Immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of distraction-flexion injury in the lower cervical spine

Immediate reduction under general anesthesia and combined anterior and posterior fusion in the... Background: Distraction-flexion of the lower cervical spine is a severe traumatic lesion, frequently resulting in paralysis. The optimal surgical treatment is controversial. It has been a challenge for orthopedic surgeons to manage distraction-flexion injury in the lower cervical spine while avoiding the risk of iatrogenic damage. Thus, safer strategies need to be designed and adopted.This study aimed to evaluate the clinical efficacy of immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of distraction- flexion injury in the lower cervical spine. Methods: Twenty-four subjects of traumatic lower cervical spinal distraction-flexion were retrospectively analyzed from January 2010 to December 2013. Traffic accident was the primary cause of injury, with patients presenting with dislocated segments in C4–5(n = 8), C5–6(n = 10), and C6–7(n = 6). Sixteen patients had unilateral facet dislocation and eight had bilateral facet dislocation. Spinal injuries were classified according to the American Spinal Injury Association (ASIA) impairment scale (2000 edition amended), with four cases of grade A, four cases of grade B, ten cases of grade C, four cases of grade D, and two cases of grade E. On admission, all patients underwent immediate reduction under general anesthesia and combined anterior and posterior fusion. The mean follow-up time was 3.5 years. Results: All operations were completed successfully, with no major complications. Postoperative X-rays showed satisfactory height for the cervical intervertebral space and recovery of the vertebral sequence. Bone fusion was completed within 4 to 6 months after surgery. Surgery also significantly improved neurological function in all patients. Conclusion: Immediate reduction under general anesthesia and combined anterior and posterior fusion can be used to successfully treat distraction-flexion injury in the lower cervical spine, obtaining completed decompression, safe spinal re-alignment, and excellent immediate postoperative stability. Keywords: Lower cervical spine, Spinal cord injury, Distraction-flexion, Immediate reduction, Anterior cervical approach, Posterior cervical approach * Correspondence: 18630159778@163.com Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang 050051, China © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 2 of 8 Background Injury Association (ASIA) impairment scale [9], encom- Lower cervical injury is the most common type of all injur- passing complete injury (grade A) to normal (grade E), we ies to the cervical spine, with lower cervical facet disloca- found that four cases were grade A, four cases were grade tion accounting for 6 to 15% [1]. This type of injury mainly B, ten cases were grade C, four cases were grade D, and involves excessive flexion-distraction or flexion-rotation, two cases were grade E (Table 1). Patients with clinical evi- present as the subluxation or dislocation of the facet joints dence of spinal cord injury accepted a methylprednisolone and may be accompanied by spinal cord injuries [2]. sodium succinate according to the National Acute Spinal Distraction-flexion of the lower cervical spine is most com- Cord Injury StudyII protocol [2]. All patients were operated monly caused by road traffic accidents and most frequently within 72 h following the injury. All surgeries ranged from affects the levels C5–6and C6–7[3]. The injuries can result 4to7hinduration. in significant impact on neurological function, high eco- nomic cost, and may at times be life-threatening. Surgical technique The goal of treatment is to restore the normal archi- A neck collar was applied to patients in the supine pos- tecture of the cervical spine, recover the anatomical and ition. Following general anesthesia, the neck collar was functional integrity of the spinal cord and nerve root, removed and patients were moved into a position of completely decompress and restore the intervertebral mild cervical flexion. Spinal cord evoked potential moni- height and physiological curvature, and avoid delayed or toring was introduced to monitor the patient’s neuro- secondary neurological injury for immediate and logical function during reduction. Intraoperative X-ray long-term stability of the cervical spine [4–7]. Methods fluoroscopy was used to observe the reduction process. described to treat distraction-flexion patients include Skull traction was performed with 5 kg weights, and the closed traction, Halo thoracic brace, anterior or posterior weight was increased at a rate of 1 kg per 10 min. Dur- approach, or both [3, 8]. However, to date, the treatment ing each interval, patients’ limb neurological function has not been standardized. The aim of the current study changes were closely monitored and the reset situation was to examine the clinical efficacy of immediate reduc- was observed through intraoperative X-ray fluoroscopy. tion under general anesthesia and combined anterior and When the upper and lower articular process was pulled posterior fusion in the treatment of distraction-flexion in- to the apex of the tip to the tip, the unilateral facet dis- jury in the lower cervical spine to provide evidence for location was unlocked by slight stretching of the head, clinical strategies. allowing the inferior articular process of the dislocated vertebra to cross the superior process of the lower verte- Methods bra. Slight rotation of the neck toward the dislocated Patients side allowed the bilateral facet dislocation to be reset. We retrospectively reviewed our experience using The traction weight was then gradually reduced to 5 kg immediate reduction under general anesthesia followed after reduction. Traction was stopped in cases where the by antero-posterior fixation in the treatment of traction