RESEARCH ARTICLE
Anterior cervical approach for decompression and
fusion in middle and lower traumatic cervical
fractures
Rizzi G.*, Berardi A., Bozzini V., Merlicco G.
Department of Neurosurgery, University Hospital, Foggia, Apulia, Italy
*Corresponding author: Gaetano Rizzi, email: gaetanorizzi6@gmail.com
Abstract:
Objectives: The aim of this report is to establish the efficacy of anterior cervical
decompression fusion (ACDF) in patients with traumatic lesions of the middle
and lower segments of the cervical spine. The goals of surgical treatment are:
maintenance of neurological function, prevention of additional functional loss
and restoration of spinal stability with bony fusion
Materials and methods: Between 2007 and 2014, a total of 35 patients (27 male
and 8 female) with a mean age of 48 (aged between 18 and 78 years) with trauma
to the middle and lower cervical spine were treated in our clinic.
The operative levels were C3-C4 in 3 patients, C4-C5 in 7 patients, C5-C6 in
15 patients, C6-C7 in 9 patients and C7-D1 in 1 patient. The preoperative degree
of neurological deficit was evaluated with Frankel scale. According to the Frankel
scale, 4 (11.4%) patients were grade A; 6 ( 17.1%) were grade B, 5 (14.3%) were
grade C, 8 (23%) were grade D and 12 (34.2%) patients were grade E. The
average preoperative VAS was 8.
The majority (30 of 35 patients) were investigated with MRI scan. All patients
underwent ACDF using a Peek cervical cage and titanium plate fixation, and in
11 cases the operation was performed after application of cervical traction. The
follow-up period ranged from 12 to 24 months with clinical and radiological
evaluation.
Open Access Article
Citation: Rizzi G., Berardi A., Bozzini V.,
Merlicco G. (2016) Anterior cervical
approach for decompression and fusion in
middle and lower traumatic cervical
fractures. ESR Journal 1(1):[link]
Academic Editor: Martin Pesl, Masaryk
University, Czech Republic
Received: 12th December 2015
Accepted: 24th February 2016
Published: 30th March 2016
Results: After the ACDF, 4 (11.4%) patients with complete lesion cord remained
unchanged; 4 (11.4%) were grade B, 3 (8.6%) were grade C, 10 (28.6%) were grade
D and 14 (40%) patients were grade E. Of patients with E grades, 5/14(36%) had
isolated radiculopathies; 3/5(60%) patients recovered totally and the
neurologically intact patients remained unchanged. The mean postoperative VAS
at the latest follow-up was 2. The follow-up showed good clinical and
radiological outcome and body fusion. For 32 patients, the follow-up was at 24
months. In this group, fusion occurred in 31/32 patients (97%) (Fig 2-4). No
wound complications or infection were present.
Copyright: © 2016 This is an open
access article under the terms of the
Creative Commons Attribution License,
which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original author and
source are credited.
Data Availability Statement:
Funding: The author(s) received no
specific funding for this work
Conclusion: Our study shows that ACDF with fusion and titanium plate fixation
can be considered a safe and effective technique to restore the stability of
traumatic lesion of middle and lower cervical spine.
Competing Interests: The authors have
declared that no competing interests
exists.
ESR Journal [link] 30th March 2016 Keywords: ACDF, Peek Cage, Cervical spine lesions
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Anterior cervical approach for decompression and fusion in middle and lower traumatic cervical fractures
Introduction
The anterior approach to cervical decompression was first described by
Cloward(2) and Robinson and Smith(9) in the 1950s. Both described an anterior
approach via a longitudinal incision along the anterior border of the
sternocleidomastoid muscle to allow for soft tissue dissection and annular incision.
Following discectomy and removal of any compressive structures, fusion was then
achieved using an autogenous graft.
The most important developments in anterior cervical surgery are related to
the introduction of anterior cervical instrumentation with technologies that have
evolved steadily over the last 40-50 years. In 1960, Bailey and Badgley expanded
the usage of ACDF to treat neoplasm and instability(3). The anterior cervical
plates were developed by Declos and Tapies in 1970, and they were the first to be
used in an unstable cervical lesion induced by a trauma(21). The plates and
screws system was subsequently improved by the studies of Caspar who
developed a system of trapezoidal anterior stabilization that improved the fusion
after the trauma(6).
The apposition of a plate, in theory, determines an immediate stabilization,
prevents the extrusion of the graft and reduces the necessity of an additional
cervical external stabilization to the surgical procedure. Furthermore, an anterior
stabilization with plates helps to reconstitute the sagittal alignment of the
cervical spine and prevents the collapse of the graft and its expulsion. The
purpose of this study is to analyze the results in terms of neurological outcome,
fusion rates, symptomatic adjacent–segment disease, complications following
ACDF with cage in Peek, and use of titanium plate fixation with bi-cortical
screws in treatment of traumatic lesions of the middle and lower cervical spine.
