Predicting the loss of correction after isolated anterior stabilization in the surgical treatment of subaxial cervical dislocations

Objective. To identify factors leading to the loss of correction and re-dislocation of the vertebrae after isolated anterior reconstruction and stabilization in the surgical treatment of subaxial cervical dislocations.

Material and Methods. A retrospective cohort STROBE-type study was carried out using data of 175 patients with dislocations of vertebrae in the subaxial cervical spine who were operated on in 2010–2019. The key parameters of the study were the relevant indices of the cervical sagittal balance and morphological characteristics of the injury: thoracic inlet angle (TIA), T1 vertebra slope, neck tilt, regional cervical C2–C7 lordosis, fracture of the vertebral body, and fracture of the articular process at the level of dislocation. Statistical analysis of the obtained data was carried out in the RStudio program.

Results. At preoperative TIA value of 74.5°, the risk of correction loss corresponds to 28 %. In the group with TIA < 74.5° and that with TIA ≥ 74.5°, the risk of correction loss is 17.3 % (95 % CI: 7–37 %) and 85.7 % (95 % CI: 60–96 %), respectively. With an increase in TIA by 10°, the chance of recurrence increases by 23.3 times. The effect of the articular process fracture  on the loss of correction is equivalent to an increase in TIA by 10°, namely, it increases the chance of recurrence by 20.7 times. The parameter “duration of injury” has an effect on the loss of correction, but it is statistically insignificant (p > 0.05).

Conclusion. The parameter of the cervical sagittal balance, thoracic inlet angle, as well as the fracture of the articular process at the level of injury are statistically significant factors that determine the initial stability in isolated anterior surgical reconstruction and stabilization of the lower cervical spine for Allen type 3 flexion-distraction injuries.

1. Nightingale RW, Bass CR, Myers BS. On the relative importance of bending and compression in cervical spine bilateral facet dislocation. Clin Biomech (Bristol, Avon). 2019;64:90–97. DOI: 10.1016/j.clinbiomech.2018.02.015.

2. Wilson JR, Vaccaro A, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R, Okonkwo DO, Fehlings MG. The impact of facet dislocation on clinical outcomes after cervical spinal cord injury: results of a multicenter North American prospective cohort study. Spine. 2013;38:97–103. DOI: 10.1097/brs.0b013e31826e2b91.

3. Quarrington RD, Jones CF, Tcherveniakov P, Clark JM, Sandler SJI, Lee YC, Torabiardakani S, Costi JJ, Freeman BJC. Traumatic subaxial cervical facet subluxation and dislocation: epidemiology, radiographic analyses, and risk factors for spinal cord injury. Spine J. 2018;18:387–398. DOI: 10.1016/j.spinee.2017.07.175.

4. Jack A, Hardy-St-Pierre G, Wilson M, Choy G, Fox R, Nataraj A. Anterior surgical fixation for cervical spine flexion-distraction injuries. World Neurosurg. 2017;101:365–371. DOI: 10.1016/j.wneu.2017.02.027.

5. Theodotou CB, Ghobrial GM, Middleton AL, Wang MY, Levi AD. Anterior reduction and fusion of cervical facet dislocations. Neurosurgery. 2019;84:388–395. DOI: 10.1093/neuros/nyy032.

6. Nassr A, Lee JY, Dvorak MF, Harrop JS, Dailey AT, Shaffrey CI, Arnold PM, Brodke DS, Rampersaud R, Grauer JN, Winegar C, Vaccaro AR. Variations in surgical treatment of cervical facet dislocations. Spine. 2008;33:E188–E193. DOI: 10.1097/BRS.0b013e3181696118.

7. Del Curto D, Tamaoki MJ, Martins DE, Puertas EB, Belloti JC. Surgical approaches for cervical spine facet dislocations in adults. Cochrane Database Syst Rev. 2014;2014:CD008129. DOI: 10.1002/14651858.cd008129.pub2.

8. Lins CC, Prado DT, Joaquim AF. Surgical treatment of traumatic cervical facet dislocation: anterior, posterior or combined approaches? Arq Neuropsiquiatr. 2016;74:745–749. DOI: 10.1590/0004-282x20160078.

9. Schleicher P, Kobbe P, Kandziora F, Scholz M, Badke A, Brakopp F, Ekkerlein H, Gercek E, Hartensuer R, Hartung P, Jarvers JS, Matschke S, Morrison R, Muller CW, Pishnamaz M, Reinhold M, Schmeiser G, Schnake KJ, Stein G, Ullrich B, Weiss T, Zimmermann V. Treatment of injuries to the subaxial cervical spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018;8(2 Suppl):255–335. DOI: 10.1177/2192568217745062.

