provided. At 3-year follow-up, our patient remained minimally symptomatic with no progression of neurologic deficits.

CONCLUSION

Consistent with previous reports, conservative management was used rather than surgical fusion in a patient with stable osseous fusion complexes and minimal neurologic symptoms.

Spinal Cord Injury Management on the Front Line: ABCs of Spinal Cord Injury Treatment Based on American Association of Neurological Surgeons/Congress of Neurological Surgeons Guidelines and Common Sense

Spinal cord injury (SCI) affects approximately 54 per 1 million people annually in the United States. Treatment strategies for this patient population focus on initial stabilization and early intervention. The cornerstones of early management are clinical assessment, characterization of the injury, medical optimization, and definitive surgical treatment, including surgical stabilization and/or decompression. This article discusses the important strategies in caring for patients with SCI that are supported with significant literature.

Risk Factors for Poor Prognosis of Cervical Spinal Cord Injury with Subaxial Cervical Spine Fracture-Dislocation After Surgical Treatment: A CONSORT Study

BACKGROUND The objective of the study was to identify risk factors for poor prognosis of cervical spinal cord injury (SCI) with subaxial cervical fracture-dislocation after surgical treatment. MATERIAL AND METHODS A total of 60 cervical SCI patients with subaxial cervical fracture-dislocation were primarily included in the study from April 2013 to April 2018. All the enrolled subjects received surgical treatment. The enrolled patients with complete follow-up record were divided into 2 groups based on the neural function prognosis: a non-functional restoration group and a functional restoration group. Multivariate regression analysis was performed to identify independent risk factors for poor prognosis of SCI after surgical treatment. RESULTS Fifty-five subjects were included in this study, and the follow-up time ranged from 8.5 to 44.5 months. A total of 25 subjects were categorized into the non-functional restoration group and 30 subjects into the functional restoration group. According to the results of multivariate regression analysis, time from injury to operation (more than 3.8 days), subaxial cervical injury classification (SLIC, score more than 7.5), and maximum spinal cord compression (MSCC, more than 55.8%) are independent risk factors for poor prognosis of SCI after surgical treatment (p<0.05), with AUCs of 0.95 (time from injury to operation), 0.91 (SLIC score), and 0.96 (MSCC). CONCLUSIONS Time from injury to operation (more than 3.8 days), SLIC score (more than 7.5), and MSCC (more than 55.8%) are independent risk factors for poor prognosis of SCI with subaxial cervical fracture-dislocation after surgical treatment.

Outcomes of Unstable Subaxial Cervical Spine Fractures Managed by Posteroanterior Stabilization and Fusion

STUDY DESIGN

Retrospective study.

PURPOSE

To evaluate clinical and radiological outcomes of unstable subaxial cervical spine injuries managed by both posterior tension band column stabilization and anterior decompression, stabilization, and fusion.

OVERVIEW OF LITERATURE

Unstable subaxial cervical spine injuries often involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries need immediate surgical intervention. Different methods of reduction and surgical approaches have been published in the literature, with lack of consensus on a uniform or standardized method. Controversy still exists regarding stabilization of unstable cervical fractures by anterior or posterior approach alone or combined approaches.

METHODS

We retrospectively evaluated 24 patients with post-traumatic unstable subaxial cervical spine injuries with their preoperative clinical details, X-ray, computed tomography, and magnetic resonance imaging of the cervical spine for fracture classification based on the mechanism of injury with status of disc herniation and posterior tension band disruption. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to pre- and postoperative neurological status based on American Spinal Injury Association grading, Visual Analog Scale score, the observation of bony fusion, and implant failure at 1, 3, 6, and 12 months. Data were analyzed using paired t-test.

RESULTS

All patients had solid fusion at the desired level with considerable neurological improvement at the 1-year follow-up.

CONCLUSIONS

In unstable cervical injuries, stabilization of disrupted posterior tension band increases the stability of anterior plating and fusion. This method of immediate reduction and circumferential stabilization is rapid, safe, and effective and has a low rate of complications.