Materials and methods
Between 2007 and 2014, a total of 35 patients (27 male and 8 female) with a
mean age of 48 (aged between 18 and 78 years) with trauma to the middle and
lower cervical spine were treated in our clinic. The cause of the trauma was due
to a road accident in 20 patients, a fall from a height in 10 patients and a dive in
water in 5 patients. The operative levels were C3-C4 in 3 patients, C4-C5 in 7
patients (Fig. 1), C5-C6 in 15 patients, C6-C7 in 9 patients (Fig. 3) and C7-D1 in
1 patient.
The AO classification showed type A injury in 24 patients, type B in 7
patients and type C in 4 patients.
Type-A injuries
Failure under axial compression of the anterior
elements with intact posterior constraining elements
Type-B injuries
Failure of the posterior constraining elements
Type-C injuries
Failure of anterior and posterior elements leading to
displacement
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Anterior cervical approach for decompression and fusion in middle and lower traumatic cervical fractures
The preoperative and postoperative degree of neurological deficit was
evaluated with the VAS and Frankel scales. All patients had severe pain at the
site of lesion and the preoperative VAS was 8.According to the Frankel scale, 4
patients were grade A, 6 were grade B, 5 were grade C, 8 were grade D and 12
patients were grade E (Table 1).
Table 1: The Frankel scale for spinal cord Injury that classifies the extent of the
neurological/functional deficit into five grades
Frankel scale
A
Complete
No motor or sensory function
Preoperative neurological
Postoperative neurological
status
status
4(11.4%)
4(11.4%)
6(17.1%)
4(11.4%)
5(14.3%)
3(8.6%)
8(23%)
10(28.6%)
12(34.2%)
14(40%)
below level of lesion
B
Sensory
No motor function, but some
only
sensation preserved below level
lesion
C
D
E
Motor
Some motor function without
useless
practical application
Motor
Useful motor function below level
useful
of lesion
Recovery
Normal motor and sensory
function, may have reflex
abnormalities
The majority (30 of 35 patients) underwent an MRI scan. All patients underwent
ACDF using a Peek cervical cage and titanium plate fixation. In 11 cases, the
operation was performed after application of cervical traction. The follow-up
period ranged from 12 to 24 months with clinical and radiological evaluation.
Results
After the ACDF, 4 (11.4%) patients with complete lesion cord remained
unchanged; 4 (11.4%) were grade B, 3 (8.6%) were grade C, 10 (28.6%) were
grade D and 14 (40%) patients were grade E. Of patients with E grades, 5/14
(36%) had isolated radiculopathies, 3/5 (60%) recovered totally, and the
neurologically intact patients remained unchanged. The mean postoperative VAS
at the latest follow-up was 2. The length of post-operative hospital stay was three
days for patients in D/ E grade of the Frankel scale and two or three weeks for
other patients. All patients received a Philadelphia collar for thirty days.
Radiographic outcomes with respect to segmental stability were excellent.
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Anterior cervical approach for decompression and fusion in middle and lower traumatic cervical fractures
For 32 patients, the follow-up was at 24 months. In this group, fusion
occurred in 31/32 patients (97%) (Fig 2-4). Three patients were not included due
to a too short follow-up period. There were no wound complications. One patient
had a transitory dysphagia. At the latest follow-up we found no cases of screw
breakage.
Discussion
Cervical spine injury is the most frequent problem in young adults with a
male predominance. The goals of surgical treatment are: maintenance of
neurological function, prevention of additional functional loss and restoration of
spinal stability with bony fusion. Road accidents are the most frequent cause of
spinal cord lesions(20), and in our study road accidents were the cause of trauma
in 20 patients.
The rationale for the use of screw-plate system is that patients who receive
these implants may require shorter hospitalizations and may return to normal
socio-econominal activities earlier than those undergoing cervical fusion
procedures without plating.
The appropriate selection of position and length of the screws is important.
In our procedures we used bi-cortical screws, although several issues stressed the
concept of damage to the spinal cord with the use of bi-cortical screws(7-19). No
spinal cord injury was present in our study.
