Management of delayed posttraumatic cervical kyphosis

We describe three patients with misdiagnosed unstable fractures of the cervical spine, who were treated conservatively and developed kyphotic deformity, myelopathy, and radiculopathy. All three patients were then managed with closed reductions by crown halo traction, followed by instrumented fusions. Their neurologic function was regained without permanent disability in any patient. Unstable fractures of the cervical spine will progress to catastrophic neurologic injuries without surgical fixation. Posttraumatic kyphosis and the delayed reduction of partially healed fracture dislocations by preoperative traction are not well characterized in the subaxial cervical spine. The complete evaluation of any subaxial cervical spine fracture requires CT scanning to assess for bony fractures, and MRI to assess for ligamentous injury. This allows for assessment of the degree of instability and appropriate management. In patients with delayed posttraumatic cervical kyphosis, preoperative closed reduction provided adequate realignment, facilitating subsequent operative stabilization.     

Early mobilisation of patients with cervical cord injury using the halo brace device

The halo brace device for cervical spine stabilisation has been in use predominantly in North America since 1959. It has not yet found widespread use for the management of the spinal cord injured in the UK. At the Yorkshire Regional Spinal Injuries Unit we have used the device over 2 years on 20 patients with complete and incomplete traumatic cervical spinal cord injuries, and compared our results with those for the previous 20 patients with similar injuries treated with skull calipers and bed rest. Patients using a halo brace device begin more active rehabilitation earlier as they are mobilised on average 5 weeks earlier than those whose traction is administered via skull calipers. Halo brace patients begin weekend leave usually within 7 weeks of their injury compared to 14 weeks post-injury for caliper treated patients and were discharged on average 2 months earlier than the comparison group. We believe that earlier mobilisation, weekend leave and discharge for halo brace patients in the absence of any neurological deterioration afford significant physical, psychological and management benefits.     

Occult occipital condyle fracture with normal neurological function and torticollis

Occipital condyle fracture is a rare and easily neglected fracture. We describe a case of type III fracture with torticollis and normal neurological function. A young woman who had experienced a head injury was suffering from neck pain. Torticollis developed several days later and a CT scan of the cervical spine revealed a type III left occipital condyle fracture. She had no neurological deficits. External cervical traction and 3 months of halo vest immobilization were applied. A follow-up CT scan showed good healing and re-attachment of the bony fragment. The patient recovered well without adverse sequelae. We conclude that physicians should be alert to the possibility of occipital condyle fracture in trauma patients.     

Lateral C1–C2 dislocation complicating a type II odontoid fracture

We describe a unique C1–C2 lateral dislocation complicating a displaced type II odontoid fracture. We report a 63-year-old female pedestrian involved in a motor vehicle accident who required posterior open reduction and segmental C1–C2 instrumentation and fusion. Radiological examination of the cervical spine demonstrated a lateral dislocation of the atlantoaxial joint with a displaced type II fracture of the odontoid, fracture of the right lateral mass of C1 and left superior articular facet of C2. Neurological examination revealed the patient to be myelopathic and closed halo traction failed to achieve reduction. Due to the irreducible nature of the dislocation, posterior open reduction and segmental C1–C2 instrumentation and fusion was performed. The dislocated C1–C2 articulation was successfully reduced surgically with subsequent bony fusion and resolution of all neurological symptoms and signs at final follow-up. To our knowledge, this the first report of this type of injury. We also review the related literature on this unique injury pattern.     

Intradural extramedullary tumor of lower spinal cord in a 89-year-old man with cervical spondylosis and lumbar spondylolisthesis

A 89-year-old man was admitted because of slowly progressive gait disturbance during these several years. Neurological examination revealed paraparesis with bilateral sensory disturbance in the lower extremities, more severely on the left side. Vibration sense was almost completely disturbed under the level of bilateral crista iliaca. Deep tendon reflexes decreased in the lower extremities. No urinary incontinence was observed. The narrow spinal canal and cervical spondylosis were seen at the C 5-6 level, showing the anterior-posterior distance of 10 mm. Computed tomography of the lumbar spine showed spondylolisthesis between the level 4 and 5. CSF showed high protein concentration (300 mg/dl), whereas normal cell counts. These findings suggested the following two possibilities; cervical myelopathy associated with the disturbance of the cauda equina due to lumbar spondylolisthesis, or the disturbance at the lower thoracic or upper lumbar level of spinal cord. The spinal MRI revealed the irregular mass lesion in the lower spinal cord at the level of spine Th 11-12 on T2 weighted images, with enhancement by Gd-DTPA on T1 weighted images. These MRI findings suggested the intradural extramedullary tumor, such as benign neurinoma or meningioma. No clear cut lesions were found at the cervical spinal cord or at the cauda equina. MRI was useful for the diagnosis of sites and lesions of spinal cord in the present case, whose neurological signs and symptoms could be explained by the coexistent cervical spondylosis and lumbar spondylolisthesis.     

