Abstract

Background:There have been rare cases of traumatic cervical spondyloptosis without neurological compromise. We report another case and provide a review of the literature, with a focus on appropriate management.

Case Description:A 60-year-old male rode his bicycle into a stationary semi-truck. He reported initial bilateral upper extremity paresthesias that resolved. Imaging demonstrated C7 on T1 spondyloptosis. Traction did not achieve reduction and a halo was applied. Subsequently, he underwent posterior decompression C6-T1, reduction via bilateral complete facetectomies at C7, and fixation from C4 to T2 fixation. Afterward, an anterior C7-T1 fixation occurred, where exposure was performed through a midline sternotomy. Postoperatively, he woke up with baseline motor and sensory examination in his extremities. He did exhibit voice hoarseness due to paralysis of the left vocal cords. He was discharged home 3 days after surgery. At 6 months follow-up, there was a progressive improvement of the left vocal cords to slight paresis; dynamic X-rays demonstrated no instability with good fusion progression.

Conclusion:Traumatic cervical spondyloptosis without neurological compromise is a rare and challenging scenario. There is a concern for neurologic compromise with preoperative traction, but if specific posterior elements are fractured, the spinal canal may be wide enough where the concern for disc migration is minimal. For patients who have not been reduced preoperatively, a posterior approach with initial decompression to widen the canal, before reduction, appears safe. This scheme may avoid an initial anterior approach for decompression, necessitating a 3-stage procedure if circumferential stabilization is pursued.

Keywords: Fracture dislocation, neurologically intact, spondyloptosis

INTRODUCTION

Spondyloptosis leads to severe spinal cord compression and neurological deficits. Here, we report another case of cervical spondyloptosis where the patient remained neurologically intact and provided a review of the literature, focusing on appropriate management.

CASE PRESENTATION

Clinical presentation and neurodiagnostic studies

A 60-year-old male presented to the hospital after riding his bicycle into a stationary semi-truck. He reported initial bilateral upper extremity paresthesias that resolved before presentation. A computed tomography (CT) scan of the cervical spine demonstrated C7 on T1 spondyloptosis, with fractures of both C7 pedicles, C7/T1 facets, and C7 lamina [ Figure 1 ]. CT angiography of the neck was negative for a vascular injury. The cervical magnetic resonance imaging documented severe canal compromise but no increased signal in the cord at the C7/T1 level [ Figure 2 ].

Figure 1

(a) Sagittal computed tomography cervical spine, (b) axial computed tomography cervical spine

Figure 2

Sagittal magnetic resonance T2

Treatment strategies

Cervical traction of 10 pounds was applied with tongs but failed to reduce the subluxation. A halo was placed; the next day the patient underwent a posterior decompression (inferior C6 laminectomy, bilateral C7 laminectomy, superior T1 laminectomy), with reduction of the fracture/dislocation utilizing bilateral complete facetectomies at C7, and fusion from C4 to T2. Intraoperatively, the O-arm documented adequate reduction. Subsequently, on the same day, an anterior C7-T1 fusion was performed through a midline sternotomy.

Intraoperative monitoring

Intraoperative monitoring (somatosensory evoked potentials [SSEPs], motor evoked potentials [MEPs], electromyography) was employed for both procedures; after reduction of the fracture via the posterior approach, SSEPs improved. At the end of the anterior procedure, SSEP and MEP remained normal. Postoperatively, he was neurologically intact.

Left-sided recurrent laryngeal nerve injury

Postoperatively, the patient was hoarse. This was attributed to the anterior C7/T1 exposure, which involved moderate retraction of the recurrent laryngeal nerve. He had paralysis of the left vocal cords. Six months later, this was just a mild paresis.

Six-month outcome and dynamic X-rays

Six months postoperatively, the patient was intact, and dynamic X-rays demonstrated no instability (e.g., adequate fusion) [ Figure 3 ].

Figure 3

Six months follow-up (a) flexion, (b) extension, and (c) Swimmer's view

DISCUSSION

Spondyloptosis is more common within the lumbar spine than the cervical spine.[ 9 ] Etiologies include traumatic,[ 11 ] congenital,[ 4 10 ] inflammatory,[ 4 ] and neoplastic[ 5 ] conditions. The majority of traumatic cases that involve the cervical spine result in devastating neurological injuries (e.g., acute myelopathy and quadriparesis).[ 12 ] There are only rare cases where patients remained neurologically intact [ Table 1 ]. This is likely due to spontaneous decompression at the level of the decompression attributed to “fractures along the posterior elements, including bilateral pedicular fractures and posterior arch fractures.”[ 8 ]

Table 1

Review of literature

Management of cervical spondyloptosis

The management of cervical spondyloptosis for patients with severe deficits involves reduction, and fusion, which can occur anteriorly and/or posteriorly.[ 12 ] Menku et al.,[ 7 ] reported the first patient with cervical spondyloptosis without a neurological deficit and cautioned against cervical traction; their patient exhibited disc material behind the spondyloptic body, and traction could have led to acute spinal cord compression. However, traction was attempted in all the subsequent cases with variable success, but without neurological compromise [ Table 1 ].

