Options for surgical treatment of cervical fractures in patients with spondylotic spine: a case series and review of the literature

The cervical spine is a complex anatomical structure, and the treatment of lesions
in this region is still controversial and challenging for spinal surgeons. Columns
afflicted by AS become stiff and more susceptible to fractures, with lesions occurring
mostly in the cervical region. Furthermore, there is a high rate of neurological impairment
1]–4].

Without established guidelines for the best treatment of these fractures, reports
of surgical treatment have increased the extent to which new fixation devices are
used during surgery 4].

The surgical methods for fractures of the subaxial cervical spine include the anterior
approach with the use of plates, the posterior approach with lateral mass screws and
the combined approach. In addition, there are some reports of the use of corrective
osteotomies for kyphotic deformities found in patients with spondyloarthropathies
3]–5]. Complications specific to AS must be considered when opting for open treatment,
such as the increased risk of epidural bleeding and the widespread presence of osteoporotic
bone, as well as multi-segmental fusion of long segments of the spine, which is often
combined with sagittal deformity and makes the surgery more complex 6]. It is important to emphasize that the surgical approach for each patient discussed
here was chosen based on the surgeons’ experience.

In the first clinical case, the patient presented local pain with sensitivity deficit
of C5 dermatome. On the initial evaluation, no injuries were identified in the radiographs.
Due to local pain, neurological deficit and the associated AS, a magnetic resonance
imaging (MRI) scan was done revealing a fracture in the C5 to C6 vertebrae. Some researchers
have reported difficulties in visualizing fractures in patients with spondylotic cervical
spine, and additional imaging examinations are important to confirm the diagnosis
6], 7].

In this case, because the patient presented a neurological deficit the MRI was done
as the primary examination to rule out any intervertebral disc, posterior ligament
injury or occult bone fracture 8] allowing surgeons to decide treatment with lower costs.

The isolated anterior approach was chosen because although ligamentum flavum bulging
was noted, the most important lesion was in the anterior column. The patient reported
a continued improvement of pain without neurological deterioration and an early return
to daily activities (Fig. 1).

The anterior decompression technique is associated with less than 2% of significant
complications related specifically to the use of the plate, and it provides excellent
fusion rates (98.9%) that occur, on average, 3.2 months after surgery 9]. Anterior decompression can promote stability, safety and rigidness, improving neurologic
outcomes satisfactorily and representing a good option for early surgery 9], 10].

The anterior plate is predominantly used with anterior lesions but also can be used
to treat posterior injuries when performed properly. However, several authors advocate
the use of a posterior procedure over an anterior one because they argue that an anterior
approach alone should not be performed for predominantly posterior lesions 10].

In our second case we chose posterior decompression and stabilization (Fig. 1) with a good clinical outcome, resulting in an improvement in the patient’s pain
and sensibility.

Cervical spinal fractures in patients with AS can be adequately treated with lateral
mass plating or interspinous wiring of an autologous rib graft. Adequate postoperative
immobilization can be attained with a cervical collar and does not require a halo
vest 11], 12].

Nakashima et al.13] demonstrated no neurological deterioration after a posterior open reduction, even
in cases of traumatic cervical disc herniation. The favorable clinical and radiological
results were obtained through a primary posterior procedure.

In our third clinical case the patient developed cervical pain and paraplegia after
an automobile collision with a wall. He presented significant pain, deformity in flexion
of the neck and a medullary lesion.

In this case, we chose the dual approach, performing decompression and stabilization
using a posterior approach with lateral mass screws associated with the anterior plate,
screws and an iliac graft (Fig. 2) in order to guarantee a complete decompression of the medulla and better positioning
of his neck.

Fig. 2. Clinical and surgical presentation of Patient 3. Observe in (a) and (b) the sagittal computed tomography scan images showing ankylosed cervical spine and
a fracture-dislocation of C6 to C7. In (c) and (d), the radiographic images in sagittal (c) and posteroanterior (d) views demonstrating the stabilization in 360 degrees

The patient showed improvement in postoperative pain and in the neurological deficits
of his upper limb, predominantly at C6 and C7, but his motor deficit below C8 persisted.
Furthermore, he reported improvement in his head position. Before surgery, his head
was tilted downward. During the fracture treatment, a deformity correction was performed
with placement of an anterior wedge iliac graft, producing a satisfactory jaw–neck
angle.

Some researchers have taken the opportunity of cervical trauma to perform a surgical
extension osteotomy at the lower cervical spine fracture site by using stretching
with a halo for the correction of a flexion deformity of the spine in AS after traumatic
injury 5]. However, conservative treatment of fractures in patients with AS can have serious
complications, such as infection and loosening pins, brain hemorrhages and pseudoarthrosis,
as demonstrated by Schroder et al.14]. We agree with some authors who suggest that the anterior and posterior combined
approach is stable and provides immediate decompression. Furthermore, this option
is a reasonable surgical strategy for fracture-dislocations of the cervical spine
in patients with AS 4], 15].