Pathological studies and pathological principles on the management of extension injuries of the cervical spine

Extension injury to the arthritic spine of elderly individuals involves rupture of the anterior longitudinal ligaments and disks at several levels, but no bony injury can be observed on X-ray. There are many small focal haemorrhages in the central portion of the spinal cord and the injury is often accompanied by incomplete paresis. As the injury is a stable injury with the posterior ligament complex being intact, it is only necessary to immobilise the cervical spine conservatively. Laminectomy is not indicated. In hyperextension injury of the rigid cervical spine and in momentary posterior dislocation observed in middle aged individuals, rupture of the anterior longitudinal ligament and disk is observed at a single site, but being spontaneously reduced, traumatic findings cannot be observed on X-ray. The spinal cord is crushed at the site of injury to bring about severe neural damage. When this type of injury is diagnosed or suspected, further damage may be inflicted on the spinal cord if skull traction is made with calipers in the extended position and the condition at the time of injury is reproduced. Therefore, the patient should be nursed in a shell or between sandbags in a neutral position or even in a position of slight flexion. In extension fracture dislocation with compression which resembles on X-ray a flexion injury, all of the three columns of the spine are destroyed to bring about an extremely unstable condition. As the spinal cord is extensively injured to involve several segments, decompression surgery for relief of neuroparalysis should not be performed when complete paralysis develops simultaneously with fracture dislocation. Therefore, it should be first treated conservatively with skull traction, and in cases where stability cannot be restored, surgical fixation of the spine should be performed.     

Is juvenile spinal muscular atrophy of the distal upper limbs due to cervical flexion myelopathy? A case report

A 22-year-old woman developed a slowly progressive symmetric weakness and muscular atrophy of distal upper limbs at the age of 17. Radiography during anteflexion and retroflexion showed a hypermobile cervical spine with a maximum at the C5/6 disc level. Cervical myelography and postmyelographic computed tomography (CT) of the lower cervical spine demonstrated a remarkable anterior shift of the dural sac during anteflexion resulting in anteroposterior compression of the lower spinal cord. Postmyelographic CT and magnetic resonance imaging (MRI) revealed atrophy of the lower spinal cord with bilateral cystic lesions. We suppose that repetitive straining and compression of the lower cervical cord during neck flexion of the hypermobile cervical spine caused selective necrosis of anterior horn cells with secondary cystic transformation. Mechanically induced flexion myelopathy should be considered in all young patients presenting with muscular atrophy of the distal upper limb. Functional CT myelography or dynamic MRI of the cervical spine are appropriate to demonstrate lower spinal cord compression during flexion.     

Hybrid lateral mass screw sublaminar wire construct: A salvage technique for posterior cervical fixation in pediatric spine surgery

We present a novel salvage technique for pediatric subaxial cervical spine fusion in which lateral mass screw fixation was not possible due to anatomic constraints. The case presentation details a 4-year-old patient with C5–C6 flexion/distraction injury with bilateral jumped facets. Posterior cervical fixation was attempted; however, lateral mass fracture occurred during placement of screws. Using a wire-screw construct, an attempt was made to provide stable fixation. The patient was followed post-operatively for assessment of outcomes. After the patient had progressive kyphosis following initial closed reduction and external orthosis, internal reduction with fusion/fixation was performed. Lateral mass fracture occurred during placement of lateral mass screws. After placement of a sub-laminar wire-lateral mass screw construct, intra-operative evaluation determined stability. Post-operatively, the procedure resulted in stable fixation with evidence of bony fusion on follow-up. Pediatric subaxial cervical spine instrumentation provides rigid fixation however is technically difficult due to anatomic and instrumentation related constraints. In the presented patient, the wire-screw construct resulted in stable fixation and bony fusion on follow-up. A modified sublaminar wire-lateral mass screw construct is an example of a salvage technique that provides immediate stability in the event of instrumentation related lateral mass fracture.     