Effects of Treatment of Cervical Spinal Cord Injury without Fracture and Dislocation in A Medium-to Long-Term Follow-Up Study

OBJECTIVES

The purpose of this study is to evaluate the clinical effects of cervical spinal cord injury without fracture and dislocation (CSCIWFD) treatment in a medium-to long-term follow-up study. The clinical treatment of CSCIWFD is also discussed.

METHODS

A consecutive series of 42 CSCIWFD patients with complete follow-up data were retrospectively analyzed. Among these patients, 9 received conservative treatment and 33 underwent surgical treatment from June 2009 to March 2013. Neurologic functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the Frankel grade on admission, during hospital discharge, and at final follow-up. The average follow-up time was 49.6 months (range, 36-68 months).

RESULTS

The 33 cases with surgical treatment showed significantly higher JOA scores at the final follow-up than those with conservative treatment. In addition, statistically significant differences were found in all of the follow-up visits between patients whose operations were performed within 7 days after injury and those performed after 7 days (P < 0.05). Early surgery promoted spinal cord recovery. However, JOA scores at 49.6 months postsurgery were not significantly different between patients treated via the anterior approach and those treated via the posterior approach (P > 0.05). On the basis of Frankel functional classification, differences were also significant between surgical treatment and conservative treatment at all of the follow-up visits.

CONCLUSIONS

Early surgical treatment for CSCIWFD can directly relieve spinal cord compression. The medium-to long-term follow-up revealed that surgery clearly promotes decompression.

Circumferential Reconstruction of Subaxial Cervical and Cervicothoracic Spine by Simultaneously Combined Anterior-posterior Approaches in the Sitting Position

OBJECTIVE

To introduce and analyze the feasibility of a new surgical strategy for circumferential reconstruction of subaxial cervical and cervicothoracic spine by simultaneously combined anterior-posterior approach in the sitting position.

METHODS

A retrospective review was performed for seven patients who underwent the above surgical procedure between July 2011 and January 2015. Among the seven patients, there were six men and one woman, with an average age of 52 years (range, 36-79 years). Six patients were confirmed to have a lower subaxial cervical fracture and dislocation with a locked facet joint, and the other patient had an invasive tumor involving both anterior and posterior parts of vertebrae and lamina, detected by radiological examination. The levels involved for all patients were from C₄ to T₂ . According to American Spinal Injury Association (ASIA) classification, one case was class A, four were class B, and two were class D. The patients were restricted in the sitting position with traction and a halo in extension to immobilize the head during the operation. The simultaneously combined anterior-posterior operation for reduction, decompression or tumor resection and circumferential reconstruction was carried out.

RESULTS

Both anterior and posterior procedures were successfully completed simultaneously in the sitting position in all cases. There were no perioperative complications. The average operative time was 175 ± 32 min (range, 120-240 min), and the mean blood loss was 430 ± 85 mL (range, 200-1100 mL). The patients were followed up for 35.8 months (range, 18-60 months). The symptom of neck pain improved distinctly and no evidence of implant failure was noted in any patients. Neurological status improvement was confirmed in six patients, who had suffered incomplete paralysis. The ASIA grade improved in five patients, and two cases had no change in grade.

CONCLUSIONS

The "sitting position" simultaneously combined anterior-posterior approach is safe and is superior to the traditional prone position and supine position, and the surgical results are satisfactory.