weight exceeded 15 kg, the dislocation was un- distraction-flexion injury in the lower cervical spine during able to be reset, or neurological deterioration was ob- a consecutive 4-year period (from January 2010 to Decem- served through spinal cord evoked potential monitoring. ber 2013). The inclusion criteria consisted of unilateral or A standard Smith-Robinson anterior approach [10] bilateral facet dislocations, with disc herniation existed both was used to perform anterior decompression and fix- anteriorly and posteriorly, or unstable 3-column injuries of ation after closed traction. Plate with screw fixation and lower cervical spine. We enrolled a final cohort of 24 pa- inter-body cages were used for fusion. For patients who tients (14 males, 10 females), who were diagnosed with failed closed reduction, a Caspar distractor was used to distraction-flexion injury in the lower cervical spine. Pa- distract the intervertebral space after discectomy tients’ age ranged from 21 to 68 years, with a mean age of followed by a thin distractor for poking to achieve re- 44.42 years. The etiology of trauma included traffic acci- duction. Then, the patient was turned to the prone pos- dents (18 patients), high falls (2 patients), and others (2 pa- ition, the dislocated spinous process was fastened by tients). All patients were imaged using cervical X-rays, CT lateral mass or pedicle screws and rods, fusion consisted scanning, and MRI of the cervical spine. Plain radiography of excising the articular cartilage and filling the articular and CT showed facet dislocations at C4–5(8patients),C5– gap with autogenous or allograft bone. Posterior decom- 6 (10 patients), and C6–7 (6 patients). Sixteen cases pre- pression was also done if necessary. sented with unilateral facet dislocation and eight cases with A neck collar was used for 1 to 1.5 months postopera- bilateral facet dislocation. Two patients presented with in- tively. All patients were graded before and after surgery tact neurological function, 4 patients with complete spinal according to the Japanese Orthopedic Association (JOA) cord injury, and 18 patients with incomplete spinal cord in- score and ASIA grades to evaluate the neurological state, jury. As per the classifications of the American Spinal and the cervical curvature index (CCI) (Fig. 1)was Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 3 of 8 Table 1 General data of enrolled cases Case Age Sex (male/ Involved Unilateral/ Spinal cord injury Time to Traction weight Time of reduction no. (year) female) segment bilateral surgery (h) (kg) (min) 133 M C6–7 U Incomplete spinal cord 12 11 60 injury 249 F C4–5 U Incomplete spinal cord 14 10 50 injury 368 M C6–7 B Complete spinal cord 72 12 70 injury 421 F C4–5 U Intact neurological 89 40 function 545 M C4–5 B Incomplete spinal cord 52 10 50 injury 658 F C5–6 U Incomplete spinal cord 32 10 50 injury 754 M C5–6 B Complete spinal cord 26 11 60 injury 846 F C4–5 U Incomplete spinal cord 39 9 40 injury 937 M C6–7 U Incomplete spinal cord 40 12 70 injury 10 38 F C4–5 B Incomplete spinal cord 44 9 40 injury 11 50 M C5–6 U Incomplete spinal cord 30 11 60 injury 12 34 F C4–5 U Incomplete spinal cord 32 10 50 injury 13 29 M C5–6 U Incomplete spinal cord 16 12 70 injury 14 50 M C6–7 B Complete spinal cord 48 11 60 injury 15 42 M C5–6 U Incomplete spinal cord 36 9 40 injury 16 39 F C4–5 U Incomplete spinal cord 23 10 50 injury 17 56 F C5–6 B Complete spinal cord 30 9 40 injury 18 28 M C5–6 U Intact neurological 24 11 60 function 19 44 M C4–5 U Incomplete spinal cord 34 10 70 injury 20 64 F C5–6 B Incomplete spinal cord 64 12 70 injury 21 55 M C6–7 U Incomplete spinal cord 48 11 60 injury 22 42 M C5–6 U Incomplete spinal cord 28 12 70 injury 23 48 F C5–6 B Incomplete spinal cord 28 11 60 injury 24 36 M C6–7 U Incomplete spinal cord 40 11 60 injury Average 44.42 34.17 10.54 56.25 Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 4 of 8 measured pre-and postoperatively to evaluate the stabil- completed within 4 to 6 months after surgery (obvious ity of the cervical spine. fiber through and bone connections can be seen in the X-ray and CT scans). Statistical method No severe complications were noted for any of the pa- SPSS 22.0 statistical software (IBM, Armonk, NY, USA) tients. None of the patients showed plate fracture, screw was used for statistical analysis. Data was recorded as loosening, cage prolapse, or pseudarthrosis at the mean ± SD and was compared by using a t test. Wil- follow-up. X-ray examination showed satisfactory recov- coxon rank test was applied to analyze ASIA grades that ery of the cervical intervertebral height space and verte- recorded preoperatively and at the latest follow-up visit. bral sequence. P value < 0.05 was considered statistically significant. Neurological function was also significantly improved at the follow-up as compared with preoperative values Results (Table 2). The paralysis plane for patients with complete The skull traction weight ranged from 9 to 12 kg, with a spinal cord injury did not increase after surgery. Neuro- mean of 10.54 kg. Reduction was achieved after 40 to logical function in patients with incomplete spinal cord 70 min of traction (mean, 56.25 min). All subjects got injury was restored to varying degrees. The postoperative reduction except two patients who got reduction JOA scores and CCI showed improvement as compared incompletely. with preoperative (Table 3, Fig. 2). The surgery length was 328.33 ± 47.88 min, and the Although some patients complained of slight neck amount of blood loss was 734.58 ± 96.68 ml. All patients stiffness and discomfort postoperatively, none of them were followed up for 3 to 6 years. Bone fusion was complained of neckache, limited neck activity, and a sore back. Figure 3 shows typical case imaging data. Discussion Distraction-flexion injuries of the lower cervical spine are usually accompanied by a disruption to the anterior or posterior