Anterior cervical plating combined with zero-profile anchored spacer for the treatment of cervical facet dislocation in elderly patients

OBJECTIVE

The purpose of this study was to evaluate the efficacy of anterior cervical plating combined with zero-profile (Z-P) anchored spacer for the treatment of cervical facet dislocation in elderly patients.

METHODS

This is a retrospective study. Twelve elderly patients (from 57 to 77 years old, averaged 65 years) with unilateral or bilateral facet dislocation of sub-axial cervical spine from September 2015 to September 2019 surgically treated at the authors' hospital were enrolled in this study. The patients with osteoporosis or osteopenia were all surgically treated by anterior-only procedure using cervical plating combined with zero-profile anchored spacer after closed manual reduction under general anesthesia and spinal cord monitoring. The operation times (OT), estimated blood loss (EBL), perioperative complications, were recorded. The clinical evaluation included visual analogue scales (VAS) and the American Spinal Injury Association (ASIA) scale. The radiographic evaluation included kyphotic angle (KA) and disc height (DH) and the fusion rate.

RESULTS

Anterior discectomy, interbody fusion and fixation were performed in all patients after the disloctions were reduced by manual maneuver. The average OT was 66 minutes, with a range from 45 to 110 minutes. The EBL averaged 42 ml per surgical procedure, with a range from 20 to 60 ml. The VAS, ASIA, KA were improved significantly after surgery (P<0.05). The average follow-up time was 24.2 months, with a range from 12 to 38 months. There were no statistical differences between the immediately post-op KA and KA at the last follow-up (P>0.05). No disc space subsidence was observed statistically (P<0.05) Interbody fusion was obtained in all patients. Two patient experienced slight difficulty in swallowing, which were improved 6 weeks later. There were no hardware failure, no segmental instability, no wound infection or other complications.

CONCLUSIONS

Manual reduction with spinal cord monitoring under general anesthesia is a safe and efficient option and the anterior cervical plating combined with Z-P spacer could achieve reliable fixation for the patients with cervical facet dislocation in the elderly patients with osteoporosis or osteopenia.

Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations

Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.

Gardner Wells tongs modification in pre-operative management for cervical facet dislocation: A case report

Introduction

Cervical facet dislocations are one of the traumas that caused the neurological disability, and it is often found and shows a spectrum of facet fracture-dislocations. Cervical facet dislocation classified by the mean of mechanism into a flexion-distraction injury. The goal of the treatment is to reduce the dislocation in favour of the patient's condition and hospital facility.

Method

We reported a case of 32 years old female with incomplete spinal cord injury due to Flexion distraction injury of C4–C5 spine, cervical X-Ray shows anterior translation for about 50% of C4 relative to underlying C5 on lateral projection, the patient was diagnosed with bilateral facet cervical dislocation and treated by gradual closed reduction using Gardner Wells Tongs followed by posterior body stabilization and fusion.

Results

We initially load of 4 kg gradually along with continuous observation using lateral cervical radiograph and careful neurological assessment. The dislocation was finally reduced after gradual and dynamic loading with 14 kg load.

Discussion

There are several strategies for managing cervical injuries. Aside from whether the MRI has to perform before or after the reduction, the option on whether to use closed or open reduction can be managed at best in favour of the current condition.

Conclusion

Gardner Wells tongs is one of the best alternatives when the surgical approach is unavailable.

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The dislocation reduced using gradual and dynamic loading with 14 kg load.

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Gardner Wells tongs is one of the best alternatives to surgery.

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Gradual and dynamic loading proof to be safe and effective.

Bilateral traumatic C6-C7 facet dislocation with C6 spondyloptosis and large disk sequestration in a neurologically intact patient

Traumatic cervical spondyloptosis is an uncommon and severe form of facet joint dislocation that commonly leads to severe neurological damage. Decision making regarding the reduction and fixation technique is challenging, especially when a patient is neurologically intact, since an undiagnosed prolapsed disk at the involved level may lead to severe neurological consequences during reduction. A 24-year-old male was admitted after sustaining a severe direct axial blow to his head. Computed tomographic and magnetic resonance imaging scans revealed an acute C6C7 fracture dislocation with spondyloptosis of C6 vertebra and a large disk fragment posterior to C6 vertebral body. The patient was neurologically intact, apart from mild bilateral numbness over C6 distribution. The patient underwent C6 corpectomy to avoid acute cord compression related to the large sequestered disk behind C6 vertebra. Following C6 corpectomy, we were unable to exert enough axial pull to reduce the facet dislocation through the anterior approach. Therefore, the reduction was performed through a posterior approach with C5T1 posterior fusion, followed by anterior cage placement and C5-7 anterior fusion (front-back-front approach). At postoperative follow-up of 24 months, the patient demonstrated a full and pain-free cervical range-of-motion and remained neurologically intact. Follow-up radiographs of the cervical spine demonstrated good instrumental alignment with solid fusion at 6-month follow-up.