Anterior cervical distraction and screw elevating-pulling reduction for traumatic cervical spine fractures and dislocations: A retrospective analysis of 86 cases

Treatment of cervical fracture and dislocation by improving the anterior cervical technique.Anterior cervical approach has been extensively used in treating cervical spine fractures and dislocations. However, when this approach is used in the treatment of locked facet joints, an unsatisfactory intraoperative reduction and prying reduction increases the risk of secondary spinal cord injury. Thus, herein, the cervical anterior approach was improved. With distractor and screw elevation therapy during surgery, the restoration rate is increased, and secondary injury to the spinal cord is avoided.To discuss the feasibility of the surgical method of treating traumatic cervical spine fractures and dislocations and the clinical application.This retrospective study included the duration of patients' hospitalization from January 2005 to June 2015. The potential risks of surgery (including death and other surgical complications) were explained clearly, and written consents were obtained from all patients before surgery.The study was conducted on 86 patients (54 males and 32 females, average age of 40.1 ± 5.6 years) with traumatic cervical spine fractures and dislocations, who underwent one-stage anterior approach treatment. The effective methods were evaluated by postoperative follow-up.The healing of the surgical incision was monitored in 86 patients. The follow-up duration was 18 to 36 (average 26.4 ± 7.1) months. The patients achieved bones grafted fusion and restored spine stability in 3 to 9 (average 6) months after the surgery. Statistically, significant improvement was observed by Frankel score, visual analog scale score, Japanese Orthopedic Association score, and correction rate of the cervical spine dislocation pre- and postoperative (P < .01).The modified anterior cervical approach is simple with a low risk but a good effect in reduction. In addition, it can reduce the risk of iatrogenic secondary spinal cord injury and maintain optimal cervical spine stability as observed during follow-ups. Therefore, it is suitable for clinical promotion and application.

Outcome Instruments in Spinal Trauma Surgery: A Bibliometric Analysis

Study Design Literature review. Objective To identify outcomes instruments used in spinal trauma surgery over the past decade, their frequency of use, and usage trends. Methods Five top orthopedic journals were reviewed from 2004 to 2013 for clinical studies of surgical intervention in spinal trauma that reported patient-reported outcome instruments use or neurologic function scale use. Publication year, level of evidence (LOE), and outcome instruments were collected for each article and analyzed. Results A total of 58 studies were identified. Among them, 26 named outcome instruments and 7 improvised questionnaires were utilized. The visual analog scale (VAS) for pain was used most frequently (43.1%), followed by the Short Form 36 (34.5%), Frankel grade scale (25.9%), Oswestry Disability Index (20.7%) and American Spinal Injury Association Impairment Scale (15.5%). LOE 4 was most common (37.9%), and eight LOE 1 studies were identified (10.3%). Conclusions The VAS pain scale is the most common outcome instrument used in spinal trauma. The scope of this outcome instrument is limited, and it may not be sufficient for discriminating between more and less effective treatments. A wide variety of functional measures are used, reflecting the need for a disease-specific instrument that accurately measures functional limitation in spinal trauma.

Simultaneously Combined Anterior-Posterior Approaches for Subaxial Cervical Circumferential Reconstruction in a Sitting Position

The purpose of this article is to introduce and analyze the feasibility of simultaneously combined anterior-posterior approaches for subaxial cervical circumferential reconstruction in sitting position. A retrospective case review was performed for above surgery procedure. A 79-year-old man was confirmed subaxial cervical fracture and dislocation with facet locked by radiological examination, and the involved levels were C5-6. According to American Spinal Injury Association (ASIA) classification, the impairment scale was grade B. And the Subaxial Cervical Spine Injury and Severity Score (SLIC) were 9. The patient was restricted in sitting position with traction on a halo in extension to immobilize the head during the operation. A posterior laminectomy and pedicle screws insertion to the involved cervical spine was performed firstly. And then the anterior discectomy and strut graft were accomplished through an anterior cervical approach. The final fixation was finished by clamping the strut graft with pedicle screw system. Total blood loss was 600 ml and the total operating time was 150 min. The patient was followed up for 6 months. The symptom of neck pain improved distinctly and no evidence about implant failure was noted. Neurological status improvement was confirmed and the ASIA scale was improved to grade C. We believed that the simultaneously combined anterior-posterior approach in sitting position was safe and more advantageous for appropriate cases.

