THE ROY-CAMILLE TECHNIQUE FOR FRACTURES AND DISLOCATIONS
OF THE SUBAXIAL CERVICAL SPINE IN WEST AFRICA
JB. SIE ESSOH, A D. KACOU, I. BAMBA, A.TRAORE, G.VARANGO, Y. LAMBIN
Department of Orthopedics Surgery, University of Yopougon Teaching Hospital
21 BP 632 Abidjan 21 Côte d’Ivoire Tel: (225) 23-53-75-50 Fax: (225) 23-53-75-60
Email: siessoh@yahoo.com
Correspondence: Dr Sié Essoh: Address above
1
ABSTRACT
Background and purpose: The treatment of unstable subaxial cervical injuries remains a
daunting task for the orthopedic surgeon and has been the topic of extensive discussions in the
literature without a clear-cut protocol. In most developing countries, the management of these
injuries is fundamentally by conservative means. The aim of this article was to review and
share our experience in treating fractures and dislocations of the subaxial cervical spine using
the Roy-Camille technique.
Patients and methods: Patients with unstable injuries involving the vertebral segments C3
through C7 treated surgically with the Roy-Camille plates between 1991 and 1994 form the
basis of this study.
Results: Thirty patients, 19 (63.3%) males and 11 (36.7%) females with a mean age of
38 years were involved. The cause of trauma was road traffic accidents in 63.3% of the
patients. Fractures-dislocations involved the segments C5-C6 and C6-C7 in 86.73% of the
patients. Twenty-four (80%) patients presented with neurologic deficit. After the index
operation all the patients but one had an excellent alignment. No neurological complication
stemming from the surgery was encountered. Eight (26.7%) patients with complete spinal
cord injury died of infection. Two cases of ocular complication related to the positioning were
noted. At the latest follow-up with a mean of 35 months 16 patients available of which ten
with incomplete cord injury or roots involvement significantly improved their neurologic
function by at least one or two Frankel grades and could return to their previous status.
Conclusion: The Roy-Camille technique is a valuable method in treating fractures and
dislocations of the subaxial cervical spine. This procedure can be performed in developing
countries, provided that image intensifiers are available. The positioning of the patient is of
utmost importance.
Key words: Lateral mass plating, Roy-Camille technique, Subaxial cervical spine trauma
2
Cervical spine trauma are among the most common injuries affecting the vertebral column.
The risks of spinal cord lesions and their subsequent complications make major cervical spine
trauma one of the serious skeletal injuries resulting in substantial mortality even in the richest
of countries.(1,10,25) An expanding population and increasing number of falls especially from
trees and motor vehicle accidents in the West African subregion make unstable injuries of the
subaxial cervical spine a target of concern from medical and socioeconomic standpoints.
This has sparked a flurry of studies toward the epidemiological data, prehospital cares and
conditions of transportation to hospitals, lesions encountered, prognosis, prevention of this
condition, and challenges in follow-up of discharged patients.(3,11,24,30) Previous studies have
been published in our environment dealing with these findings.(14,27) The treatment of these
injuries remains a daunting task for the orthopedic surgeon and has been the topic of
extensive discussions in the literature.(1,25) Lateral mass plating pioneered by Roy-Camille (18)
has gained significant popularity in Europe (13,15) and North America (6,8,9) in treating bony or
ligamentous unstable injuries of the cervical spine. Fixation in the absence of midline
posterior elements and avoidance of the spinal canal make this technique appealing among
posterior stabilization methods.(12,26) In literature from our subregion, little attention is
devoted to the treatment which is fundamentally by nonoperative means.(24,30)
In Côte d’Ivoire the surgical treatment of spinal injuries by the vertebral osteosynthesis using
metal plates and screws has been popularized by Lambin et al.(14) This procedure is the
mainstay in the surgical treatment of spinal fractures in our department.(22,27)
Since neurosurgeons cope also with spinal fractures in our institution, cervical spine surgery
has recently blossomed, with the last decade witnessing the development of new and
improved techniques and instrumentation for decompressing and stabilising the cervical
spine.
3
The purpose of this retrospective study was to review and share our experience with the
Roy-Camille technique in the management of fractures and dislocations of the subaxial
cervical spine, paying special attention to the surgical technique, peculiar complications
encountered, and results achieved.
PATIENTS AND METHODS
Patient population
Between 1991 and 1994, 30 patients with fractures dislocations involving the vertebral
segments C3 through C7 were treated surgically with the Roy-Camille plates at our
department. The notes and imaging findings were reviewed with particular attention to the age
at presentation, gender, injury mechanism, vertebral lesions, neurological injury, treatment,
complications, results achieved, and follow-up assessment. Diagnosis of the lesions was made
using plain radiographs. Computed axial tomography scan was obtained in 15 patients.
