Cervical spine mechanics as a function of transection of components

Ten patients who suffered iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body.

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Vertebral artery injury during anterior decompression of the cervical spine. A retrospective review of ten patients

One hundred patients were managed with one-stage anterior decompression and posterior stabilization of the cervical spine. The underlying indication for the operation was cervical trauma in thirty-one patients; a neoplasm with a pathological fracture or an incomplete neurological deficit in fifty-five; and a miscellaneous condition, such as infection, rheumatoid arthritis, or cervical spondylotic myelopathy, in fourteen. The duration of follow-up ranged from twenty-four to 108 months (mean, thirty-two months) for the living patients. Sixteen patients had the procedure after the failure of an operation that had been performed elsewhere. The development of more biomechanically rigid cervical instrumentation did not obviate the need for a combined anterior and posterior approach. Twenty-six patients (26 per cent) had supplemental cervical instrumentation as part of the circumferential arthrodesis: seventeen had insertion of an anterior cervical plate and nine had insertion of a posterior facet plate. There were no iatrogenic neurological deficits. Of the seventy-five patients who had had a neurological deficit preoperatively, fifty-one improved one grade and six improved two grades according to the system of Frankel et al. Of the thirty-five patients who had not been able to walk preoperatively, twenty-one regained enough motor strength to walk postoperatively. Because the anterior and posterior procedures were performed during one session of general anesthesia, the prevalence of perioperative complications related to the airway was lower than that previously reported in the literature. No patient had an obstruction of the airway.

One-Stage Anterior Cervical Decompression and Posterior Stabilization. A Study of One Hundred Patients with a Minimum of Two Years of Follow-up*

Although the actual management is vital for success, the institution in which spinal injuries are cared for shares equally in importance. When responsibility is accepted by a multidisciplinary team, better restoration of function occurs whilst greater social and financial support is possible. The piecemeal care of spinal fractures with paralysis (Morgan, Wharton and Austin 1 97 1 ; Botterell et a!. 1 975 ; Sussman 1 978) is a practice endemic in every community and to be condemned. The creation of comprehensive units (Fig. 1) served by all specialties but co-ordinated by one-an emergent discipline-has allowed solution of fragm entary care (Guttmann 1977a, 1978; Botterell 1978) and has seen the emergence of new talents in seriously injured people (Guttmann 1968). Covalt et al. (1953) and Talbot (1969) showed

Spinal injuries with tetraplegia and paraplegia

There is still some controversy about the reduction of unilateral and bilateral facet dislocations in the cervical spine. We have reviewed the notes and radiographs of 210 such patients; reduction was attempted by manipulation under anaesthesia (MUA) in 91, and by rapid traction under sedation in 119, using weights up to 150 lb (68 kg). Our results suggest that early reduction in patients with neurological deficit gives the best chance of neurological recovery, that rapid traction is more often successful than MUA, and that traction is safer than MUA. We found that the use of heavy weights with close monitoring was safe and brought about reduction in an average time of 21 minutes. We recommend this technique for the reduction of all cervical facet dislocations.

Rapid traction for reduction of cervical spine dislocations

A follow-up study of forty-seven patients treated for traumatic lesions of the cervical spine with and without associated neural deficits is presented. Operation was performed six hours to eight months after injury. The objectives of these procedures were to remove any causes of compression of the cord or nerve roots, especially anterior compression, to reduce the dislocation and kyphosis, and to stabilize the cervical spine by interbody fusion.

Preoperative and postoperative care is described as well as the exposure used for different levels of the spine and the three types of bone-grafting procedures that were developed to correct and stabilize the deformities associated with the various fractures and fracture-dislocations encountered.

Normal or satisfactory alignment was regained in all but three of the forty-one surviving patients, and solid fusion occurred in the forty-one surviving patients who were followed long enough to determine the results of fusion.

There was no evidence that the operation had aggravated any neural deficits, although in two of the six patients who died after acute complete transverse cord lesions it was thought that early operation within twelve hours of injury may have contributed to the fatal outcome.

The functional results of operation in terms of relief of neck pain and recovery of cord and nerve-root function were encouraging. The prompt recovery of function of a few patients who had not improved after as long as 3.5 months of non-operative treatment suggested that reduction of the dislocation and correction of the kyphosis, combined with removal of the posteriorly extruded disc material in nine patients, had corrected a vascular insufficiency.

It was concluded that anterolateral operations may be harmful for patients with acute complete transverse lesions of the cord but that traumatic abnormalities causing compression of the anterior part of the cord or traction and consequent anterior pressure on the cord (the result of angulation of the cervical spine) can be eliminated or corrected under direct vision in a way not possible by laminectomy. It was further concluded that fusion is easily effected through the anterolateral approach, whereas after laminectomy posterior fusion may be difficult or impossible.

H. Verbiest

Papers

Anterolateral operations for fractures and dislocations in the middle and lower parts of the cervical spine. Report of a series of forty-seven cases.