elements, such as the longitudinal liga- ments, the ligamentum flavum, apophyseal joint liga- ments, the annulus fibrosus, and the interspinous ligaments [11], which could cause instability of the lower cervical spine. The goals of treatment of the lower cer- vical spine injury include a return to the normal archi- tecture of the cervical spine, a minimum of residual pain, a recover of the functional integrity of the spinal a cord, and the prevention of delayed or secondary disabil- ity [12]. However, to date, the treatment has not been standardized, and there remain several unanswered ab questions with regard to treatment [13]. We performed an immediate reduction under general anesthesia and followed by a combined anterior and posterior fusion a and fixation in 24 patients with distraction-flexion injur- ies of the lower cervical spine. Bone fusion and postop- erative re-alignment were obtained in all patients and maintained throughout the follow-up period. Table 2 Pre- and postoperative ASIA grade ASIA Pre- The last follow-up ASIA grade grade op AB CD E cases A4 1 2 1 B4 1 1 2 Fig. 1 Calculation of CCI. “ab” was the line connecting posterior C10 2 4 4 inferior edge of the C2 and C7 vertebral body. “a1” to “a4” D4 1 3 respectively represented the vertical distance from posterior inferior edge of the C3-C6 to “ab.” CCI = [(a1 + a2 + a3 + a4)/ab] × 100% E2 2 Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 5 of 8 Table 3 Pre- and postoperative JOA grade and cervical curvature index (CCI) and ASIA grade Preoperative The last follow-up p Improvement rate of JOA grade (%) JOA grade 9.21 ± 4.38 13.17 ± 4.01 0.000 54.88 ± 33.72 CCI 18.90 ± 0.91 10.60 ± 0.43 0.000 ASIA grade 0.010 Manually closed reduction is usually initially adopted, head, allowing the inferior articular process of the dislo- which is a basis on which the next steps are based [13]. cated vertebra to cross the superior process of the lower On the other hand, it is comprehensively accepted that vertebra while slight rotation of the neck toward the dis- cervical spine dislocations should be reduced as early as located side allowed the bilateral facet dislocation to be possible by closed means, because this has great impact reset. In this method, all subjects got reduction (two pa- on neurologic recovery [14]. The most common form of tients got reduction incompletely) and making it possible initial reduction has been always an attempt at awake to manage the combined anterior and posterior fusion closed reduction with skull tongs. However, awake and fixation after traction. closed reduction has some drawbacks, such as requires Open reduction can be achieved through an anterior heavy traction weights, exposes the patients to unbear- approach alone, a posterior approach alone, or a com- able immobilization and pain, or may cause secondary bined anterior and posterior approach [21]: the surgical neurological injury [15–17]. However, some biomechan- approach is not standardized. Previously, anterior reduc- ical studies have demonstrated the safety of skull trac- tion alone was commonly used for facet dislocation pa- tion [18–20]. In our study, we performed immediate tients, because anterior approach rarely causes reduction under general anesthesia with spinal cord iatrogenic soft tissue injury as it reaches the injury more evoked potential monitoring, which ensured the safety directly. In addition, decompression can be achieved of the closed traction procedure. During the process of with direct observation of anterior pathology including traction, when the upper and lower articular process was rupture of the anterior longitudinal ligament or hernia- pulled to the apex of the tip to the tip, the unilateral tion or rupture of the nucleus pulposus [22]. Maynard facet dislocation was unlocked by slight stretching of the et al. reported a series of direct anterior open reduction A1 A2 A4 A3 A5 A6 B1 B2 B3 B5 B4 Fig. 2 Pre- and postoperative JOA grade and cervical curvature index (CCI) and ASIA grade Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 6 of 8 Fig. 3 A typical case imaging data. A1-A6, lateral view of radiographs demonstrated bilateral facet dislocation of C4-C5. MRI images showing disc herniation existed both anteriorly and posteriorly. B1–5, stabilization was performed via an anterior-posterior cervical approach with discectomy and fusion with inter-body cage, allograft, and Synthes plate; CT and MRI show good alignment and satisfactory decompression. C, last follow-up X-ray shows good alignment and union of allograft with the adjacent vertebral bodies of distraction-flexion injuries without attempting closed fixation was adopted in our study, and all patients showed reduction [23]; their procedure is very similar to the one evidence of stability and neurological recovery on the final used in our study. The increased use of an anterior follow-up examination, which is consistent with the conclu- approach has meant that its indication is no longer lim- sions of many studies [28–30]. ited to injuries of anterior structures, with posterior in- The combined approach can provide the strongest in- juries also treatable. However, Henriques et al. reported ternal fixation and significantly limiting motion [27]. A that anterior fixation alone has a lower fusion rate; 7/13 combined anterior and posterior fixation of the lower patients achieve inadequate fusion for bilateral disloca- cervical dislocation increase the bone fusion rate, and it tion [24]. However, many other scholars also suggest is helpful to restore cervical alignment and neural de- that anterior fixation alone is less effective in bilateral compression, especially for patients with chronic injuries dislocations or cervical spine injuries with severe in- associated with pseudoarthrosis. A combined approach stability than combined approach [22, 24–26]. And a is also recommended to patients with poor bone quality, potential problem after anterior approach