Patients with vertebral body fractures necessitating a decompression via an anterior approach
handled by neurosurgeons were excluded from this study. Clinically spinal cord compromises
were graded according to the Frankel classification. The Frankel scale is well described; grade
A: with no motor or sensory function, grade B: sensory function only, grade C: useless motor
function, grade D: useful motor function, and grade E: normal function.
Operative management
The spinal column reduction was attempted in patients with spinal cord injury as soon as
possible after arrival at our service. The reduction procedures began with application of
Gardner-Wells or Crutchfield skull tongs. Neurologically intact or patients with radicular
deficits wore a cervical collar until the operation was done. All patients were taken to the
operating room as soon as their medical condition was stable, usually on the next elective list.
The patients were induced with general anesthesia and underwent surgery in prone position.
4
The surgical procedure has been well described by Roy-Camille.(18,19) Emphasis is placed on
the main steps and our tactics. The head was placed on a horseshoe-shaped head rest.
The drapes were fixed by sutures rather than by clamps which hamper the intraoperative
X-ray control. All levels to be fused were exposed through a standard posterior midline
approach. The correct level was identified with a lateral intraoperative X-ray. Locked facets
were reduced by manipulation of the affected level using Farabeuf-Lambotte bone holding
forceps. Most often a tyre lever maneuver with spatula introduced between the dislocated
facets was helpful in achieving the reduction. The center of the lateral mass was determined.
The cortex at this site was pierced with an awl. A drill bit 2.7 mm in diameter with an
automatic stop at 18 mm was used to start a hole using the Roy-Camille technique. The drill
was aimed directly anterior and 10° lateral. All drilling were done before application of the
plate. Before application of the plates, the drill holes were prepared by tapping the dorsal
cortex only. Non-self-tapping cortical screws of 14-16 mm in length and 3.5 mm in diameter
were positioned and then connected to the plate. When thoracic or lumbar custom made plates
were used, the length of the screws was 19 mm. Plates of the same size were placed
bilaterally and symmetrically to stabilize identical motion segments. In all cases,
supplemental bone grafting procedure was not used. Lateral X-ray was not used during the
drilling but was employed to assess screw position once all screws were placed. Selecting the
number of motion segments to incorporate into the instrumentation is of critical
importance.(9,18,19) One motion segment was stabilized with a two-hole plate in patients with
isolated ligamentous injury at one level. A three hole plate was used in patients with
disruption of the vertebral body (›10° of kyphosis), in dislocations associated with fractures
of articular pillar (Fig.1), and in cases with fracture separation of the articular mass (Fig. 2).
In the latter situation a screw was placed in the intact lateral mass above and below the
disrupted articular pillar.
5
Laminectomy was performed in patients sustaining dislocations with tetraplegia of whom
clinical symptoms were complete in the setting of associated fractures of lamina and/or
vertebral body. Postoperatively the patients were immobilized in a collar or minerva for six
weeks.
Follow-up study
Patient follow-up was conducted by physical examination and radiological studies.
Fusion was assessed clinically and by flexion-extension radiographs. The presence or absence
of neck and extremity pain or any other complications was noted. Three periods were
considered when assessing the results obtained. The first was related to complications
encountered perioperatively and results obtained during the hospitalization. The medium-term
follow-up referred to the evolution in the outpatient department until the end of the
rehabilitation program. In third one, the long term follow-up functional results and sequelae
were assessed.
6
RESULTS
Injury data
The gender distribution was such that there were 19 (63.3%) males and 11 (36.7%) females.
Average patient age was 38 (SD: 11.3, range 19 to 60) years at the time of the injury.
The causes of injury were road traffic accident, fall while carrying a heavy weight on the
head, fall from a tree, direct hit on the neck by a branch, and shallow dive in the ratio of
19 (63.3%), three (10%), seven (23.4%), and one (3.3%). The dislocations sustained by the
patients involved the C4-C5 segment in four (13.3%) patients, C5-C6 in 15 (50%), and C6-C7
in 10 (35.7%). Associated vertebral fractures are listed in Table I. Neurological examination
revealed the diversity within this population. Six patients were neurologically intact and five
suffered from radiculopathies. Nineteen patients had a spinal cord injury of which 11 with
complete tetraplegia (Frankel A). Eight patients presented with incomplete spinal cord injury,
of which one was Frankel B, four were Frankel C, and three Frankel D.
