|Year : 2021 | Volume
| Issue : 4 | Page : 15-19
Post-Traumatic Cervicothoracic Junction Fracture–Dislocations: Technical Considerations and Outcome Analysis
Ravi Sharma, Sachin A Borkar, Ajay Kumar, Priya Narwal, Deepak Gupta, Deepak Agrawal, Shashank Sharad Kale
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||14-Oct-2021|
|Date of Acceptance||16-Oct-2021|
|Date of Web Publication||24-Dec-2021|
Sachin A Borkar
Department of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
Aim: This study aimed to evaluate the factors determining the outcome after surgical management of C7–D1 fracture–dislocation and compare the various surgical approaches.
Materials and Methodology: Retrospective analysis of 41 patients operated on for C7–D1 fracture–dislocation between 2015 and 2019 is assessed for the outcome. The data about preoperative clinicoradiological parameters and the surgical approach were collected and correlated with the outcome 1 week after surgery and final follow-up.
Results: Forty-one patients were operated on for cervicothoracic junction (CTJ) fracture–dislocation during the study period. Out of these, 33 patients were treated via the anterior-only approach, while 4 were treated using the posterior-only and combined approach. Patients with American Spinal Injury Association (ASIA)-B score were found to have significant improvement as opposed to those with ASIA-A score at 1 week after surgery (54% vs. 10%, P = 0.005), at discharge (72.7% vs. 16%, P = 0.002), and at final follow-up (43.5% vs. 91%, P = 0.01). Pneumonia was the most common complication in the postoperative period developing in 36.5% of the patients. Other complications were sepsis (19.5%), bedsores (12.1%), and inhospital mortality (12.1%).
Conclusions: CTJ is a notorious area for surgical management due to its unique biomechanical properties. The surgical approach should be customized according to the individual patient profile for optimum results in the postoperative period. CTJ injuries can be surgically managed with anterior, posterior, or combined approaches. Preoperative ASIA score can act as a valuable predictor of postoperative outcome in patients with CTJ injuries.
Keywords: Cervicodorsal, cervicothoracic junction, fracture–dislocations, posttraumatic
|How to cite this article:|
Sharma R, Borkar SA, Kumar A, Narwal P, Gupta D, Agrawal D, Kale SS. Post-Traumatic Cervicothoracic Junction Fracture–Dislocations: Technical Considerations and Outcome Analysis. J Spinal Surg 2021;8:15-9
|How to cite this URL:|
Sharma R, Borkar SA, Kumar A, Narwal P, Gupta D, Agrawal D, Kale SS. Post-Traumatic Cervicothoracic Junction Fracture–Dislocations: Technical Considerations and Outcome Analysis. J Spinal Surg [serial online] 2021 [cited 2022 Jan 21];8:15-9. Available from: http://www.jossworld.org/text.asp?2021/8/4/15/333612
| Introduction|| |
The cervicothoracic junction (CTJ) is the transition between the mobile lordotic cervical spine and the rigid kyphotic thoracic spine. It is a complex, potentially unstable anatomical location with unique biomechanical properties. Acute traumatic fractures and dislocations of the CTJ are often incorrectly diagnosed because of suboptimal imaging studies and associated severe injuries at other vital organs. Therefore, the possibility of CTJ injury should always be kept in mind in patients with polytrauma, and prompt evaluation of the C7–D1 junction should be undertaken to secure the spinal stability in such patients.
Management of the unstable CTJ is particularly challenging because significant biomechanical forces act at this part of the spinal column. All immobilization techniques should ideally avoid further neurological deficits, prevent loss of reduction, and promote bone healing for long-term stability. This retrospective study analyzes the surgery results and their outcomes to identify the best approaches for dealing with complex CTJ injuries.
| Materials and Methodology|| |
This is a retrospective study conducted in the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi. During the study period between 2015 and 2019, all patients operated at the Apex Trauma Center under the Department of Neurosurgery for traumatic C7–D1 fracture–dislocations were included. The patients who refused surgery were deemed unfit for surgery by the anesthesia team, or those who were not willing to participate in the study were excluded. Ethical clearance was obtained from the Institutional Ethics Committee.
Preoperative details such as age, sex, American Spinal Injury Association (ASIA) grading, X-ray, computerized tomography (CT), magnetic resonance imaging (MRI), and details of operative procedure such as the approach used, blood loss, and hospital stay were collected. Postoperative details such as postoperative X-ray/CT, ASIA grading, and complications were obtained after 1 week of surgery and at the last follow-up. This was achieved by tracing the patients from hospital records and contacting the patients via the contact details provided.
The anterior approach, posterior approach, and combined approach were used. A team of experienced surgeons performed all the operative procedures. The decision-making was based on the sternum level to C7–D1 junction, complete or incomplete spinal injury, and failure of reduction by intraoperative traction/manipulation.