alone is postop- such as those with ankylosing spondylitis, osteoporosis, erative kyphosis. Concern about the mechanical failure of or other chronic conditions. However, benefits of a com- distraction-flexion injuries should be high; hence, a com- bined approach must be weighed against the risk of an bined anterior and posterior fusion and fixation was rec- addition surgery and increasing morbidity related to ommended for patients with distraction-flexion injuries, each approach as well as increasing surgical costs [29]. especially for patients with fractures of both facets and The timing of the surgery is another controversial as- endplate. pect of this treatment. Cervical facet dislocation should Posterior open reduction can be obtained by distract- be reduced as soon as possible, as recommended in the ing the two dislocated spinous processes with two guidelines published in 2013 [31]. However, there are bone-holding forceps and, if necessary, simultaneously some risks associated with early reduction, such as poking the facets with a narrow osteotome. When satis- neurological deterioration caused by a herniated disc or factory reduction was achieved, the cervical spine was vertebral artery injury with posterior circulation stroke moved into slight extension, and the dislocated spinous [32, 33]. Nagata et al. indicated that early reduction of process fastened by lateral mass or pedicle screws. This cervical spine dislocation (≤ 6 h of injury) might facilitate method is a good alternative for treating distraction-flexion motor function improvement, even in patients with injuries; additionally, patients with posterior fracture or complete motor paralysis [34]. In contrast, Vaccaro sug- compression associated with facet dislocation, such as a gested that a delay in surgery allows for better preoperative lamina fragment into the canal, can be successfully treated preparation and that decompression is safer after the edema by using a posterior approach [27]. However, posterior ap- has subsided [35]. Most authors accept that rapid reduction proach alone may add some risk of neurological deterior- should give patients with distraction-flexion injuries the ation in patients with anterior compression and less likely chance for neurological recovery or at least prevent pro- to restore cervical lordosis. Therefore, one-stage operation gressive secondary spinal cord injury if the patient’scondi- in combination with an anterior and posterior fusion and tion allows. We recommend that surgery should be Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 7 of 8 performed within 72 h of injury if the patient’scondition Abbreviations ASIA: American Spinal Injury Association; CCI: Cervical curvature index; permits, which is conducive to the recovery of neurological JOA: Japanese Orthopedic Association function. The recovery of neurological injury was examined by Availability of data and materials The datasets analyzed during the current study are available from the comparing the difference in pre-operative ASIA grade corresponding author on reasonable request. and JOA scores of motor and sensory function in our study. No neurological worsening occurred; neurological Authors’ contributions function in patients with incomplete spinal cord injury D-cM performed the data collection, analyzed and interpreted the patient data, and wrote the manuscript. YS performed background research for the was restored to varying degrees, yet symptoms of nerve topic, conducted the whole study, and prepared the manuscript for root irritation had disappeared. Considering our result submission. FW performed the data collection. All authors read and and previous report, an effective reduction decompres- approved the final manuscript. sion and internal fixation system for lower cervical Ethics approval and consent to participate distraction-flexion relieve neurological deterioration, All experimental protocols in this research were approved by The Third provide immediate stabilization, enhance bony fusion, Hospital of Hebei Medical University Ethics Committee, and informed consent was obtained from all patients. The methods were carried out in and correct the spine deformity [36]. However, the accordance with the relevant guidelines, including any relevant details. choice of surgical approach in the treatment of trau- matic cervical dislocation is highly variable and may be Consent for publication Informed consent was obtained from all individual participants included in influenced by a variety of factors. Nassr et al. conducted the study. a retrospective survey analysis of surgical approach in treatment of lower cervical distraction-flexion and found Competing interests that combined approach is recommended for the treat- No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. ment of bilateral dislocation [29], which is in line with our findings. Publisher’sNote In this study, we measured the CCI as described by Springer Nature remains neutral with regard to jurisdictional claims in Ishihara [37] (Fig. 1) to evaluate the stability of the cer- published maps and institutional affiliations. vical spine. The biomechanical superiority of posterior Received: 18 September 2017 Accepted: 21 May 2018 instrumentation and a high stability of cervical lateral mass or pedicle screws in cervical trauma have been re- ported [38]. However, Brodke et al. found no significant References difference in stability between patients treated via an an- 1. Maiman DJ, Barolat G, Larson SJ. Management of bilateral locked facets of the cervical spine. Neurosurgery. 1986;18(5):542–7. terior approach [3]. On the other hand, Du et al. sug- 2. Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc gested that reconstruction of cervical lordosis and associated with traumatic subluxation or dislocation of cervical facets. 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Immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of distraction-flexion injury in the lower cervical spine

