The medical and economic impact of closed cervical spine dislocations

Subaxial cervical spine ligamentous instability anterior versus posterior fixation: prospective nonrandomized study

Background

The goals of cervical internal fixation are to provide immediate stability to control an unstable segment and to improve bony union. Early cervical fixation methods preferred a posterior approach and consisted of simple wire and cancellous bone graft. Later, anterior, and posterior fixation became recent additions to surgeon’s armamentarium.

Objectives

Comparing between anterior and posterior fixation in cervical subaxial ligamentous subluxation regarding the applicability, safety, and clinical efficacy in achieving stability and enhancing bony union. Also cost-related variables are studied.

Methods

This prospective clinical and radiographic analysis was performed on 40 patients with cervical subaxial ligamentous subluxation. Half of these patients were treated with anterior cervical fixation and interlocking screws with inter-body cage fusion. The other half was treated by posterior fixation with lateral mass fixation and inter-facet bone fusion.

Results

There were 27 male and 13 female patients with mean age 37.4 years. The level of cervical dislocation was C4–5 in four, C5–6 in 14, C6–7 in 20 and more than one level in two patients. Closed reduction was achieved in 33 patients while open reduction through the posterior approach was done in four cases and through anterior approach in other three cases. Statistically significant difference between the two groups was found for estimated blood loss and operating room time with better results in the anterior group. There were no perioperative deaths in both groups. Regarding surgery-related complications, there was injury to a cervical root during posterior fixation in two cases. There was no statistical difference between the two groups regarding the length of the hospital stay. The mean hospital stay was 7 days. Positioning of the plate and screws in all cases was satisfactory. All patients were followed up for at least 6 months. Mean follow-up period was 13 months. Vertebral body alignment (radiological stability) was achieved in all cases with anterior fixation while one case with posterior fixation showed delayed subluxation. Solid bony cage fusion was found in 85% with anterior fixation and solid bony fusion in 70% with lateral mass fixation.

Conclusions

Although some of the literature have indicated that posterior fixation in ligamentous cervical subaxial injury is more solid than anterior fixation, yet most of these studies were done on cadaver subjects so eliminating any bony fusion, long-term stability, and hardware failure. This study proved that anterior cervical fixation is not only safer and simple procedure than posterior fixation, but also it restores the cervical stability better than the posterior fixation.

Traumatic subaxial cervical facet subluxation and dislocation: epidemiology, radiographic analyses, and risk factors for spinal cord injury

BACKGROUND CONTEXT

Distractive flexion injuries (DFIs) of the subaxial cervical spine are major contributors to spinal cord injury (SCI). Prompt assessment and early intervention of DFIs associated with SCI are crucial to optimize patient outcome; however, neurologic examination of patients with subaxial cervical injury is often difficult, as patients commonly present with reduced levels of consciousness. Therefore, it is important to establish potential associations between injury epidemiology and radiographic features, and neurologic involvement.

PURPOSE

The aims of this study were to describe the epidemiology and radiographic features of DFIs presenting to a major Australian tertiary hospital and to identify those factors predictive of SCI. The agreement and repeatability of radiographic measures of DFI severity were also investigated.

STUDY DESIGN/SETTING

This is a combined retrospective case-control and reliability-agreement study.

PATIENT SAMPLE

Two hundred twenty-six patients (median age 40 years [interquartile range = 34]; 72.1% male) who presented with a DFI of the subaxial cervical spine between 2003 and 2013 were reviewed.

OUTCOME MEASURES

The epidemiology and radiographic features of DFI, and risk factors for SCI were identified. Inter- and intraobserver agreement of radiographic measurements was evaluated.

METHODS

Medical records, radiographs, and computed tomography and magnetic resonance imaging scans were examined, and the presence of SCI was evaluated. Radiographic images were analyzed by two consultant spinal surgeons, and the degree of vertebral translation, facet apposition, spinal canal occlusion, and spinal cord compression were documented. Multivariable logistic regression models identified epidemiology and radiographic features predictive of SCI. Intraclass correlation coefficients (ICCs) examined inter- and intraobserver agreement of radiographic measurements.

