Recurrence of kyphotic deformity following implant removal in pediatric pure discoligamentous Chance-type injury: A case report.

Pediatric pure discoligamentous Chance-type injury is relatively rare and the appropriate surgical method has not yet been established, particularly, whether spinal fixation with fusion or without fusion is more effective. This case report describes a 10-year-old-boy who sustained an L2-3 pure discoligamentous Chance-type injury following a car accident and underwent an L2-3 posterior fixation without fusion. The implants were removed after eight months of an uneventful postoperative course. However, four months later, the kyphotic deformity recurred. Although the deformity gradually progressed over nine months, the patient remained neurologically intact and asymptomatic. This report suggests that fixation without fusion may not be appropriate in pediatric patients with pure discoligamentous Chance-type injuries. Spinal fixation with fusion may be recommended to prevent loss of correction and ensure secure stabilization.

Evaluation of subjective anterior disc space widening on trauma cervical spine CT as a potential sign of ligamentous injury.

INTRODUCTION: MRI is commonly accepted as the gold standard imaging technique for identification of isolated discoligamentous injury to the cervical spine. Widening of the anterior disc space (ADW) has been suggested as signs of injury to the anterior longitudinal ligament (ALL). The purpose of this study aimed to assess the accuracy of ADW reported on CT as a sign of ligamentous injury compared. METHODS: The study was performed at a level 1 trauma centre. All patients over a 5-year period from 1 January 2015 to 31 January 2019 who underwent a cervical CT scan for the indication of trauma and who subsequently received a cervical spine MRI during the same admission were included if no fracture was found on the initial CT. Demographic data were collected along with mechanism of injury and time period between CT and MRI. Presence or absence of subjective CT-ADW along with presence or absence of ALL injury on MRI was recorded by retrospective review of the radiology reports. Sensitivity, specificity and positive and negative predictive values were then calculated. RESULTS: Over a 5-year period, 1,305 patients fulfilled the study criteria. CT-ADW had a sensitivity, specificity and positive predictive value of 8.2% (95% CI: 2.7-18.1%), 96.2% (95% CI: 95.3-97.4%) and 10.2% (95% CI: 3.4-22.2%) respectively. CONCLUSION: Subjective CT-ADW is a poor predictor of ALL injury as assessed by MRI and should not be relied upon in isolation to diagnose ligamentous injury of the cervical spine in the setting of trauma.

Incidence of discoligamentous injuries in patients with acute central cord syndrome and underlying degenerative cervical spinal stenosis.

Introduction: Surgical treatment for CCS in patients with an underlying cervical stenosis without instability remains controversial. Research question: The aim was to assess the incidence of concomitant discoligamentous injury (DLI) in patients with CCS and underlying degenerative cervical spinal stenosis and to determine the sensitivity of MRI by comparing intraoperative site inspection to preoperative imaging findings. Material and methods: We performed a retrospective analysis of our clinical prospective database. Fifty-one patients (39 male, 12 female) between January 2010 and June 2019 were included. Age, sex, neurological deficits, preoperative MRI, and surgical treatment were recorded. Sensitivity was determined by the quotient of patients in whom all levels of DLI were correctly identified on MRI and the total number of patients with intraoperatively confirmed DLI. Results: Mean age at surgery was 64.1 â€‹± â€‹11.3 (range 41-86). DLI was suspected in 33 (62.1%) patients based on MRI findings, which could be confirmed intraoperatively in 29 patients (56.9%). In 2 patients, DLI was detected intraoperatively that was not suspected in preoperative MRI; in 5 patients, another level was affected intraoperatively than was indicated by MRI. The overall specificity and sensitivity of preoperative MRI imaging to identify discoligamentous lesions of the cervical spine was 73% and 79%, respectively. Discussion and conclusion: The incidence of DLI in patients with traumatic CCS based on preexisting spinal stenosis was 60.78%, which is higher than previously reported. The sensitivity of MRI imaging to detect DLI of 79% suggests that these patients are at risk of missing traumatic DLI on imaging.

Surgical Outcomes for C2 Tear Drop Fractures: Clinical Relevance to Hangman's Fracture and C2-3 Discoligamentous Injury.