The Surgical Management of Traumatic C6-C7 Spondyloptosis

A case of traumatic spondyloptosis of the cervical spine at the C6-C7 level is reported. The patient was treated succesfully with a anterior-posterior combined approach and decompression. The patient had good neurological outcome after surgery. A-51-year-old female patient was transported to our hospital''s emergency department after a vehicle accident. The patient was quadriparetic (Asia D, MRC power 4/5) with severe neck pain. Plain radiographs, computerize tomography and spinal magnetic resonance imaging (MRI) showed C6-7 spondyloptosis and C5, C6 posterior element fractures. Gardner-Wells skeleton traction was applied. Spinal alignment was reachived by traction and dislocation was decreased to a grade 1 spondylolisthesis. Then the patient was firstly operated by anterior approach. Anterior stabilization and fusion was firstly achieved. Seven days after first operation the patient was operated by a posterior approach. The posterior stabilization and fusion was achieved. Postoperative lateral X-rays and three-dimensional computed tomography showed the physiological realignment and the correct screw placements. The patient''s quadriparesis was improved significantly. Subaxial cervical spondyloptosis is a relatively rare clinical entity. In this report we present a summary of the clinical presentation, the surgical technique and outcome of this rarely seen spinal disorder.     

Pattern,management and outcome of cervical spine injuries associated with head injuries in paediatric patients

Introduction This study examines the management and outcome of cervical spine injuries in children with head injuries, to assess the need for surgical treatment. Material and methods We performed a retrospective analysis (1995–2005) of 445 children admitted intubated and ventilated to the intensive care unit with head injuries. Outcome measures: Frankel grade for spinal injuries and Glasgow Outcome Scale (GOS) for head injuries. Results Cervical spine injuries were detected in 11 patients (incidence 2.5%, mean age: 6.3 years, range: 21 months–15 years). The injuries were: C1/2 distraction: 2; C1/2 subluxation: 2; odontoid peg fracture with C1/2 dislocation and cord transection: 1; disruption of posterior longitudinal ligament at C2: 1; odontoid peg fracture with C2/3 distraction: 1; C2/3 subluxation: 1; C3 lamina fracture: 1; C3/4 facet fracture: 1; C6/7 fracture dislocation with cord transection: 1. One patient was managed operatively, ten patients nonoperatively, two with halo vests and eight with hard collars. There were three deaths (mortality 27%) associated with severe head injuries. At 6 months follow-up, two patients remained quadriplegic (Frankel Grade A), one of them ventilator dependent, one had residual motor function but of no practical use (Frankel Grade C), five had good spinal outcome (Frankel Grade E). Seven patients had good head injury outcomes (GOS 5), one remained disabled (GOS 3). Conclusion Most children with cervical injury can be managed nonoperatively with good outcomes. Surgical management may be necessary in severe unstable injuries.     

Compressive hyperextension injury of C2-C3 managed with anterior plate fixation: case report

We report a C2 tear-drop fracture of a 69-year-old patient which occurred after a fall. Although tear drop fractures of the subaxial cervical spine mostly develop due to a flexion type injury, the mechanism is often compressive hyperextension injury at the C2 vertebra. Rigid external stabilization and internal fixation are the treatment alternatives. Internal fixation may be performed using the posterior or anterior approach. This paper describes a C2 tear drop fracture which was treated with an anterior plate fixation.     

Assessment of cervical range of motion in patients after axis fracture

Background

Surgical treatment of odontoid fractures with posterior C1/C2 fusion always leads to severe limitations in mobility of the cervical spine and head.

Cervical spine injuries: a follow-up of 332 patients

A follow-up of 332 consecutive cervical spine injury patients is described. Treatment was with collars (47%), operation (6%), skull traction (24%) and Halo vest (23%). There was a large number of cervical spine injuries at the C2 level, and odontoid process fractures constituted 35% of all cervical spine injuries. The bad reputation of cervical spine injuries with high mortality rates, high non-union rates, and a high incidence of severe neurological impairment could not be confirmed. Traffic accidents affected the younger age categories, and injuries from falls the older ages. The accidents occurred in 95% during leisure, and at least 22% of the patients were under the influence of drugs and/or alcohol. Halo vest treatment gave a low complication rate, a low use of hospital bed days, sick leave and disability pension, compared with operations and skull traction treatment. The complication rate associated with the skull traction and operative treatment was unacceptably high.     