RESULTS

The majority of patients (56.2%) sustained a unilateral (51.2%) or a bilateral facet (48.8%) dislocation. The C6-C7 vertebral level was most commonly involved (38.5%). Younger adults were over-represented among motor-vehicle accidents, whereas falls contributed to a majority of DFIs sustained by older adults. Greater vertebral translation, together with lower facet apposition, distinguished facet dislocation from subluxation. Dislocation, bilateral facet injury, reduced Glasgow Coma Scale, spinal canal occlusion, and spinal cord compression were predictive of neurologic deficit. Radiographic measurements demonstrated at least a "moderate" agreement (ICC>0.4), with most demonstrating an "almost perfect" reproducibility.

CONCLUSIONS

This large-scale cohort investigation of DFIs in the cervical spine describes radiographic features that distinguish facet dislocation from subluxation, and associates highly reproducible anatomical and clinical indices to the occurrence of concomitant SCI.

Nonoperative management and treatment of spinal injuries

STUDY DESIGN

Review of literature.

OBJECTIVE

To delineate and discuss nonoperative treatment and treatment of spinal injuries.

SUMMARY OF BACKGROUND DATA

Nonoperative methods have been a mainstay of care for spinal injuries since ancient Egypt. The vast majority of all spinal injuries should be treated in the nonoperative fashion. The indications and methods continue to evolve.

METHODS

A PubMed search of the literature returned more than 1000 articles related to spine trauma. A total of 270 were references to nonoperative treatment, and 100 were thought to be relevant and included in this review.

RESULTS

All spine injuries are treated in a nonoperative manner, at least initially. The vast majority of injuries are successfully and appropriately treated in a definitive manner with nonsurgical methods. Over the past 10-15 years, the advent of better rigid cervical fixation has decreased the use of halo vests as definitive treatment of many cervical injuries. In contrast, during the same time, more thoracolumbar injuries are being treated in a nonsurgical fashion because the outcomes have been shown to be similar or superior.

CONCLUSIONS

As with all of medicine, the treatment of spine trauma will continue to evolve with time. It is paramount that the physician selects the treatment that will provide the best short-term recovery with the least impact on long-term function.

Treatment of subaxial cervical spinal injuries

SUBAXIAL CERVICAL FACET DISLOCATION INJURIES:

STANDARDS

There is insufficient evidence to recommend treatment standards.

GUIDELINES

There is insufficient evidence to recommend treatment guidelines.

OPTIONS

Closed or open reduction of subaxial cervical facet dislocation injuries is recommended. Treatment of subaxial cervical facet dislocation injuries with rigid external immobilization, anterior arthrodesis with plate fixation, or posterior arthrodesis with plate or rod or interlaminar clamp fixation is recommended. Treatment of subaxial cervical facet dislocation injuries with prolonged bedrest in traction is recommended if more contemporary treatment options are not available. SUBAXIAL CERVICAL INJURIES EXCLUDING FACET DISLOCATION INJURIES:

STANDARDS

There is insufficient evidence to recommend treatment standards.

GUIDELINES

There is insufficient evidence to recommend treatment guidelines.

OPTIONS

Closed or open reduction of subluxations or displaced subaxial cervical spinal fractures is recommended. Treatment of subaxial cervical spinal injuries with external immobilization, anterior arthrodesis with plate fixation, or posterior arthrodesis with plate or rod fixation is recommended.

Extending simulation modeling to activity-based costing for clinical procedures

A simulation model was developed to measure costs in an Emergency Department setting for patients presenting with possible cervical-spine injury who needed radiological imaging. Simulation, a tool widely used to account for process variability but typically focused on utilization and throughput analysis, is being introduced here as a realistic means to perform an activity-based-costing (ABC) analysis, because traditional ABC methods have difficulty coping with process variation in healthcare. Though the study model has a very specific application, it can be generalized to other settings simply by changing the input parameters. In essence, simulation was found to be an accurate and viable means to conduct an ABC analysis; in fact, the output provides more complete information than could be achieved through other conventional analyses, which gives management more leverage with which to negotiate contractual reimbursements.

Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis

PURPOSE

To investigate the cost-effectiveness of computed tomography (CT) relative to radiography for cervical spine screening in trauma patients.

MATERIALS AND METHODS

A decision analysis model was constructed to compare the incremental cost-effectiveness of radiography and CT as primary cervical spine screening modalities in trauma patients. Analyses were performed from a societal perspective, and probability and cost estimates from the literature and institutional experience were used. In separate cost-effectiveness analyses, hypothetical cohorts of trauma patients from three defined clinical scenarios were considered: high, moderate, and low risk for cervical spine fracture. Outcome measures included cases of paralysis prevented, total cost of screening strategies, and incremental cost-effectiveness ratios.