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Abstract

Background: Distraction-flexion of the lower cervical spine is a severe traumatic lesion, frequently resulting in paralysis. The optimal surgical treatment is controversial. It has been a challenge for orthopedic surgeons to manage distraction-flexion injury in the lower cervical spine while avoiding the risk of iatrogenic damage. Thus, safer strategies need to be designed and adopted.This study aimed to evaluate the clinical efficacy of immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of distraction- flexion injury in the lower cervical spine. Methods: Twenty-four subjects of traumatic lower cervical spinal distraction-flexion were retrospectively analyzed from January 2010 to December 2013. Traffic accident was the primary cause of injury, with patients presenting with dislocated segments in C4–5(n = 8), C5–6(n = 10), and C6–7(n = 6). Sixteen patients had unilateral facet dislocation and eight had bilateral facet dislocation. Spinal injuries were classified according to the American Spinal Injury Association (ASIA) impairment scale (2000 edition amended), with four cases of grade A, four cases of grade B, ten cases of grade C, four cases of grade D, and two cases of grade E. On admission, all patients underwent immediate reduction under general anesthesia and combined anterior and posterior fusion. The mean follow-up time was 3.5 years. Results: All operations were completed successfully, with no major complications. Postoperative X-rays showed satisfactory height for the cervical intervertebral space and recovery of the vertebral sequence. Bone fusion was completed within 4 to 6 months after surgery. Surgery also significantly improved neurological function in all patients. Conclusion: Immediate reduction under general anesthesia and combined anterior and posterior fusion can be used to successfully treat distraction-flexion injury in the lower cervical spine, obtaining completed decompression, safe spinal re-alignment, and excellent immediate postoperative stability. Keywords: Lower cervical spine, Spinal cord injury, Distraction-flexion, Immediate reduction, Anterior cervical approach, Posterior cervical approach * Correspondence: 18630159778@163.com Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang 050051, China © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 2 of 8 Background Injury Association (ASIA) impairment scale [9], encom- Lower cervical injury is the most common type of all injur- passing complete injury (grade A) to normal (grade E), we ies to the cervical spine, with lower cervical facet disloca- found that four cases were grade A, four cases were grade tion accounting for 6 to 15% [1]. This type of injury mainly B, ten cases were grade C, four cases were grade D, and involves excessive flexion-distraction or flexion-rotation, two cases were grade E (Table 1). Patients with clinical evi- present as the subluxation or dislocation of the facet joints dence of spinal cord injury accepted a methylprednisolone and may be accompanied by spinal cord injuries [2]. sodium succinate according to the National Acute Spinal Distraction-flexion of the lower cervical spine is most com- Cord Injury StudyII protocol [2]. All patients were operated monly caused by road traffic accidents and most frequently within 72 h following the injury. All surgeries ranged from affects the levels C5–6and C6–7[3]. The injuries can result 4to7hinduration. in significant impact on neurological function, high eco- nomic cost, and may at times be life-threatening. Surgical technique The goal of treatment is to restore the normal archi- A neck collar was applied to patients in the supine pos- tecture of the cervical spine, recover the anatomical and ition. Following general anesthesia, the neck collar was functional integrity of the spinal cord and nerve root, removed and patients were moved into a position of completely decompress and restore the intervertebral mild cervical flexion. Spinal cord evoked potential moni- height and physiological curvature, and avoid delayed or toring was introduced to monitor the patient’s neuro- secondary neurological injury for immediate and logical function during reduction. Intraoperative X-ray long-term stability of the cervical spine [4–7]. Methods fluoroscopy was used to observe the reduction process. described to treat distraction-flexion patients include Skull traction was performed with 5 kg weights, and the closed traction, Halo thoracic brace, anterior or posterior weight was increased at a rate of 1 kg per 10 min. Dur- approach, or both [3, 8]. However, to date, the treatment ing each interval, patients’ limb neurological function has not been standardized. The aim of the current study changes were closely monitored and the reset situation was to examine the clinical efficacy of immediate reduc- was observed through intraoperative X-ray fluoroscopy. tion under general anesthesia and combined anterior and When the upper and lower articular process was pulled posterior fusion in the treatment of distraction-flexion in- to the apex of the tip to the tip, the unilateral facet dis- jury in the lower cervical spine to provide evidence for location was unlocked by slight stretching of the head, clinical strategies. allowing the inferior articular process of the dislocated vertebra to cross the superior process of the lower verte- Methods bra. Slight rotation of the neck toward the dislocated Patients side allowed the bilateral facet dislocation to be reset. We retrospectively reviewed our experience using The traction weight was then gradually reduced to 5 kg immediate reduction under general anesthesia followed after reduction. Traction was stopped in cases where the by antero-posterior fixation in the treatment of traction weight exceeded 15 kg, the dislocation was un- distraction-flexion injury in the lower cervical