Hospital data
Perioperative period
A two-hole plate was used in 12 patients and a three hole plate in18. The average hospital stay
was 40 (20 to 180) days. Two patients had ocular complications encountered during the
operation, with one patient being definitively blind. All the patients but one had an excellent
alignment on the lateral plain radiograph. In this patient, there was an error of judgement of
the level to be stabilized during the operation. He was reoperated on with an excellent result.
No patient’s neurological status deteriorated subsequent to surgery. Complications related to
prolonged recumbency position encompassed pressure ulcer (n=10 patients), urinary tract
infection (n=12 patients), respiratory tract infection (n=7 patients), and deep vein thrombosis
(n=1 patient). There was no case of postoperative wound infection.
7
Eight (26.7%) patients with complete spinal cord injury died of infection. The neurologic
function in the survival patients with spinal cord involvement is summarized in Table II.
The neurologic status was improved partially to varying degrees in eight patients whose initial
status were incomplete spinal cord injury in four patients and nerve roots injury in four also.
Of the 11 patients who remained unchanged there were seven cases of spinal cord injury and
one of nerve roots injury. There was no improvement in neurologic function in those patients
with complete cord injuries. No deterioration of the neurological status was observed in the
follow-up in the six patients who were intact before surgery.
Medium-term follow-up
Of the 30 patients seen in the first period, eight (26.7%) died leaving 22, of whom 16 were
available for examination in the second stage with an average follow-up of 6 (2.5 to 8)
months. Six patients with tetraplegia, four incomplete and two complete were lost to
follow-up. Solid fusion occurred at an average of 2.8 months. There were no cases of screws
or plates breakage, screws loosening. The hardwares were removed in one patient who
remained intact neurologically before surgery. Complete recovery of the neurologic status
was observed in two cases of incomplete tetraplegia and four of radiculopathies. Partial
recovery was noted in three cases, of which two cases of incomplete spinal cord injury and
one of nerve root injury. The status was unchanged in one patient with complete tetraplegia.
Long term follow-up
With an average follow-up of 35 (12 to 42) months the long term results were assessed in
16 patients, of whom six were neurologically intact, five suffered from radiculopathies, and
five with spinal cord injury. The neurologic status of the spinal injured patients had improved
so that they could walk with sticks. The neurologically intact patients and those patients with
radiculopathies could return to their previous activities with occasional pain and used
intermittently mild analgesics.
8
DISCUSSION
Posterior cervical spine surgery is well-known to most spine surgeons. Posterior cervical
fixation finds its greatest use in patients who have facet injury with dislocations commonly
affecting the subaxial cervical spine. Deformity reduction, decompression, fixation, and
fusion can be performed in the same setting.(4) Studies regarding the biomechanics and
application of internal fixation for correction of spinal deformity and early stabilization are
constantly evolving and methods based on lateral mass fixation are universally recognized
as being effective in the lower cervical spine.(7,23,26) The aforementioned goals can be
achieved through the use of lateral mass plating technique pioneered by Roy-Camille.(19)
Patients with vertebral body fractures are amenable to posterior plating unless spinal cord
compression and the residual neurological function below the level of the injury mandated
decompression through an anterior approach.(9) In cases of vertebral body fracture treated with
posterior plating, the plates designed by Roy-Camille are like internal minerva. With their
slight curve, they facilitate correction of alignment and restore the normal cervical
lordosis.(9,17) The majority of plates designed by Roy-Camille can be used. If the cervical
plates are not available, thoracic or lumbar plates can be cut and contoured to follow normal
lower cervical spinal curvature in order to obtain plates of two, three, or more holes since the
distance between two holes is 13-mm.(14) Given the thickness of these costum made plates,
we have used screws of 19-mm of length in order to obtain a bicortical purchase.
This procedure has been performed in the cervicothoracic junction where the other techniques
of plating mass could not be correctly applied owing to the variable shape and size of C7.(12,20)
The learning curve is relatively short for those surgeons already familiar with cervical spine
surgery.(12) In assessing the results, we have endeavoured to consider three stages.
This has allowed us to gather a sufficient number of patients at each step rather than taking
them in sum with an average follow-up.