人工颈椎间盘置换对下颈椎活动影响的三维有限元分析

建立人工椎间盘置入后下颈椎C3~7的三维模型,分析颈椎人工椎间盘置换后下颈椎运动情况。根据1例人工椎间盘置入患者术后6个月CT片,应用有限元方法建立其包含BryanTM人工颈椎间盘假体的下颈椎三维有限元模型,导入Ansys 9.0中,对椎体皮质骨、松质骨、椎间盘用三维十节点四面体结构实体单元进行网格划分后进行分析。对模型加载2 N•m的力矩,观察其在前屈/后伸、侧屈及旋转几种状态下的运动情况,了解其运动特性。通过与以往的研究结果比较,试验结果基本符合或趋势基本一致。结果提示,颈椎间盘置换后能基本保证下颈椎运动稳定性。     

A case of Hirayama disease

We report a male patient with Hirayama disease aged 13. The disease was insidiously progressive and he had severe disability of the right hand at presentation. He had muscular atrophy in the intrinsic muscles of the right hand and in the distal muscles of the right forearm. The atrophy was pronounced on the ulnar side. Cold paresis was also noticed. There was no sensory disturbance. On Electromyography, neurogenic changes were recorded in several atrophic muscles. Motor and sensory nerve conduction was normal. MR images of the spinal cord were normal when it was performed with a conventional method (i.e., without neck flexion). However, characteristic MR findings were obtained when the patient lay with maximum neck flexion. The posterior wall of the cervical dural canal was shifted anteriorly at the C3-7 vertebral level, which caused cord compression at the lower cervical spinal canal. The epidural space was crescent-shaped and showed high signal intensity on T2-weighted imaging. These clinical features are typical of Hirayama disease. Pediatrician should be aware of this disease and treat it as soon as possible in order to prevent progression of the atrophy.     

Cervical vertebral body fracture with ankylosing spondylitis treated with cervical pedicle screw: A fracture body overlapping reduction technique

We describe a patient with ankylosing spondylitis (AS) with cervical spinal fracture treated with cervical pedicle screw placement (CPS) through a single posterior approach.A 43-year-old male patient with AS visited our emergency centre due to paralysis following a trauma. Coronal reconstructed cervical spine computed tomography (CT) scan showed a C5 oblique fracture, and the bilateral pedicles were separated superiorly and inferiorly. The sagittal reconstructed CT image revealed bamboo spine and C5 vertebrae body fracture. Hyperextension between the fractured segments of the C5 body was noted because the fracture gap was anteriorly open. Magnetic resonance imaging (MRI) showed cord compression and injury at the C4–5 level.CPS was performed at the C3–6 levels. Because the left and right pedicles were displaced superiorly and inferiorly, dual compressions between the left C5 and left C6 pedicle screws and between the right C5 and right C4 pedicle screws were performed. Decompression at the C4 and C5 levels was performed after identifying good alignment. This posterior fusion surgery was performed for two hours. After surgery, the radiograph showed complete reduction and fracture gap apposition. The patient was rehabilitated, and his muscle strength improved. Postoperative CT and X-rays revealed complete fracture site fusion and correct CPS position.Considering increased morbidity of long-level or -duration surgery, our fracture body overlapping technique using CPS and posterior only approach seems to be a possible and good surgical method in traumatic cervical fracture with AS.     

MRI findings in Hirayama’s disease: flexion-induced cervical myelopathy or intrinsic motor neuron disease?

Hirayama’s disease is a benign juvenile form of focal amyotrophy affecting the upper limbs. Previous studies have suggested that the disorder is a neck flexion induced cervical myelopathy. We report clinical and magnetic resonance imaging findings in nine patients with Hirayama’s disease. Cervical imaging of seven patients revealed spinal cord changes consisting of focal atrophy and foci of signal alterations. On neck flexion a forward movement and mild reduction in the anteroposterior diameter of the lower cervical cord against the vertebral bodies was noted in affected individuals as well as in five normal controls. In contrast to earlier reports, none of our patients showed complete obliteration of the posterior subarachnoid space. Measurement of the anteroposterior spinal cord diameter in each vertebral segment (C4–C7) revealed no significant differences in the degree of spinal cord flattening between the two groups. Furthermore, two of our patients had significant degenerative changes in the cervical spine (disc herniation, retrospondylosis) contralateral to the clinically affected side. These degenerative changes resulted in a marked cord compression on neck flexion but were not associated with ipsilateral clinical abnormalities or spinal cord alterations. Our results argue against a flexion-induced cervical myelopathy and support the view that Hirayama’s disease is an intrinsic motor neuron disease. Received: 15 March 1999 Received in revised form: 25 May 1999 Accepted: 1 June 1999     