Categorical variables were presented in number and the percentage (%), and continuous variables were presented as mean ± standard deviation. The Kolmogorov–Smirnov test tested the normality of the data. The Student's paired t-test was applied to test the difference between preoperative and postoperative values. P < 0.05 was considered significant at a 95% confidence level. The statistical software SPSS (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp) for windows was used in the statistical analysis.
| Results|| |
In this study, 41 patients operated for C7–D1 traumatic fracture–dislocations under the department of neurosurgery from 2015 to 2019 were included. Out of 41, two (4.8%) patients were lost to follow-up in this study. Five (12.1%) patients died during the follow-up period. Therefore, the number of patients available for follow-up was 34. In this study, 33 (80%) patients were male, whereas 8 (20%) were female. The most common age group for injury was between 20 and 39 years, accounting for 23 (56%) of the patients. The least common age group was >50 years, comprised only 4 (10%) patients.
Mode of injury
Fall from height was the most common mode of injury and was encountered in 66% (n = 27) of the patients, followed by road traffic accidents which were found in 32% (n = 13) of the patients, whereas the least common was the history of assault, seen in the 2% (n = 1) of the patients. Low-velocity trauma contributed in 66% (n = 27) of the cases, and high-velocity trauma was seen in the rest, 34% (n = 14).
Preoperative American Spinal Injury Association score
Total 73% (30) of the patients belonged to ASIA-A grading, whereas 27% (11) of the patients belonged to ASIA-B grading. Seven (17.1%) patients had associated head injuries. The mean subaxial injury classification score was 6.3, and the mean preoperative ASIA scale score was 1.2.
Combined fracture of C7 and D1 occurred in 49% (20) of the patients, isolated C7 was involved in 44% (18) of the patients, and only 7% (3) of the patients had isolated D1 involvement. Spinal cord injury was seen on MRI in 68% (28) of the patients, whereas it was absent in the remaining 32% (13).
The anterior-only approach was used in 80% (33) of the patients. The posterior-only approach was used in 10% (4) of the patients. A combined anterior and posterior approach was used in 10% (4) of the patients.
Three out of the 30 patients (10%) with preoperative ASIA-A score and 6 out of the 11 patients (54%) with preoperative ASIA-B scores had shown statistically significant improvement after surgery (P = 0.005). Four out of the 16 patients (25%) were operated within 7 days, and 4 out of the 25 patients (16%) operated on or after 8 days had shown improvement. Seven out of the 33 patients (21%) who were operated by the anterior-only approach had shown improvement. Similarly, one patient each operated via posterior only (four patients in total), and the combined approach (four patients in total) improved after surgery. One patient showed improvement out of the five patients belonging to the <20 years age group. Similarly, between 20 and 39 years, five out of the 23 showed improvements, whereas in the >40 years age group, three patients improved out of the 13 patients [Table 1].
Chest infection was the most common complication in the immediate postoperative period affecting 36.5% (15) of the patients. This was followed by postoperative sepsis in 19.5% (8) and bedsores in 12.1% (5) patients. Inhospital mortality occurred in 12.1% (5) of the patients.
Outcome at discharge
In our study, a significant correlation was found between preoperative ASIA scale score and improvement at the time of discharge from the hospital (P = 0.002). Four patients (16%) with ASIA-A score and eight patients (72.7%) with ASIA-B score had shown improvement at discharge. Five patients (16.7%) with ASIA-A score had died postoperatively due to chest infections and sepsis. The mean ASIA score at the time of discharge was 2.1.
At the final follow-up, 10 patients (43.5%) with preoperative ASIA-A scores and 10 patients (91%) with preoperative ASIA-B scores showed improvement after surgery which was found to be statistically significant (P = 0.001). Nine patients (56.3%) were operated within 7 days, and 11 patients (61.1%) were operated on or after 8 days had shown improvement. Eighteen patients (54.5%) operated by the anterior-only approach had shown improvement. Similarly, one patient each in posterior-only and combined approach showed improvement. In the <20 years age group, one patient (25%) showed improvement, while 12 patients (60%) and 7 patients (70%) showed improvement between 20 and 39 years and >40 years age group, respectively. The mean follow-up time was 4.8 years (6 months–6.5 years). Two patients were lost to follow-up. Among the patients with a head injury, only two patients (40%) improved, whereas 18 patients (62%) without head injury showed improvement [Table 2].
| Discussion|| |
Cervical spine injuries have long been recognized as a cause of significant morbidity and mortality in trauma victims. The incidence of fracture–dislocation at the CTJ is 2.4% to 9% in patients with a cervical spine injury.,, Injuries can range from vertebral body fractures, unilateral and bilateral facet dislocations, fracture–dislocations, and isolated fractures of the posterior elements.
The instability of the CTJ is mainly due to the unique interplay of biomechanics at this location., Spinal instability at the CTJ poses significant clinical challenges as it ultimately leads to kyphosis and spinal cord compression, causing neurological deficits.,
In our study, both C7 and D1 were involved in 49% (20) of the patients, isolated C7 was involved in 44% (18) of the patients. Only 7% (3) of the patients had isolated D1 involvement, whereas Amin and Saifuddin found an isolated lesion at the C7 and D1 vertebra in 60% (18) and 16.7% (5) patients, respectively, as compared to 23.3% (7) patients with C7–D1 dislocation.