Surgical Management of Old Lower Cervical Dislocations With Locked Facet

STUDY DESIGN

Prospective study.

OBJECTIVE

To evaluate the role of the canal and vertebrae sagittal diameter (C/V) ratio in the treatment of old dislocations of the lower cervical spine.

SUMMARY OF BACKGROUND DATA

Few studies have reported the management of old dislocations of the lower cervical spine. Conservative treatments including the use of a Halo vest, neck brace, and prolonged traction have been problematic. Operative treatment consisted of a primary or staged reduction and fusion using an anterior, posterior, or combined approach.

METHODS

Fourteen consecutive patients with old dislocations of the lower cervical spine were included in this series. The preoperative C/V value was calculated based on the measurement on the neutral sagittal computed tomography at the most narrow place of the dislocated segments. Closed reduction was attempted in 9 patients with moderate stenosis (C/V>0.5). Five patients with severe stenosis (C/V≤0.5) were treated with a primary combined anterior and posterior operation. Patient's radiographic information, pain, and neurological function were assessed and recorded before and after surgery.

RESULTS

Closed reduction followed by anterior cervical discectomy and fusion was performed in 3 of 9 patients with moderate stenosis. Eleven patients underwent circumferential release, posterior reduction, and fixation followed by anterior fusion. No severe complications were found. The average operative time was 138±43 minutes. The average blood loss was 239±140 mL. The postoperative C/V value was significantly increased. The neurological status improved at least one grade in all 13 neurologically impaired cases except for 2 who had complete spinal cord injuries. Bony fusion was obtained in all patients at 1-year follow-up.

CONCLUSIONS

The C/V value plays an important role in determining surgical solutions for old lower cervical dislocations with locked facets. Favorable clinical outcomes can be achieved using closed reduction and surgical procedures with anterior or anterior plus posterior approaches.

Treatment of isolated cervical facet fractures: a systematic review

OBJECT

In this clinically based systematic review of cervical facet fractures, the authors’ aim was to determine the optimal clinical care for patients with isolated fractures of the cervical facets through a systematic review.

METHODS

A systematic review of nonoperative and operative treatment methods of cervical facet fractures was performed. Reduction and stabilization treatments were compared, and analysis of postoperative outcomes was performed. MEDLINE and Scopus databases were used. This work was supported through support received from the Association for Collaborative Spine Research and AOSpine North America.

RESULTS

Eleven studies with 368 patients met the inclusion criteria. Forty-six patients had bilateral isolated cervical facet fractures and 322 had unilateral isolated cervical facet fractures. Closed reduction was successful in 56.4% (39 patients) and 63.8% (94 patients) of patients using a halo vest and Gardner-Wells tongs, respectively. Comparatively, open reduction was successful in 94.9% of patients (successful reduction of open to closed reduction OR 12.8 [95% CI 6.1–26.9], p < 0.0001); 183 patients underwent internal fixation, with an 87.2% success rate in maintaining anatomical alignment. When comparing the success of patients who underwent anterior versus posterior procedures, anterior approaches showed a 90.5% rate of maintenance of reduction, compared with a 75.6% rate for the posterior approach (anterior vs posterior OR 3.1 [95% CI 1.0–9.4], p = 0.05).

CONCLUSIONS

In comparison with nonoperative treatments, operative treatments provided a more successful outcome in terms of failure of treatment to maintain reduction for patients with cervical facet fractures. Operative treatment appears to provide superior results to the nonoperative treatments assessed.

Bony fusion in a chronic cervical bilateral facet dislocation

BACKGROUND

Cervical facet dislocation injuries typically present shortly after occurrence due to the pain and neurologic deficit that can be associated with this injury. Bilateral dislocations of the facet joint require prompt evaluation, reduction, and surgical intervention. Rare case reports present bilateral dislocations presenting in a delayed fashion.