RESULTS

In high-risk patients, screening with CT is a dominant strategy that prevents cases of paralysis and saves money for society. In moderate-risk patients, screening with CT is cost-effective with reference-case assumptions and within the range of most sensitivity analyses. In the low-risk group, CT screening helps prevent cases of paralysis, but the incremental cost-effectiveness ratio is high (> $80,000 per quality-adjusted life year).

CONCLUSION

CT is the preferred cervical spine screening modality in trauma patients at high and moderate risk for cervical spine fracture.

Operative and nonoperative management of spinal cord injury. A review

Technological developments over the last two centuries have advanced the spinal surgeon's capability to service the needs of the spinal cord injured person. While the role that surgery can play in shortening hospitalization for tetraplegics has yet to be proven, it does play a much needed role in the correction of instability and prevention of deformity when the possibility of these conditions exist. Surgical intervention for purposes of neural decompression has yet to be proven as justifiable in view of the risks involved. All surgical procedures must be undertaken only after due consideration of the patients' general medical condition, including coexisting trauma, the potential for and actual instability and deformity of the spine, and the neurological level and degree of incompleteness of the patient. In general, the greater the remaining neurological function, the more there is to be gained by early mobilization. Yet, in the face of progressive improvement in neurological function, caution is advised since there will be much to lose if anything goes wrong with the operation.

Neurological and skeletal outcomes in 113 patients with closed injuries to the cervical spinal cord

Neurological and skeletal outcomes were evaluated in 113 patients for one year following closed lower cervical spinal cord injuries. The extent of neurological recovery did not depend on surgical versus nonsurgical management, or the degree of spinal angulation, vertebral displacement, spinal stenosis, or inferred mechanism of injury based on the initial plain cervical x-rays. Assessment of skeletal outcomes demonstrated significantly less vertebral angulation, more rapid stabilization, and less anterior callus formation among the patients in the surgical group. In addition, the surgical patients had marginally shorter lengths of hospitalization.

The treatment of cervical spine trauma: a century of progress

The past century has resulted in an explosion of knowledge centering around the basic pathophysiology of cervical spinal cord injury and treatment. We have gained significant ground in the fight for overcoming paralysis. In the next century, we must focus on continued and better educational programs for injury prevention, as well as molecular analysis of injury for reversal.

Operative management of bilateral facet dislocation

Fifty-two patients with acute traumatic bilateral locked facets were treated at one trauma center during a 3 1/2-year period (July, 1987, to December, 1990). The patients presented with complete motor quadriplegia (34 cases), incomplete myelopathy (13 cases), or intact long-tract function (five cases). The injuries occurred at C2-3 (one patient, with intact function), C4-5 (12 patients), C5-6 (16 patients), C6-7 (19 patients), and C7-T1 (four patients). Immediate traction (with increasing weight and serial x-ray studies) and/or induction of general anesthesia and muscle relaxation reduced the dislocation in 40 patients, but 12 needed prompt operative reduction as their injuries failed to reduce within 4 hours. Stabilization was indicated for all patients, but three did not undergo surgery: two elderly patients with complete injuries (one refused surgery and one died), and one patient with multiple injuries (fusion was achieved by halo-vest immobilization for 3 months). Of the 49 patients treated operatively, 23 (44.2%) underwent surgery on the day of injury and 26 on a delayed basis (mean 8.7 days postinjury). Surgical treatment included fusion of the posterior facet to a spinous process (44 cases), an anterior Caspar plate technique (three cases), and both procedures (two cases). Of these 49 patients, three (6.1%) with complete injuries died due to an adult respiratory distress syndrome. Improvement of cord function, judged by functional grade change, was observed at discharge in 15 patients (31.9%) and in 15 (71.4%) of the 21 patients with a 1-year follow-up period. Of the 34 patients with complete myelopathy on admission, three are ambulatory after 1 year, and 13 others have gained function in at least one nerve root. It is concluded that prompt reduction (nonoperative or surgical) and internal stabilization facilitate recovery even in neurologically compromised patients, and that early operative intervention is a wiser option than conservative management. This report also documents a higher incidence of this injury without deficit (five of the 52 cases) than reported in other series.