Management of CTJ injuries is divided into two types: nonoperative and operative management.
Nonoperative management was historically used in cervical traction, the reduction under general anesthesia, and external orthoses. The halo fixation device is the most commonly used and provides a more rigid cervical spine immobilization. However, the failure of immobilization in the lower cervical spine is well-documented in the literature, presumably owing to the residual mobility at individual segments of the unstable spine. Therefore, surgical treatment is alluring because it provides spinal stability and permits early mobilization and rehabilitation. Lesions involving the vertebral body or disc indicate anterior stabilization, while posterior elements warrant posterior stabilization. However, nonoperative management is still used in patients who are waiting for surgery and manipulation under anesthesia.,
The literature is still divided regarding the optimal operative strategy at the CTJ, especially with advances in posterior-only approaches. The decision-making process, i.e. whether to use anterior/posterior/360°/540° surgical approaches, should be individualized based on the merits of each case. The comparison of various surgical approaches is summarized in [Table 3].
|Table 3: Comparison of various surgical approaches for cervicothoracic junction injuries|
Click here to view
The existing literature has reported paraplegia, dysphonia, injury to the thoracic duct, pneumonia, biomechanical failure of orthopedic implants, hematoma, wound infection, and bedsores as common complications in patients having CTJ injuries.,,, Our study found that 36.5% of the patients developed pneumonia, 19.5% developed postoperative sepsis, and 12.1% developed bedsore. The rest of the complications were not seen in our patients.
| Conclusions|| |
Low-velocity trauma is the most common cause of cervicothoracic fracture–dislocations. C7–D1 fracture–dislocation has its own set of challenges owing to the unique biomechanics at the CTJ and limited surgical corridors. Careful preoperative clinicoradiological assessment and tailoring surgical decision-making to individual patient's requirements and fracture patterns is paramount for optimal patient outcomes. The anterior surgical approach is safe and effective. A preoperative ASIA score helps to predict neurological outcome after surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Amin A, Saifuddin A. Fractures and dislocations of the cervicothoracic junction. J Spinal Disord Tech 2005;18:499-505.
Sapkas G, Papadakis S, Katonis P, Roidis N, Kontakis G. Operative treatment of unstable injuries of the cervicothoracic junction. Eur Spine J 1999;8:279-83.
Ames CP, Bozkus MH, Chamberlain RH, Acosta FL Jr., Papadopoulos SM, Sonntag VK, et al.
Biomechanics of stabilization after cervicothoracic compression-flexion injury. Spine (Phila Pa 1976) 2005;30:1505-12.
Vanden Hoek T, Propp D. Cervicothoracic junction injury. Am J Emerg Med 1990;8:30-3.
Krishnamoorthy, Venkidesh. Surgical management of traumatic cervico thoracic junction fracture subluxation - a single centre experience. International Journal of Current Research 2015;7:22748-52.
Schmidt-Rohlfing B, Nossek M, Knobe M, Das M. Combined approach for a locked unilateral facet fracture-dislocation of the cervicothoracic junction. Acta Orthop Belg 2008;74:875-80.
An HS, Vaccaro A, Cotler JM, Lin S. Spinal disorders at the cervicothoracic junction. Spine (Phila Pa 1976) 1994;19:2557-64.
Astawa NM, Wiguna IG, Purvance I, Stanu GN, Simanjuntak HA, Putra IG. Outcome following cervicothoracic junction fusion in T1 pathological fracture of breast cancer spinal metastases: A case report. Int J Res Med Sci 2020;8:3389-93.
Chapman JR, Anderson PA, Pepin C, Toomey S, Newell DW, Grady MS. Posterior instrumentation of the unstable cervicothoracic spine. J Neurosurg 1996;84:552-8.
Pick RY, Segal D. C7--T1 bilateral facet dislocation: A rare lesion presenting with the syndrome of acute anterior spinal cord injury. Clin Orthop Relat Res 1980;150:131-6. PMID: 7428210.
Pointillart V, Aurouer N, Gangnet N, Vital JM. Anterior approach to the cervicothoracic junction without sternotomy: A report of 37 cases. Spine (Phila Pa 1976) 2007;32:2875-9.
Falavigna A, Righesso O, Teles AR. Anterior approach to the cervicothoracic junction: Proposed indication for manubriotomy based on preoperative computed tomography findings. J Neurosurg Spine 2011;15:38-47.
Placantonakis DG, Laufer I, Wang JC, Beria JS, Boland P, Bilsky M. Posterior stabilization strategies following resection of cervicothoracic junction tumors: Review of 90 consecutive cases. J Neurosurg Spine 2008;9:111-9.
Lenoir T, Hoffmann E, Thevenin-Lemoine C, Lavelle G, Rillardon L, Guigui P. Neurological and functional outcome after unstable cervicothoracic junction injury treated by posterior reduction and synthesis. Spine J 2006;6:507-13.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]