CASE REPORT

We report the case of a 60-year-old male who presented with mild neck pain 1 year after initial injury. Computed topography of the cervical spine showed healing with bony fusion of a bilateral C6-7 facet dislocation. Given the chronic healed nature of the injury and minimal symptoms, the patient is being followed without intervention.

CONCLUSIONS

Although most bilateral facet dislocations present and are treated immediately after injury; this case illustrates that some may be missed during initial evaluation. Once healed, these injuries may be stable without surgical intervention.

Controversies in the treatment of cervical spine dislocations

BACKGROUND CONTEXT

Cervical spine dislocations represent an area of great controversy among spine surgeons.

PURPOSE

The purpose of this review is to present the specific areas of controversy and to provide a review of the literature.

STUDY DESIGN

A case of cervical spine dislocation is presented to illustrate the major controversies related to the treatment of cervical spine dislocations.

METHODS

A review of the literature is presented regarding the major controversial aspects of the treatment of cervical spine dislocations.

RESULTS

The major areas of controversy include the choice of imaging, closed versus open reduction and surgical approach.

CONCLUSIONS

Guidelines for the management of cervical spine dislocations are presented based on evidence-based medicine.

Correction of Late Traumatic Thoracic and Thoracolumbar Kyphotic Spinal Deformities Using Posteriorly Placed Intervertebral Distraction Cages

Objective:

To assess the safety and stability of thoracic or thoracolumbar deformity correction from a solely posterior approach with placement of modular anterior cages and posterior segmental fixation in one operation.

Methods:

Twenty-eight patients who failed brace trial for 6 months or longer were included in the series. All patients had progressive neurological deficit and/or deformity progression at time of operation. All patients underwent a single operation in the prone position. Segmental fixation was accompanied by anterior column reconstruction using modular cages avoiding nerve root sacrifice. Stackable cages were used for high thoracic deformity. Deformity, Cobb angle, visual analog pain score, and x-ray evaluation of fusion ensued for mean follow-up period of 31 months.

Results:

Patients achieved a mean sagittal deformity correction of 13.3 degrees ± 7.4 standard deviation. Improved or maintained American Spinal Injury Association scores were noted in all patients. The mean time of operation was 334 minutes ± 85 standard deviation, or 6 to 7 hours. At a mean follow-up of 31 months (range, 12–36 mo), the following complications were noted: subsidence greater than 2.5 mm (n = 3), cage migration requiring revision (n = 1), brachial plexopathy from malpositioning (n = 1), and intraoperative cerebrospinal fluid leak managed via lumbar drain (n = 2). Plain and dynamic radiographic evidence of maintained deformity correction was noted in 27 patients.

Conclusion:

Delayed kyphotic deformity correction of the thoracolumbar spine is achieved via a posterior-only approach. At a mean follow-up period of 31 months, sagittal angles remained acceptable. Improved fusion criteria and patient numbers will be required to determine fusion and loss of correction rates over time.

Clinical outcomes of 90 isolated unilateral facet fractures, subluxations, and dislocations treated surgically and nonoperatively

STUDY DESIGN

A retrospective outcomes study.

OBJECTIVE

The purposes of this study were 1) to identify plausible patient and interventional variables that influence the outcome of unilateral facet injuries and 2) to determine if patients return to normal general health status after unilateral facet injuries.

SUMMARY OF BACKGROUND DATA

The management of unilateral subaxial cervical facet fractures and dislocations lacks agreement on treatment options and the variables that influence outcome.

METHODS

Injury data, radiographs, and outcomes (North American Spine Society Cervical Follow-up Questionnaire and Short Form-36) were collected from 9 centers and 13 surgeons, members of the Spine Trauma Study Group.