spine during able to be reset, or neurological deterioration was ob- a consecutive 4-year period (from January 2010 to Decem- served through spinal cord evoked potential monitoring. ber 2013). The inclusion criteria consisted of unilateral or A standard Smith-Robinson anterior approach [10] bilateral facet dislocations, with disc herniation existed both was used to perform anterior decompression and fix- anteriorly and posteriorly, or unstable 3-column injuries of ation after closed traction. Plate with screw fixation and lower cervical spine. We enrolled a final cohort of 24 pa- inter-body cages were used for fusion. For patients who tients (14 males, 10 females), who were diagnosed with failed closed reduction, a Caspar distractor was used to distraction-flexion injury in the lower cervical spine. Pa- distract the intervertebral space after discectomy tients’ age ranged from 21 to 68 years, with a mean age of followed by a thin distractor for poking to achieve re- 44.42 years. The etiology of trauma included traffic acci- duction. Then, the patient was turned to the prone pos- dents (18 patients), high falls (2 patients), and others (2 pa- ition, the dislocated spinous process was fastened by tients). All patients were imaged using cervical X-rays, CT lateral mass or pedicle screws and rods, fusion consisted scanning, and MRI of the cervical spine. Plain radiography of excising the articular cartilage and filling the articular and CT showed facet dislocations at C4–5(8patients),C5– gap with autogenous or allograft bone. Posterior decom- 6 (10 patients), and C6–7 (6 patients). Sixteen cases pre- pression was also done if necessary. sented with unilateral facet dislocation and eight cases with A neck collar was used for 1 to 1.5 months postopera- bilateral facet dislocation. Two patients presented with in- tively. All patients were graded before and after surgery tact neurological function, 4 patients with complete spinal according to the Japanese Orthopedic Association (JOA) cord injury, and 18 patients with incomplete spinal cord in- score and ASIA grades to evaluate the neurological state, jury. As per the classifications of the American Spinal and the cervical curvature index (CCI) (Fig. 1)was Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 3 of 8 Table 1 General data of enrolled cases Case Age Sex (male/ Involved Unilateral/ Spinal cord injury Time to Traction weight Time of reduction no. (year) female) segment bilateral surgery (h) (kg) (min) 133 M C6–7 U Incomplete spinal cord 12 11 60 injury 249 F C4–5 U Incomplete spinal cord 14 10 50 injury 368 M C6–7 B Complete spinal cord 72 12 70 injury 421 F C4–5 U Intact neurological 89 40 function 545 M C4–5 B Incomplete spinal cord 52 10 50 injury 658 F C5–6 U Incomplete spinal cord 32 10 50 injury 754 M C5–6 B Complete spinal cord 26 11 60 injury 846 F C4–5 U Incomplete spinal cord 39 9 40 injury 937 M C6–7 U Incomplete spinal cord 40 12 70 injury 10 38 F C4–5 B Incomplete spinal cord 44 9 40 injury 11 50 M C5–6 U Incomplete spinal cord 30 11 60 injury 12 34 F C4–5 U Incomplete spinal cord 32 10 50 injury 13 29 M C5–6 U Incomplete spinal cord 16 12 70 injury 14 50 M C6–7 B Complete spinal cord 48 11 60 injury 15 42 M C5–6 U Incomplete spinal cord 36 9 40 injury 16 39 F C4–5 U Incomplete spinal cord 23 10 50 injury 17 56 F C5–6 B Complete spinal cord 30 9 40 injury 18 28 M C5–6 U Intact neurological 24 11 60 function 19 44 M C4–5 U Incomplete spinal cord 34 10 70 injury 20 64 F C5–6 B Incomplete spinal cord 64 12 70 injury 21 55 M C6–7 U Incomplete spinal cord 48 11 60 injury 22 42 M C5–6 U Incomplete spinal cord 28 12 70 injury 23 48 F C5–6 B Incomplete spinal cord 28 11 60 injury 24 36 M C6–7 U Incomplete spinal cord 40 11 60 injury Average 44.42 34.17 10.54 56.25 Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 4 of 8 measured pre-and postoperatively to evaluate the stabil- completed within 4 to 6 months after surgery (obvious ity of the cervical spine. fiber through and bone connections can be seen in the X-ray and CT scans). Statistical method No severe complications were noted for any of the pa- SPSS 22.0 statistical software (IBM, Armonk, NY, USA) tients. None of the patients showed plate fracture, screw was used for statistical analysis. Data was recorded as loosening, cage prolapse, or pseudarthrosis at the mean ± SD and was compared by using a t test. Wil- follow-up. X-ray examination showed satisfactory recov- coxon rank test was applied to analyze ASIA grades that ery of the cervical intervertebral height space and verte- recorded preoperatively and at the latest follow-up visit. bral sequence. P value < 0.05 was considered statistically significant. Neurological function was also significantly improved at the follow-up as compared with preoperative values Results (Table 2). The paralysis plane for patients with complete The skull traction weight ranged from 9 to 12 kg, with a spinal cord injury did not increase after surgery. Neuro- mean of 10.54 kg. Reduction was achieved after 40 to logical function in patients with incomplete spinal cord 70 min of traction (mean, 56.25 min). All subjects got injury was restored to varying degrees. The postoperative reduction except two patients who got reduction JOA scores and CCI showed improvement as compared incompletely. with preoperative (Table 3, Fig. 2). The surgery length was 328.33 ± 47.88 min, and the Although some patients complained of slight neck amount of blood loss was 734.58 ± 96.68 ml. All patients stiffness and discomfort postoperatively, none of them were followed up for 3 to 6 years. Bone fusion was complained of neckache, limited neck activity, and a sore back. Figure 3 shows typical case imaging data. Discussion Distraction-flexion injuries of the lower cervical spine are usually accompanied by a disruption to the anterior or posterior elements, such as the longitudinal liga- ments, the ligamentum flavum, apophyseal joint liga- ments, the