9
In resource-poor environment, one must take into account the fact that patients customarily do
not visit the surgeon once fracture healing is obtained. On the other hand, in low income
countries, with a longer follow-up, the number of patients would have most likely decreased
significantly due to reasons associated to the socioeconomic criteria.(11,30) The study by
Nwadinigwe et al (16) performed in Nigeria evidenced these features with an impressive 97%
loss to follow-up of discharged patients. That the outlook for complete spinal cord injury is
bleak in developing countries(30) was attested by the current study. The current report also
supports the view that patients with lesser degrees of neurological involvement tend to
achieve greatest motor recovery after surgery. No neurological complication stemming from
the operative procedure was encountered. The worst and most dreaded complications due to
lateral mass plating are nerve root injury and vertebral artery lesions.(20,21,28) As a result,
this technique has been slow to gain universal acceptance by older cervical spine surgeons.
In order to minimize the potential of risk of injury to the underlying vital structures, several
investigators have used variations of the Roy-Camille technique by altering either the angle of
the screw trajectory or the entry point of the screw.(2,4,20,28) In the current series bicortical
screw purchase that provides a greater degree of stabilization was attempted for all screws.
This procedure is however thought to expose the nerve root and vertebral artery to additional
risk from the drill bit, the tap, the depth gauge, and the screw itself when compared with
unicortical screw insertion.(12,21) Clinically, no patient experienced complications related to
placement of screws as in reports by Cooper et al (6) and Ebraheim et al (8) who performed the
Roy-Camille for the first time. Therefore lateral mass screws were not thoroughly evaluated
radiologically for encroachement into the foramen transversarium or into the neural
foramen.(29)
10
The zero incidence of screw related complications could be ascribed to the use of a drill bit
with a guard that precludes from incremental drilling and the avoidance of performing
measurement of the length of screw with a gauge depth to get a bicortical purchase.
This considerably quickened the duration of operation as incremental procedures were not
performed.(20) The striking complication making this report exceptional was the occurrence of
two cases of ocular complications related to the positioning. Such intolerable complications
are never seen in hospitals where the head is placed on a Mayfield head holder.
The Roy-Camille plates are relatively easy to apply, with achievement of a strong and
immediate stability making the need for rigid external immobilization optional.(5)
This method allows early rehabilitation and more efficient nursing in case of neurologic
involvement.(19) Clinical reports attest that lateral mass plate fixation especially the
Roy-Camille technique is a safe and effective stabilization procedure. Ebraheim et al (8)
reported 100% fusion rate using this technique with autogenous iliac bone grafting.
Cooper et al (6) observed a 95% fusion rate. Fehling and coworkers (9) who had used like us the
technique of Roy-Camille without additional bone grafting demonstrated a 93% fusion rate.
Excellent immediate stability, good maintenance of alignment, and solid fusion were attained
in all patients available for review in our study. The clinical outcomes seen in our patient
series are consistent with reports on pertinent literature(9,19) suggesting that supplemental
bone grafting is not required in patients with acute instability from trauma to achieve high
rates of arthrodesis.
11
CONCLUSION
The treatment of fractures and dislocations of the subaxial cervical spine has been
controversial and continues to evolve to this day particularly in terms of surgical approaches
without a clear-cut protocol. Experience with our patients at a single trauma center along with
review of other reports lead us to concede that the Roy-Camille technique is a valuable and
feasible procedure in the management of unstable injuries of lower cervical spine in
developing countries, provided image intensifiers are available. This procedure is simple and
safe when rigorously applied. This study confirms that the positioning of the patient is of
utmost importance.
12
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14
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16
Table I - Associated vertebral fractures
Vertebral level
Vertebral body
Lamina
FSAM
Articular pillar
C4
2
2
1
3
C5
4
1
4
4
C6
2
4
0
3
C7
1
0
0
0
FSAM: Fracture separation of the articular mass
17
Table II - Neurologic status of the 11 surviving patients with spinal cord injuries
according to Frankel classification
Patient n°
At admission
Postoperatively
Medium-term
Long-term
1
A
A
LFU
LFU
2
A
A
LFU
LFU
3
A
A
A
LFU
4
C
C
D
D
5
C
D
E
E
6
D
D
LFU
LFU
7
B
C
D
LFU
8
C
D
E
E
9
D
D
D
D
10
D
D
D
D
11
C
D
D
LFU
LFU: lost to follow-up
18
Legends to figures
Figure 1: C5-C6 dislocation with facet fracture of C 5 treated with C4-C6 lateral mass plates
a: Initial lateral X-Ray.
b: Postoperative lateral X-Ray
c: Post operative AP view
Figure 2: C5-C6 dislocation with fracture separation of articular mass of C5 treated with
lateral C4-C6 lateral mass custom plates.
a: Preoperative lateral view
b: Postoperative lateral radiograph
c: Post operative AP X-Ray
19