Fluoroscopy-assisted posterior percutaneous reduction for the management of unilateral cervical facet dislocations after unsuccessful closed reduction: A case report

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Open reduction of cervical facet dislocation is needed when closed reduction fails.

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Anterior cervical discectomy and fusion after posterior percutaneous reduction was performed.

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Posterior percutaneous reduction can be useful for cervical facet dislocations.

Introduction

In some cases of cervical facet dislocations, open reduction becomes imperative when closed reduction fails. In these cases, posterior open reduction with subsequent posterior fixation has been favored in previous reports as reduction using the posterior approach is less challenging than that using the anterior approach. However, it invades the posterior cervical muscles, is associated with a high risk of postoperative axial neck pain, and is less likely to restore cervical lordosis than anterior surgery. In this report, we describe a novel reduction technique, posterior percutaneous reduction, which can address this dilemma.

Presentation of case

An attempt to perform closed reduction in a 19-year-old adolescent with a unilateral facet dislocation at the C4-C5 level was unsuccessful. To preserve the posterior cervical muscles and obtain good cervical alignment, we opted for posterior percutaneous reduction and subsequent anterior cervical discectomy and fusion instead of posterior open reduction and fixation. An elevator was inserted into the locked facet percutaneously with fluoroscopic assistance, and reduction was achieved by lever action. Seven days after the percutaneous reduction, anterior cervical discectomy and iliac bone grafting with plate fixation were performed. There were no complications or neurological deficits postoperatively.

Discussion

This report describes the case of a patient who underwent anterior cervical discectomy and fusion after posterior percutaneous reduction with preservation of the posterior cervical muscles for unilateral facet dislocation when closed reduction was unsuccessful.

conclusion

Posterior percutaneous reduction could be a useful option for the management of cervical facet dislocations.

A Novel Anterior-Only Surgical Approach for Reduction and Fixation of Cervical Facet Dislocation

BACKGROUND

The anterior-only surgical procedure, including discectomy, open reduction, fusion, and fixation, is a recommended approach in the treatment of cervical facet dislocations. This approach has a reduction failure rate of up to 40%. When it fails, a posterior approach is usually required.

OBJECTIVE

To report a novel anterior-only surgical approach for reduction and fixation in patients with cervical facet dislocation, even for severe vertebral fracture, articular process fracture, and delayed surgical management.

METHODS

Sixty-three consecutive patients with unilateral/bilateral facet dislocation of the subaxial cervical spine were treated with this anterior-only procedure. After discectomy, kyphotic paramedian distraction reduction with Caspar pins plus vertebral screw plate fixation was performed. If the reduction failed, anterior facetectomy reduction plus anterior cervical pedicle screw plate fixation was introduced.

RESULTS

Among the 63 patients treated, 52 patients achieved successful reduction with the technique of kyphotic paramedian distraction with Caspar pins; the remaining 11 patients with failure of the former technique experienced successful reduction with the anterior facetectomy technique. No supplemental posterior approach surgery was performed. The American Spinal Injury Association grade was improved by at least 1 grade in 23 patients after this procedure, and no neurologic deterioration occurred in any of the patients. After at least 12 months of follow-up, all patients achieved satisfactory fusion, and there was no implant failure.

CONCLUSIONS

An anterior-only surgical procedure including kyphotic paramedian distraction with Caspar pins, anterior facetectomy, and anterior pedicle screw plate fixation is safe and effective for subaxial cervical facet dislocations.

The impact of stenosis and translation on spinal cord injuries in traumatic cervical facet dislocations

BACKGROUND CONTEXT

Although facet dislocations account for only 6% of cervical trauma, the consequences are often devastating. Cervical facet dislocations are associated with a disproportionate amount of spinal cord injuries; however, neurologic examination of patients is often difficult, as patients commonly present with reduced levels of consciousness. There are limited studies that have investigated the impact of spinal canal diameter and translation on neurologic injury following facet dislocations.

PURPOSE

Review a consecutive series of patients with facet dislocations to assess the impact of sagittal diameter and translation on Spinal Cord Injury (SCI).

STUDY DESIGN

Retrospective review at a level I trauma center identified 97 patients with facet dislocations.

METHODS

Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with traumatic facet dislocation. Demographic data, neurologic exams, and radiographic findings were reviewed. We assessed sagittal diameter at the injury level, as well as above and below, and translation. This study has no funding source and its authors have no potential conflicts of interest-associated biases.