annulus fibrosus, and the interspinous ligaments [11], which could cause instability of the lower cervical spine. The goals of treatment of the lower cer- vical spine injury include a return to the normal archi- tecture of the cervical spine, a minimum of residual pain, a recover of the functional integrity of the spinal a cord, and the prevention of delayed or secondary disabil- ity [12]. However, to date, the treatment has not been standardized, and there remain several unanswered ab questions with regard to treatment [13]. We performed an immediate reduction under general anesthesia and followed by a combined anterior and posterior fusion a and fixation in 24 patients with distraction-flexion injur- ies of the lower cervical spine. Bone fusion and postop- erative re-alignment were obtained in all patients and maintained throughout the follow-up period. Table 2 Pre- and postoperative ASIA grade ASIA Pre- The last follow-up ASIA grade grade op AB CD E cases A4 1 2 1 B4 1 1 2 Fig. 1 Calculation of CCI. “ab” was the line connecting posterior C10 2 4 4 inferior edge of the C2 and C7 vertebral body. “a1” to “a4” D4 1 3 respectively represented the vertical distance from posterior inferior edge of the C3-C6 to “ab.” CCI = [(a1 + a2 + a3 + a4)/ab] × 100% E2 2 Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 5 of 8 Table 3 Pre- and postoperative JOA grade and cervical curvature index (CCI) and ASIA grade Preoperative The last follow-up p Improvement rate of JOA grade (%) JOA grade 9.21 ± 4.38 13.17 ± 4.01 0.000 54.88 ± 33.72 CCI 18.90 ± 0.91 10.60 ± 0.43 0.000 ASIA grade 0.010 Manually closed reduction is usually initially adopted, head, allowing the inferior articular process of the dislo- which is a basis on which the next steps are based [13]. cated vertebra to cross the superior process of the lower On the other hand, it is comprehensively accepted that vertebra while slight rotation of the neck toward the dis- cervical spine dislocations should be reduced as early as located side allowed the bilateral facet dislocation to be possible by closed means, because this has great impact reset. In this method, all subjects got reduction (two pa- on neurologic recovery [14]. The most common form of tients got reduction incompletely) and making it possible initial reduction has been always an attempt at awake to manage the combined anterior and posterior fusion closed reduction with skull tongs. However, awake and fixation after traction. closed reduction has some drawbacks, such as requires Open reduction can be achieved through an anterior heavy traction weights, exposes the patients to unbear- approach alone, a posterior approach alone, or a com- able immobilization and pain, or may cause secondary bined anterior and posterior approach [21]: the surgical neurological injury [15–17]. However, some biomechan- approach is not standardized. Previously, anterior reduc- ical studies have demonstrated the safety of skull trac- tion alone was commonly used for facet dislocation pa- tion [18–20]. In our study, we performed immediate tients, because anterior approach rarely causes reduction under general anesthesia with spinal cord iatrogenic soft tissue injury as it reaches the injury more evoked potential monitoring, which ensured the safety directly. In addition, decompression can be achieved of the closed traction procedure. During the process of with direct observation of anterior pathology including traction, when the upper and lower articular process was rupture of the anterior longitudinal ligament or hernia- pulled to the apex of the tip to the tip, the unilateral tion or rupture of the nucleus pulposus [22]. Maynard facet dislocation was unlocked by slight stretching of the et al. reported a series of direct anterior open reduction A1 A2 A4 A3 A5 A6 B1 B2 B3 B5 B4 Fig. 2 Pre- and postoperative JOA grade and cervical curvature index (CCI) and ASIA grade Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 6 of 8 Fig. 3 A typical case imaging data. A1-A6, lateral view of radiographs demonstrated bilateral facet dislocation of C4-C5. MRI images showing disc herniation existed both anteriorly and posteriorly. B1–5, stabilization was performed via an anterior-posterior cervical approach with discectomy and fusion with inter-body cage, allograft, and Synthes plate; CT and MRI show good alignment and satisfactory decompression. C, last follow-up X-ray shows good alignment and union of allograft with the adjacent vertebral bodies of distraction-flexion injuries without attempting closed fixation was adopted in our study, and all patients showed reduction [23]; their procedure is very similar to the one evidence of stability and neurological recovery on the final used in our study. The increased use of an anterior follow-up examination, which is consistent with the conclu- approach has meant that its indication is no longer lim- sions of many studies [28–30]. ited to injuries of anterior structures, with posterior in- The combined approach can provide the strongest in- juries also treatable. However, Henriques et al. reported ternal fixation and significantly limiting motion [27]. A that anterior fixation alone has a lower fusion rate; 7/13 combined anterior and posterior fixation of the lower patients achieve inadequate fusion for bilateral disloca- cervical dislocation increase the bone fusion rate, and it tion [24]. However, many other scholars also suggest is helpful to restore cervical alignment and neural de- that anterior fixation alone is less effective in bilateral compression, especially for patients with chronic injuries dislocations or cervical spine injuries with severe in- associated with pseudoarthrosis. A combined approach stability than combined approach [22, 24–26]. And a is also recommended to patients with poor bone quality, potential problem after anterior approach alone is postop- such as those with ankylosing spondylitis, osteoporosis, erative kyphosis. Concern