10. Woodworth RS, Molinari WJ, Brandenstein D, Gruhn W, Molinari RW. Anterior cervical discectomy and fusion with structural allograft and plates for the treatment of unstable posterior cervical spine injuries. Journal of Neurosurgery: Spine. 2009;10:93–101. DOI: 10.3171/2008.11.spi08615.

11. Nakashima H, Yukawa Y, Ito K, Machino M, El Zahlawy H, Kato F. Posterior approach for cervical fracture-dislocations with traumatic disc herniation. Eur Spine J. 2011;20:387–394. DOI: 10.1007/s00586-010-1589-1.

12. Tofuku K, Koga H, Yone K, Komiya S. Distractive flexion injuries of the subaxial cervical spine treated with a posterior procedure using cervical pedicle screws or a combined anterior and posterior procedure. J Clin Neurosci. 2013;20:697–701. DOI: 10.1016/j.jocn.2012.03.045.

13. Payer M, Tessitore E. Delayed surgical management of a traumatic bilateral cervical facet dislocation by an anterior-posterior-anterior approach. J Clin Neurosci. 2007;14:782–786. DOI: 10.1016/j.jocn.2006.04.021.

14. Anissipour AK, Agel J, Baron M, Magnusson E, Bellabarba C, Bransford RJ. Traumatic cervical unilateral and bilateral facet dislocations treated with anterior cervical discectomy and fusion has a low failure rate. Global Spine J. 2017;7:110–115. DOI: 10.1177/2192568217694002.

15. Henriques T, Olerud C, Bergman A, Jonsson H Jr. Distractive flexion injuries of the subaxial cervical spine treated with anterior plate alone. J Spinal Disord Tech. 2004;17:1–7. DOI: 10.1097/00024720-200402000-00002.

16. Johnson MG, Fisher CG, Boyd M, Pitzen T, Oxland TR, Dvorak MF. The radiographic failure of single segment anterior cervical plate fixation in traumatic cervical flexion distraction injuries. Spine. 2004;29:2815–2820. DOI: 10.1097/01.brs.0000151088.80797.bd.

17. Koller H, Reynolds J, Zenner J, Forstner R, Hempfing A, Maislinger I, Kolb K, Tauber M, Resch H, Mayer M, Hitzl W. Mid- to long-term outcome of instrumented anterior cervical fusion for subaxial injuries. Eur Spine J. 2009;18:630–653. DOI: 10.1007/s00586-008-0879-3.

18. Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine. 1982;7:1–27. DOI: 10.1097/00007632-198200710-00001.

19. Середа А.П., Андрианова М.А. Рекомендации по оформлению дизайна исследования // Травматология и ортопедия России. 2019. Т. 25. № 3. С. 165–184. [Sereda AP, Andrianova MA. Study design guidelines. Travmatologiya I ortopediya Rossii. 2019;25(3):165–184. In Russian]. DOI: 10.21823/2311-2905-2019-25-3-165-184.

20. Roberts TT, Leonard GR, Cepela DJ. Classifications in Brief: American Spinal Injury Association (ASIA) Impairment Scale. Clin Orthop Relat Res. 2017;475:1499–1504. DOI: 10.1007/s11999-016-5133-4.

21. Tan GH, Goss BG, Thorpe PJ, Williams RP. CT-based classification of long spinal allograft fusion. Eur Spine J. 2007;16:1875–1881. DOI: 10.1007/s00586-007-0376-0.

22. Lee SH, Son ES, Seo EM, Suk KS, Kim KT. Factors determining cervical spine sagittal balance in asymptomatic adults: correlation with spinopelvic balance and thoracic inlet alignment. Spine J. 2015;15:705–712. DOI: 10.1016/j.spinee.2013.06.059.

23. Ling FP, Chevillotte T, Leglise A, Thompson W, Bouthors C, Le Huec JC. Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review. Eur Spine J. 2018;27(Suppl 1):8–15. DOI: 10.1007/s00586-018-5462-y.

24. Lee SH, Kim KT, Seo EM, Suk KS, Kwack YH, Son ES. The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults. J Spinal Disord Tech. 2012;25:E41–E47. DOI: 10.1097/bsd.0b013e3182396301.

25. Quarrington RD, Costi JJ, Freeman BJC, Jones CF. Quantitative evaluation of facet deflection, stiffness, strain and failure load during simulated cervical spine trauma. J Biomech. 2018;72:116–124. DOI: 10.1016/j.jbiomech.2018.02.036.

26. Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, Kandziora F, Fehlings MG, Dvorak MF, Aarabi B, Rajasekaran S, Schroeder GD, Kepler CK, Vialle LR. AOSpine subaxial cervical spine injury classification system. Eur Spine J. 2016;25:2173–2184. DOI: 10.1007/s00586-015-3831-3.

27. Panjabi MM, Simpson AK, Ivancic PC, Pearson AM, Tominaga Y, Yue JJ. Cervical facet joint kinematics during bilateral facet dislocation. Eur Spine J. 2007;16:1680–1688. DOI: 10.1007/s00586-007-0410-2.