Cervical spinal cord injury without radiological abnormality in adults

Spinal cord injury occurring without concomitant radiologically demonstrable trauma to the skeletal elements of the spinal canal rim, or compromise of the spinal canal rim without fracture, is a rare event. Though documented in children, the injury is not very well reported in adults. We present seventeen adult patients with spinal cord injury without accompanying fracture of the spinal canal rim, or vertebral dislocation, seen over seven years. None had preexisting spinal canal stenosis or cervical spondylosis. Following trauma, these patients had weakness of all four limbs. They were evaluated by MRI (CT scan in one patient), which showed hypo / isointense lesion in the cord on T1 weighted images, and hyperintensity on T2 weighted images, suggesting cord contusion or oedema. MRI was normal in two patients. With conservative management, fifteen patients showed neurological improvement, one remained quadriplegic and one died. With increasing use of MRI in the evaluation of traumatic myelopathy, such injuries will be diagnosed more often. The mechanism of injury is probably acute stretching of the cord as in flexion and torsional strain. Management is essentially conservative and prognosis is better than that seen in patients with fracture or dislocation of cervical spine.     

Surgical approach in treatment of translation/rotation injuries of the lower cervical spine in 21 patients

BackgroundThe management of lower cervical spine injuries with a dislocation of one or both facet joints and a displacement of a vertebra over the adjacent stills generates considerable controversy. We describe our experience in surgical approach of these injuries.MethodsWe present 21 cases treated between 2003-2010. Neurological status was evaluated with Frankel scale. Diagnosis was done by radiograph (XR), computed tomography (CT) and/or magnetic resonance image (MRI). Cervical traction was placed in 10 cases before surgery. Posterior and/or anterior approach was used for reduction and stabilization.ResultsThe 21 cases presented were treated by surgery. Posterior approach was initially used in 17 cases and complete reduction was achieved in 13 of them. The 4 cases where we only got a partial reduction, surgery had to be delayed for different reasons. Anterior approach was initially used in 4 of the 21 cases. In 3 of them, reduction was previously obtained by traction and the fourth case anterior approach was used initially due to an important spinal cord compression. Permanent stabilization was achieved in 19 of the 21 cases. In 1 of the other 2 cases an important deformity was detected after the anterior approach. The other case had a minimal progression after a posterior approach with no increase in successive check-ups. In the first 10 cases, we used traction before surgery but reduction was achieved only in 3 of them. As the number of cases increased we rather used posterior approach in the first place, without even trying a preoperative traction. There was no case of neurological deterioration after surgery.ConclusionTranslation/rotation injuries of the lower cervical spine are unstable and surgical treatment must be indicated. It is our impression that posterior approach allows a better reduction and stabilization of this injuries and should be used initially without even trying a preoperative traction.     

Laminectomy and fusion in multilevel degenerative cervical myelopathy – Correlation between objective and subjective postoperative restriction of cervical spine mobility

For patients with multilevel degenerative cervical myelopathy (DCM), laminectomy and fusion is an established technique. A concomitant effect of multilevel fusion is a restriction of cervical spine mobility. This retrospective study on DCM-patients with at least 4 laminectomy and fusion levels, compares data between objective and subjective restriction of the postoperative cervical spine mobility. The patient-reported restriction of cervical spine mobility was acquired by a five-step score. Measurements of cervical range of motion were performed using the CROM device and were correlated with the subjective scores. Fusion was performed over 6 levels in most of the 36 patients. For the subjective cervical spine mobility, 52.8% reported none to medium, 38.9% severe and 8.3% complete restriction. Mean objective cervical range of motion was 45.0° for flexion-extension, 26.3° for total lateral flexion and 51.4° for total rotation and therefore evidently reduced compared to non-operated patient cohorts in literature. There was a significant medium, negative correlation between the objective measurements and the patient-reported general restriction of cervical spine mobility, and with the physical component summary of SF-8. The significant objective reduction of cervical range of motion after laminectomy and multilevel fusion correlates with the patient-reported assessment for general restriction.