Posterior approach for cervical fracture–dislocations with traumatic disc herniation

Abstract

In the treatment algorithm for cervical spine fracture-dislocations, the recommended approach for treatment if there is a disc fragment in the canal is the anterior approach. The posterior approach is not common because of the disadvantage of potential neurological deterioration during reduction in traumatic cervical herniation patients. However, reports about the frequency of this deterioration and the behavior of disc fragments after reduction are scarce. Forty patients with traumatic disc herniation were observed. They represented 29.2% of 137 consecutive patients with subaxial cervical spine fracturedislocations. Surgical planning was performed according to our two-stage algorithm. In the first stage, they were treated with posterior open reduction and posterior spine arthrodesis. In the second stage, anterior surgery was added for cases where neurological deterioration attributed to nonreduced disc fragments on postoperative magnetic resonance imaging (MRI). Neurological deterioration after posterior open reduction was not observed. Furthermore, 25% of total cases and 75% of incomplete paralysis cases improved postoperatively by C1 grade in the American Spinal Injury Association impairment scale. Reduction or reversal of disc herniation was observed in all cases undergoing postoperative MRI. For local sagittal alignment, preoperative 9.4°kyphosis was corrected to 6.9°l ordosis postoperatively. The disc height ratio was 72.4% preoperatively and 106.3% postoperatively. The second stage of our plan was not required after the posterior approach in this series. The incidence of neurological deterioration after posterior open reduction was zero, even in cases with traumatic cervical disc herniation. Favorable clinical and radiological outcomes could be obtained by the first stage alone. Although preparations for prompt anterior surgery should always be made to cover any contingency, the need for them is minimal.

Surgical treatment of traumatic cervical facet dislocation: anterior, posterior or combined approaches?

“…An anterior cervical approach is recommended for a disc herniation in patients without a complete neurological deficit as it allows direct decompression, avoiding neurological deterioration with an eventual indirect decompression achieved with a posterior laminectomy 1,15,24 . In the past, this was an absolute indication for an anterior approach, but Nakashima et al reported a series of 40 patients with traumatic cervical herniation treated by a posterior approach without need of anterior cervical surgery, suggesting that the risk of neurological deterioration may be less than reported previously (Level of Evidence: III) 23 .…”

“…23 Anterior approaches have the advantages of supine position, less surgical trauma, and direct anterior decompression of neural elements, such as a disk herniation or an anterior located bone fragment (Level of Evidence: III) 23 . Kwon et al reported that patients treated with anterior cervical discectomy and fusion (ACDF) for unilateral facet fracture-dislocation had slightly less pain in the postoperative period, a lower rate of wound infection, a higher rate of radiological bone union, with a better cervical alignment compared with those treated with a posterior approach (Level of Evidence: II) 9 .…”

“…Postoperative dysphagia is related to manipulation and retraction of the esophagus during cervical procedures. 23 Therefore, procedures with extended dissection, longer duration of surgery, multilevel spinal fusion, and postoperative pre-vertebral thickness, increase the risk of postoperative dysphagia 23 . This may be due to intraluminar esophageal pressure and esophageal mucosal ischemia 23 .…”

“…23 Therefore, procedures with extended dissection, longer duration of surgery, multilevel spinal fusion, and postoperative pre-vertebral thickness, increase the risk of postoperative dysphagia 23 . This may be due to intraluminar esophageal pressure and esophageal mucosal ischemia 23 . Dysphagia has also been considered to be caused by the plate prominence and thickness 23 .…”

“…This may be due to intraluminar esophageal pressure and esophageal mucosal ischemia 23 . Dysphagia has also been considered to be caused by the plate prominence and thickness 23 . Some other factors that may result in swallowing dysfunction after cervical spine surgery are pain, muscle spasm and immobilization in a cervical collar.…”