28. Бурцев А.В. Выбор оптимальной классификации и лечебного алгоритма при субаксиальных повреждениях шейного отдела позвоночника // Бюллетень ВСНЦ СО РАМН. 2012. № 4 (86). Ч. 2. С. 21–25. [Burtsev AV. Choice of optimal classification and treatment algorithm at subaxial injuries of the cervical segment of spine. Bull. ESSC SB RAMS. 2012;(4 Pt 2):21–25. In Russian].

29. Aebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J. 2010;19(Suppl 1):S33–S39. DOI: 10.1007/s00586-009-1120-8.

30. Kim SG, Park SJ, Wang HS, Ju CI, Lee SM, Kim SW. Anterior approach following intraoperative reduction for cervical facet fracture and dislocation. J Korean Neurosurg Soc. 2020;63:202–209. DOI: 10.3340/jkns.2019.0139.

31. Abumi K, Ito M, Sudo H. Reconstruction of the subaxial cervical spine using pedicle screw instrumentation. Spine. 2012;37:E349–E356. DOI: 10.1097/brs.0b013e318239cf1f.

32. Joaquim AF, Mudo ML, Tan LA, Riew KD. Posterior subaxial cervical spine screw fixation: a review of techniques. Global Spine J. 2018;8:751–760. DOI: 10.1177/2192568218759940.

33. Бурцев А.В, Губин А.В. Выбор метода стабилизации при травмах шейного отдела позвоночника // Гений ортопедии. 2017. Т. 23. № 2. C. 140–146. [Burtsev AV, Gubin AV. The choice of stabilization technique for cervical spine injuries. Genij Ortopedii. 2017;23(2):140–146. In Russian]. DOI 10.18019/1028-4427-2017-23-2-140-146.

34. Рерих В.В., Ластевский А.Д., Аветисян А.Р. Особенности тактики хирургического лечения флексионно-дистракционных повреждений субаксиального уровня шейного отдела позвоночника // Хирургия позвоночника. 2017. Т. 14. № 4. C. 32–38. [Rerikh VV, Lastevsky AD, Avetisyan AR. Features of the tactics of surgical treatment of flexion-distraction injuries of the subaxial cervical spine. Hir. Pozvonoc. 2017;14(4):32–38. In Russian]. DOI: 10.14531/ss2017.4.32-38.

35. Яриков А.В, Фраерман А.П., Перльмуттер О.А., Симонов А.Е., Смирнов И.И. Травма субаксиального уровня шейного отдела позвоночника: клиническая картина, диагностика, тактика лечения // Здоровье. Медицинская экология. Наука. 2018. № 3 (75). C. 89–97. [Yarikov AV, Fraerman AP, Perlmutter OA, Simonov AE, Smirnov II. Injury of the subaxial level of the cervical spine: clinical picture, diagnosis, treatment tactics. Health. Medical ecology. Science. 2018;3:89–97. In Russian]. DOI: 10.5281/zenodo.1488060.

36. Слынько Е.И., Нехлопочин А.С. Оптимизация хирургической коррекции сагиттального контура позвоночно-двигательного сегмента при выполнении вентрального субаксиального цервикоспондилодеза // Травма. 2018. Т. 19. № 3. С. 67–74. [Slynko EI, Nekhlopochin AS. Optimization of surgical correction of spinal motion segment sagittal contour when performing anterior subaxial cervical fusion. Travma. 2018;19(3):67–74). In Russian]. DOI: 10.22141/1608-1706.3.19.2018.136409.

37. Song KJ, Lee KB. Anterior versus combined anterior and posterior fixation/fusion in the treatment of distraction-flexion injury in the lower cervical spine. J Clin Neurosci. 2008;15:36–42. DOI: 10.1016/j.jocn.2007.05.010.

38. Tang JA, Scheer JK, Smith JS, Deviren V, Bess S, Hart RA, Lafage V, Shaffrey CI, Schwab F, Ames CP. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery. 2012;71:662–669. DOI: 10.1227/neu.0b013e31826100c9.

39. Hardacker JW, Shuford RF, Capicotto PN, Pryor PW. Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms. Spine. 1997;22:1472–1479. DOI: 10.1097/00007632-199707010-00009.

40. Guo GM, Li J, Diao QX, Zhu TH, Song ZX, Guo YY, Gao YZ. Cervical lordosis in asymptomatic individuals: a meta-analysis. J Orthop Surg Res. 2018;13:147. DOI: 10.1186/s13018-018-0854-6.

41. Guerin P, Obeid I, Gille O, Bourghli A, Luc S, Pointillart V, Vital JM. Sagittal alignment after single cervical disc arthroplasty. J Spinal Disord Tech. 2012;25:10–16. DOI: 10.1097/bsd.0b013e31820f916c.