OBJECTIVE: To analyze characteristics of surgically managed tear drop (TD) fractures of the C2 axis associated with other injuries such as hangman's fracture and C2-3 discoligamentous injury as well as treatment outcomes. METHODS: A total of 14 patients (eight men and six women) with TD fractures of the C2 , who were surgically treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017, were included in this retrospective study. The mean age of the patients was 45.5 years (ranging from 19 to 74 years). The characteristics, surgical treatment methods (anterior fusion vs posterior fusion), and results of 14 TD fractures of the C2 were analyzed retrospectively. And the clinical relevance between C2 TD fracture and hangman's fracture and C2-3 discoligamentous injury was investigated through the co-occurrence between injuries. The mean follow-up time after surgery was 22.6 months (ranging from 12 to 60 months). RESULTS: Among 14 patients with TD fracture of the C2 , four patients (28.6%) had anterior TD fracture and 10 patients (71.4%) had posterior TD fracture. All 10 posterior TD fracture patients had anterior C2-3 displacement. While two of four anterior TD fracture patients had posterior C2-3 displacement, the remaining two did not. All 14 patients of TD fracture had at least two or more other associated C2 injuries as well as C2-3 discoligamentous injuries. About 92.9% (13/14) of the patients had typical or atypical hangman's fracture; 100% (10/10) of the posterior TD fracture patients had hangman's fracture, but 75% (3/4) of the anterior TD fracture had hangman's fracture. At admission, 13 patients were neurologically intact. However, the remaining patient had spinal cord injury with American Spinal Injury Association (ASIA) impairment scale B with C2-3 bilateral facet dislocation. All four anterior TD fracture patients underwent posterior C2-3 fusion. While four of 10 posterior TD fracture patients underwent C2-3 anterior fusion, the remaining six underwent posterior fusion. At last follow-up, 100% (14/14) of the patients achieved solid fusion, and visual analog scale for neck pain was significantly improved (5.9 vs 2.2, P < 0.001). One patient with ASIA impairment scale B had significantly improved to scale D. No major complications occurred. CONCLUSION: Our study showed that surgically managed TD fractures of the C2 showed a high incidence of other associated spine injuries including hangman's fracture and C2-3 discoligamentous injury. Therefore, special attention and careful radiologic evaluation are needed to investigate the presence of other associated spine injuries including hangman's fracture and C2-3 discoligamentous injury, which are likely to require surgery.

Anterior C2-3 fusion surgery alone for highly displaced Hangman's fracture with severe angulation of C2-3 of more than 30°.

BACKGROUND: Highly displaced Hangman's fracture is a very rare and extremely unstable fracture of the C2 axis. Combined anteroposterior or posterior long-segment fusion surgery is typically performed for the treatment of highly displaced Hangman's fracture. However, these kinds of surgeries increase the risk of complications, loss of motion, and hospital costs. OBJECTIVE: We sought to investigate the surgical outcomes of anterior C2-3 fusion surgery alone for highly displaced Hangman's fractures with severe angulation of C2-3 by more than 30° and discoligamentous injury. METHODS: A total of five patients (four men and one woman) were included in this study with a mean age of 40.4 years (range, 26-70 years). The mean follow-up period after surgery was 37.2 months (range, 12-96 months). The fracture characteristics, treatment methods, and outcomes were retrospectively analyzed. RESULTS: All five patients had type II Hangman's fractures (according to the Levine and Edwards classification scheme). None of the included patients had neurologic deficit or other spine injury but all patients had complete C2-3 discoligamentous injury. Before surgery, all patients successfully achieved closed reduction by skull traction, followed by C2-3 anterior decompression and fusion (ACDF) with plating. For interbody grafting, three patients received a polyetheretherketone (PEEK) cage filled with an autogenous cancellous iliac bone graft and two received autogenous tricortical iliac bone grafts. Severe angulation (39.2° vs. 3.0°, P < 0.001) and severe displacement (76.1% vs. 4.0%, P < 0.001) of C2-3 were both significantly corrected after surgery. All patients had achieved solid fusion at last follow-up. In terms of clinical outcomes, the mean neck pain visual analog scale score was significantly improved (8.6 points vs. 1.8 points, P < 0.001). The mean neck disability index value was also significantly improved (45.4 points vs. 13.0 points, P < 0.01). According to Odom's criteria, all patients achieved satisfactory outcomes. No major complications occurred. One patient complained of dysphagia, but recovered after three months with conservative treatment. CONCLUSIONS: Preoperative closed reduction and anterior C2-3 fusion surgery alone should be considered as a less-invasive and useful surgical option for highly displaced Hangman's fracture with severe angulation of C2-3, which is an extremely unstable fracture of the C2 axis.

Anterior Cervical Reduction Decompression Fusion With Plating for Management of Traumatic Subaxial Cervical Spine Dislocations.