We had a good restoration of spinal alignment and adequate stabilization
during the follow-up period. The risk related to screw-plate stabilization of
cervical spine includes all of those associated with an anterior cervical
discectomy: injury to branches of the vagus nerve, dysphagia, radicular or
myelopathic injury, cerebrospinal leakage, anterior or posterior migration of cage,
screws and plate fracture, post-operative hematoma, tracheoesophageal lesions,
vascular injuries and infection. Oesophageal injuries are rare, but have dreaded
complications. Injury to the recurrent laryngeal nerve is considered the most
common neurological complication after anterior cervical spine surgery, and the
incidence varies between 0.2 and 11%(5-15). In anterior cervical discectomy and
fusion (ACDF), Flynn reported an incidence of 0.05% of postoperative spinal cord
injury(11).
The placement of a bone graft is a potential trauma to the spinal cord. The
depth of the bone graft should be less than that of the vertebral body.
Autologous bone graft has been used in cervical anterior procedures for more
than 50 years.
A frequently reported complication of autologous grafting from the iliac crest
is post-operative pain at the donor site reported in about 22%. Other
complications include wound infection, hematoma, pelvic fracture and nerve palsy
at the donor site region. A valid alternative to avoid this morbility is represented
by use of allografts, but their use is too expensive. For all these reasons in recent
years there has been an increase in the use of cages of different materials.
The incidence of nerve root palsy has been estimated to be 0.17%(11).
Ventral decompressive procedures have reported rates of radiculopathy from 2 to
15% caused from symptomatic adjacent–segment disease(22). Hilibrand et al.
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Anterior cervical approach for decompression and fusion in middle and lower traumatic cervical fractures
followed, in a consecutive series for twenty years, 374 patients who had a total of
409 anterior cervical arthrodesis for the treatment of cervical spondylosis and
report a constant incidence of a symptomatic adjacent–segment disease of 2.9%
per year (16). Ishihara, in a series of 112 patients followed for more than 2 years,
report an incidence of symptomatic adjacent–segment disease from 7% to 15%(
17). In the present study, 5 of 10 patients (14.3%) followed for 24 months had a
permanent radiculopathy caused by a traumatic lesion of the root nerve.
Vascular injuries can occur during ventral approaches to the cervical spine.
The carotid artery may be torn during exposure and may be occluded due to
excessive retraction; vertebral artery injury can occur if the dissection is taken
too far
laterally (14- 25). The reported incidence of this ranges from 0.3 to 0.5% of
cases(12-14-25).
Coe and Vaccaro in their review of literature, reported that the prevalence of
screw and plate loosening was between 0 and 15.4%, the prevalence of screw
fracture was between 0 and 13.3%, the prevalence of plate fracture was between 0
and 6.7%, the prevalence of plate and graft displacement was between 0 and
21.4%, and the prevalence of implant malposition was between 0 and 12.5%(10).
Fortunately, infection after cervical spine fusion is uncommon, with a prevalence
ranging from 0 to 4.5%(28).
Many clinical studies have reported high fusion rates with anterior cervical
plates (4-26-27). In several trials the fusion rate is reported from 90-100% for
single level implant and from 70-95% for multilevel procedures(13-24). Cheng et
al. reported a fusion rate of 100% in a series of 17 patients(8). Ripa et al. and
Aebi et al. reported a fusion rate near to 100% in their series(1-23). In contrast,
Johnson, in a group of 87 patients, describe a fusion rate near 93% and
incomplete fusion in 27% patients(18).
The fusion in our study was of 97% (31 of 32 patients); in three patients the
follow-up period was too short for establish an adequate fusion rate. In our study
we had no complications, in contrast to other studies in which is reported a rates
of complications from 2-3% to 17%. Only one patient experienced a transitory
dysphonia.
The results of our study, in line with the literature, shows that the ACDF
with the use of cervical cage and titanium plates, is safer and without
complications with respect the use of autologous bone graft, and has the same
favourable clinical outcome and fusion rates.
Conclusion
The effective surgical treatment of instability and operative strategies are
directed at decompressing neural structures, fixating unstable segments and
preserving as much normal cervical mobility as possible. A good understanding of
the biomechanics of the implant and the cervical spine is essential to selecting the
appropriate plating system for anterior cervical spine surgery. Our study shows
that ACDF with fusion and titanium plate fixation can be considered a safe and
effective technique to restore the stability of traumatic lesions of the middle and
lower cervical spine.
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Anterior cervical approach for decompression and fusion in middle and lower traumatic cervical fractures
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Figures:
Preoperative X-ray and MRI showing traumatic C4-C5 subluxation (fig: 1)
Post-operative X-Ray of a traumatic C4-C5 subluxation (fig: 2)
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Anterior cervical approach for decompression and fusion in middle and lower traumatic cervical fractures
Traumatic instability C6-C7. Preoperative CT Scan (fig. 3)
Post-operative X-Ray of a traumatic instability C6-C7 (fig. 4)
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