RESULTS

Causally motor vehicle accidents (49%) and sports (31%) predominated. The C6-C7 level accounted for 60% of injuries and C5-C6 represented 17%. The mean SF-36 PCS score of the operative patients with follow-up >18 months was 6.70 points higher than the mean of the nonoperative patients (P = 0.017). The SF-36 Bodily Pain mean of all patients was 67.2 (SD = 27.6), significantly lower (more pain) than the normative mean of 75.2 (SD = 23.7) (P = 0.014). Nonoperative patients also reported a mean Bodily Pain score of 63.0 (SD = 30.5) that was significantly worse than normative values (P = 0.031). Similarly, the NASS PD mean score for all patients was 84.8 (SD = 17.9), significantly lower than the normative mean of 89.1 (SD = 15.5) (P = 0.014).

CONCLUSION

To our knowledge this is the largest reported series of facet injuries to date and the only one using health-related quality of life instruments. Unilateral facet injuries of the subaxial cervical spine led to reported levels of pain and disability that are significantly worse than those of the healthy population. Although further study is required, we suggest that nonoperatively treated patients report worse outcomes than operatively treated patients, particularly at longer follow-up despite having a more benign fracture pattern. The presence of comorbidities, associated injuries, and advanced age adversely impact clinical outcomes.

A prospective randomized controlled trial of anterior compared with posterior stabilization for unilateral facet injuries of the cervical spine

OBJECT

Unilateral facet injuries can be treated with either anterior or posterior fixation techniques with reportedly good outcomes. The two approaches have not been directly compared, however, and consensus is lacking as to which is the optimal method. The primary objective of this study was to determine whether acute postoperative morbidity differed between anteriorly and posteriorly treated patients with unilateral facet injuries.

METHODS

Forty-two patients were prospectively randomized to undergo either anterior cervical discectomy and fusion or posterior fixation. The primary outcome measure was the postoperative time required to achieve a predefined set of discharge criteria. Secondary outcome measures included postoperative pain, wound infections, radiographically demonstrated fusion and alignment, and patient-reported outcome measures.

RESULTS

The median time to achieve the discharge criteria was 2.75 and 3.5 days for anterior and posterior groups, respectively, a difference that did not reach statistical significance (p = 0.096). Compared with those treated using posterior fixation, anteriorly treated patients exhibited somewhat less postoperative pain, a lower rate of wound infection, a higher rate of radiographically demonstrated union, and better radiographically proven alignment. Nonetheless, the anterior approach was accompanied by a risk of swallowing difficulty in the early postoperative period. Patient-reported outcome measures did not reveal a difference between anterior and posterior fixation procedures.

CONCLUSIONS

This prospective randomized controlled trial provided level 1 evidence that both the anterior and posterior fixation approaches appear to be valid treatment options. Although statistical significance was not reached in the primary outcome measure, some secondary outcome measures favored anterior fixation and others favored posterior treatment for unilateral facet injuries.

Single level arthrodesis as treatment for midcervical fracture subluxation: a cohort study

Although many different techniques exist for fusion of midcervical facet fracture dislocations, limiting arthrodesis to a single level could have a theoretical advantage: fewer fused segments could lessen long-term negative effects of fusion on adjacent segments. Therefore, we prospectively treated 22 consecutive patients with midcervical fracture dislocation without vertebral body fracture with single level arthrodesis even if anterior/posterior surgery were required. Twelve patients with unilateral facet subluxation underwent anterior cervical discectomy, distraction reduction with Caspar posts (AESCULAP, Tuttlingen, Germany) with allograft fusion and anterior cervical plating. Ten patients with any component of bilateral facet subluxation underwent anterior cervical discectomy, distraction reduction with Caspar posts, allograft fusion and plating followed by posterior lateral mass plating. No patients demonstrated worsening of nerve root or spinal cord function postoperatively. Interbody stability occurred in all cases. Only complications were 4 cases of pneumonia, 1 case of wound leakage, and 1 case of superficial wound infection. Good reduction was achieved for both unilateral and bilateral facet fractures. Single level interbody arthrodesis is safe and effective strategy with both unilateral and bilateral facet fractures. Single level arthrodesis may also offer long-term benefit compared with multilevel fusions.