STUDY DESIGN: Prospective case series. OBJECTIVE: To evaluate the efficacy of anterior-only approach, for treatment of type C F4 (AO classification) traumatic subaxial cervical spine injuries. METHODS: Patients with type C F4 traumatic cervical injuries presenting to a tertiary center between June 2017 and July 2018 were included. Outcome measures included self-reported measures (Neck Disability Index, visual analogue scale, and return to work), radiological measures (local segmental angle, Ishihara curvature index, cervical lordosis angle, and step-off distance), fusion state, and neurological state according to American Spinal Injury Association (ASIA) Impairment Scale (AIS). RESULTS: Twenty-one cases were operated by anterior approach with mean age 39.1 ± 13.8 years. The most common injury was at C4-5 (47.6%). Six out of 7 cases (85.7%) with preoperative neurological impairment showed late follow-up improvement by one or more grade in AIS. Complete anatomical reduction and imaging measures did not correlate significantly to the self-reported outcome measures. Median value of local segmental angle improved from -16° (-11° to -20) preoperatively to 0° (-7°) to 8°) at late follow-up. The cervical lordotic angle and Ishihara curvature index improved from 35° (29° to 43°) and 6.92 (-2.7 to 28.9) preoperatively, to 44° (33° to 51°) and 18.7 (-3.5 to 26.9) at the late follow-up, respectively. Step-off distance decreased postoperatively, however; complete reduction could not be achieved. CONCLUSION: Surgical treatment of lower cervical traumatic instability by anterior decompression and fusion is efficient regarding fusion state and patients' satisfaction. The anterior approach can be recommended in cases with neurological impairment and in patients with medical comorbidities or when a short operative time-compared with combined approach-is preferred.

Spondylotic traumatic central cord syndrome: a hidden discoligamentous injury?

PURPOSE: To revisit the concept of spondylotic traumatic central cord syndrome (TCCS) by assessing the frequency of discoligamentous injury and to correlate magnetic resonance imaging (MRI) and intraoperative findings. METHODS: A retrospective analysis of twenty-three consecutive patients (mean age: 62.7 ± 14.8 years) with profound spondylotic TCCS after acute cervical hyperextension trauma but without signs of instability on initial CT scans who underwent anterior surgical decompression and fusion was performed. Sensitivity and specificity of MRI in the detection of anterior longitudinal ligament disruption were calculated. The topographic relations between surgically verified segmental instabilities and spinal cord signals on MRI were analyzed. The cervical MRI scans of all patients were evaluated by the radiologist on call at time of admission, re-assessed by a specialized MRI radiologist for the purpose of this study and compared with intraoperative findings. RESULTS: Intraoperative findings revealed 25 cervical spine segments with hyperextension instability in 22 of 23 (95.7%) patients. The radiologist on call correctly assessed segmental hyperextension instability in 15 of 25 segments (sensitivity: 0.60, specificity: 1.00), while the specialized MRI radiologist was correct in 22 segments (sensitivity: 0.88, specificity: 1.00). In 17 of 23 (73.9%) patients, the level of spinal cord signal on MRI matched the level of surgically verified segmental instability. CONCLUSIONS: Our findings challenge the traditional concept of spondylotic TCCS as an incomplete cervical spinal cord injury without discoligamentous injury and emphasize the importance of MRI as well as the radiologist's level of experience for the assessment of segmental instability in these patients. These slides can be retrieved under Electronic Supplementary Material.

[Trauma of the lumbar spine and the thoracolumbar junction]. / Trauma der Lendenwirbelsäule und des thorakolumbalen Übergangs.

CLINICAL/METHODICAL ISSUE: Patients who have experienced high energy trauma have a particularly high risk of suffering from fractures of the thoracic and lumbar spine. The detection of spinal injuries and the correct classification of fractures before surgery are not only absolute requirements for the implementation of appropriate surgical treatment but they are also decisive for the choice of surgical procedure. STANDARD RADIOLOGICAL METHODS: By the application of spiral computed tomography (CT) crucial additional information on the morphology of the fracture can be gained in order to estimate the fracture type and possibly the indications for specific surgical treatment options. Magnetic resonance imaging (MRI) is ideally suited to provide valuable additional information regarding injuries to the discoligamentous structures of the spine. PERFORMANCE: Magerl et al. developed a comprehensive classification especially for injuries of the thoracic and lumbar spine, which was adopted by the working group for osteosynthesis (AO). This is based on a 2­pillar model of the spinal column. The classification is based on the pathomorphological characteristics of fractures recognizable by imaging. The injury pattern is of particular importance. ACHIEVEMENTS: In spinal trauma a distinction is made between stable and unstable fractures. The treatment of spinal injuries depends on the severity of the overall injury pattern. PRACTICAL RECOMMENDATIONS: Besides adequate initial treatment at the scene, a trauma CT should be immediately carried out in order that no injuries are overlooked and to ensure a rapid decision on the treatment procedure.