about the mechanical failure of or other chronic conditions. However, benefits of a com- distraction-flexion injuries should be high; hence, a com- bined approach must be weighed against the risk of an bined anterior and posterior fusion and fixation was rec- addition surgery and increasing morbidity related to ommended for patients with distraction-flexion injuries, each approach as well as increasing surgical costs [29]. especially for patients with fractures of both facets and The timing of the surgery is another controversial as- endplate. pect of this treatment. Cervical facet dislocation should Posterior open reduction can be obtained by distract- be reduced as soon as possible, as recommended in the ing the two dislocated spinous processes with two guidelines published in 2013 [31]. However, there are bone-holding forceps and, if necessary, simultaneously some risks associated with early reduction, such as poking the facets with a narrow osteotome. When satis- neurological deterioration caused by a herniated disc or factory reduction was achieved, the cervical spine was vertebral artery injury with posterior circulation stroke moved into slight extension, and the dislocated spinous [32, 33]. Nagata et al. indicated that early reduction of process fastened by lateral mass or pedicle screws. This cervical spine dislocation (≤ 6 h of injury) might facilitate method is a good alternative for treating distraction-flexion motor function improvement, even in patients with injuries; additionally, patients with posterior fracture or complete motor paralysis [34]. In contrast, Vaccaro sug- compression associated with facet dislocation, such as a gested that a delay in surgery allows for better preoperative lamina fragment into the canal, can be successfully treated preparation and that decompression is safer after the edema by using a posterior approach [27]. However, posterior ap- has subsided [35]. Most authors accept that rapid reduction proach alone may add some risk of neurological deterior- should give patients with distraction-flexion injuries the ation in patients with anterior compression and less likely chance for neurological recovery or at least prevent pro- to restore cervical lordosis. Therefore, one-stage operation gressive secondary spinal cord injury if the patient’scondi- in combination with an anterior and posterior fusion and tion allows. We recommend that surgery should be Miao et al. Journal of Orthopaedic Surgery and Research (2018) 13:126 Page 7 of 8 performed within 72 h of injury if the patient’scondition Abbreviations ASIA: American Spinal Injury Association; CCI: Cervical curvature index; permits, which is conducive to the recovery of neurological JOA: Japanese Orthopedic Association function. The recovery of neurological injury was examined by Availability of data and materials The datasets analyzed during the current study are available from the comparing the difference in pre-operative ASIA grade corresponding author on reasonable request. and JOA scores of motor and sensory function in our study. No neurological worsening occurred; neurological Authors’ contributions function in patients with incomplete spinal cord injury D-cM performed the data collection, analyzed and interpreted the patient data, and wrote the manuscript. YS performed background research for the was restored to varying degrees, yet symptoms of nerve topic, conducted the whole study, and prepared the manuscript for root irritation had disappeared. Considering our result submission. FW performed the data collection. All authors read and and previous report, an effective reduction decompres- approved the final manuscript. sion and internal fixation system for lower cervical Ethics approval and consent to participate distraction-flexion relieve neurological deterioration, All experimental protocols in this research were approved by The Third provide immediate stabilization, enhance bony fusion, Hospital of Hebei Medical University Ethics Committee, and informed consent was obtained from all patients. The methods were carried out in and correct the spine deformity [36]. However, the accordance with the relevant guidelines, including any relevant details. choice of surgical approach in the treatment of trau- matic cervical dislocation is highly variable and may be Consent for publication Informed consent was obtained from all individual participants included in influenced by a variety of factors. Nassr et al. conducted the study. a retrospective survey analysis of surgical approach in treatment of lower cervical distraction-flexion and found Competing interests that combined approach is recommended for the treat- No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. ment of bilateral dislocation [29], which is in line with our findings. Publisher’sNote In this study, we measured the CCI as described by Springer Nature remains neutral with regard to jurisdictional claims in Ishihara [37] (Fig. 1) to evaluate the stability of the cer- published maps and institutional affiliations. vical spine. The biomechanical superiority of posterior Received: 18 September 2017 Accepted: 21 May 2018 instrumentation and a high stability of cervical lateral mass or pedicle screws in cervical trauma have been re- ported [38]. However, Brodke et al. found no significant References difference in stability between patients treated via an an- 1. Maiman DJ, Barolat G, Larson SJ. Management of bilateral locked facets of the cervical spine. Neurosurgery. 1986;18(5):542–7. terior approach [3]. On the other hand, Du et al. sug- 2. Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc gested that reconstruction of cervical lordosis and associated with traumatic subluxation or dislocation of cervical facets. 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Journal of Orthopaedic Surgery and ResearchSpringer Journals

Published: May 29, 2018

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