RESULTS

Ninety-seven patients presented with facet dislocations. Fifty-nine (61%) presented with a SCI. Those with ASIA A averaged 8.0 mm of injury level canal diameter, and ASIA E averaged 12.6 mm (p < .001). Additionally, those with ASIA A averaged 8.0 mm of translation, and ASIA E averaged 4.2 mm (p < 0.001). Two groups were created based on their general motor function. Those with ASIA A-C averaged 8.4 mm of injury level canal diameter, and ASIA D-E averaged 12.3 mm (p < .001). Those with ASIA A-C averaged 7.8 mm of translation, and ASIA D-E averaged 4.4 mm (p < .001). Receiver operating characteristic (ROC) curves demonstrated that translation was a good predictor of ASIA A-C and canal diameter was an almost perfect predictor of ASIA D-E.

CONCLUSIONS

Our data indicate that patients with greater translation and/or a smaller canal diameter at the injury level have a higher rate of SCI. Adjacent canal diameter did not correlate with neurologic injury.

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.

Cervical facet dislocations in the adolescent population: a report of 21 cases at a Level 1 trauma center from 2004 to 2014

PURPOSE

The purpose of this study was to present a series of adolescent patients with cervical facet dislocations to identify the mechanism of injury, severity of neurological injury and rate of neurological recovery.

METHODS

Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with unilateral or bilateral dislocated facet(s). Demographic data, initial neurological exams, surgical data, radiographic findings, and follow-up records were reviewed.

RESULTS

Of the 21 adolescent facet dislocations, 7 were unilateral and 14 bilateral. Mean age was 14.9 years; (range 12-17). Male:female ratio was 15:6. All patients presented as a result of a high-energy injury. C6-7 was the most common level of dislocation. 1 of 18 (5.5%) patients had a cervical disc herniation on MRI. Nine (43%) patients had an associated facet fracture (8 unilateral, 1 bilateral). None of the 12 patients who presented as a complete spinal cord injury (SCI) (AISA A) had any neurological recovery. Only one of the three patients who presented as an incomplete SCI (ASIA B, C, D) had an ASIA grade improvement at final follow-up. Six patients who presented were neurologically intact (ASIA E).

CONCLUSION

Over half of children with this injury in our study had a complete SCI with no recovery. We believe that the adolescent spine is more resilient to injury, thus requiring a high-energy injury to cause a dislocation, but resulting in a high rate of SCI with a low rate of neurological recovery, and a low rate of cervical disc herniation.

Anterior pedicle screw and plate fixation for cervical facet dislocation: case series and technical note

BACKGROUND CONTEXT

The anterior-only surgical procedure is used as a recommended approach in the treatment of cervical facet dislocations, but an anterior cervical spine implant that offers higher three-column instabilities for stronger fixation is lacking.

PURPOSE

This study aimed to report a new surgical technique of anterior pedicle screw (APS) fixation for cervical facet dislocations and the results of 12 patients with successful application and described safety.

STUDY DESIGN

The study design includes case series and technical report.

PATIENT SAMPLE

The sample comprises 12 patients with cervical facet dislocations.

OUTCOME MEASURES

Analyses of plain lateral neutral and oblique radiographs and computed tomography scans were conducted to assess reduction, fusion, and the accuracy of pedicle screw placement. Spinal cord compression and decompression was defined by a 1.5-Tesla magnetic resonance imaging. Neurologic status was evaluated according to classification of American Spinal Injury Association (ASIA).

METHODS

Twelve patients with cervical facet dislocations were surgically treated by the anterior cervical pedicle screw and plate fixation. In these 12 patients (9 male and 3 females), the distribution of spine level was from C3-C4 to C6-C7; the etiologic diagnosis included four unilateral and eight bilateral facet dislocations; the neurologic status comprised four patients with ASIA A, two with ASIA B, two with ASIA D, and four with ASIA E. After discectomy, reduction, and insertion of a peek cage containing autologous bone graft, the APS was inserted along the pedicle axis with the fluoroscope-assisted view imaging.

RESULTS

Postoperatively, all patients had obtained successful reduction and satisfactory anatomic sagittal alignment. There was no complication or instrument failure owing to the use of this technique. Four ASIA A and one ASIA B patients showed no neurologic improvement; one ASIA B patient was improved neurologically to ASIA C; two patients with ASIA D were improved neurologically to ASIA E; no ASIA E patients showed neurologic deterioration.

CONCLUSIONS

Anterior pedicle screw and plate fixation represents a safe and efficacious but technically challenging option for the treatment of cervical facet dislocations.