Spontaneous decompression of the fracture level with bilateral pedicle, facet and laminar fractures and timing of reduction

The fractures of bilateral pedicles and posterior elements reduce the threat of cord compromise in these patients with C7/T1 spondyloptosis. However, prolonged dislocation may result in stasis of blood flow within the vertebral arteries, leading to thrombus formation; subsequent reduction may restore blood flow and dislodge the thrombus, leading to ischemic events.[ 15 ]

Surgical goals

Surgical goals include vertebral realignment and stabilization. Overall, preoperative reduction is only rarely, safely, and feasible. Most surgeons, therefore, advocate circumferential stabilization.[ 1 3 7 9 11 13 ] Several authors have described a 3-stage approach, involving anterior decompression (discectomy and/or corpectomies), posterior reduction and fixation, and anterior fixation.[ 3 7 9 ]

Maneuvers in this case to treat C7/T1 spondyloptosis

In the case presented, as traction failed to achieve the reduction, the patient required the placement of a halo device and subsequently underwent posterior decompression/fusion followed by anterior cervical surgery (decompression/fusion). Three of the prior reported cases[ 2 6 11 ] employed the posterior approach initially.

Financial support and sponsorship

Dr. Kurpad is funded by the Byron Riesch Paralysis Foundation.

Conflicts of interest

There are no conflicts of interest.

References

1. Acikbas C, Gurkanlar D. Post-traumatic C7-T1 spondyloptosis in a patient without neurological deficit: A case report. Turk Neurosurg. 2010. 20: 257-60

2. Dahdaleh NS, Dlouhy BJ, Greenlee JD, Smoker WR, Hitchon PW. An algorithm for the management of posttraumatic cervical spondyloptosis. J Clin Neurosci. 2013. 20: 951-7

3. Gasco J, Dilorenzo DJ, Patterson JT. C4-C5 post-traumatic spondyloptosis with in situ fusion: Systematic literature review and case report. Spine (Phila Pa 1976). 2013. 38: E621-5

4. Goel A, Muzumdar D, Dange N. One stage reduction and fixation for atlantoaxial spondyloptosis: Report of four cases. Br J Neurosurg. 2006. 20: 209-13

5. Goffin J, Grob D. Spondyloptosis of the cervical spine in neurofibromatosis. A case report. Spine (Phila Pa 1976). 1999. 24: 587-90

6. Jayakumar P, Choi D, Casey A. Late presentation of a type III axis fracture with spondyloptosis. Ann R Coll Surg Engl. 2008. 90: W1-3

7. Menku A, Kurtsoy A, Tucer B, Oktem IS, Akdemir H. The surgical management of traumatic C6 – C7 spondyloptosis in a patient without neurological deficits. Minim Invasive Neurosurg. 2004. 47: 242-4

8. Merianos P, Manousidis D, Samsonas P, Baltopoulos P, Pateras N, Mavroudis G. Injuries of the lower cervical spine associated with widening of the spinal canal. Injury. 1994. 25: 645-8

9. Munakomi S, Bhattarai B, Cherian I. Traumatic cervical spondyloptosis in a neurologically stable patient: A therapeutic challenge. Case Rep Crit Care 2015. 2015. p.

10. Muzumdar DP, Goel A. C2 over C3 spondyloptosis in a case with absent posterior elements.Report of an unusual case and analysis of treatment options. J Clin Neurosci. 2004. 11: 675-7

11. Ramieri A, Domenicucci M, Cellocco P, Lenzi J, Dugoni DE, Costanzo G. Traumatic spondylolisthesis and spondyloptosis of the subaxial cervical spine without neurological deficits: Closed re-alignment, surgical options and literature review. Eur Spine J. 2014. 23: 658-63

12. Sribnick EA, Hoh DJ, Dhall SS. Traumatic high-grade cervical dislocation: Treatment strategies and outcomes. World Neurosurg. 2014. 82: 1374-9

13. Srivastava SK, Agrawal KM, Sharma AK, Agrawal MD, Bhosale SK, Renganathan SR. C3-C4 spondyloptosis without neurological deficit-a case report. The spine journal: Official journal of the North American Spine Society. 2010. 10: e16-20

14. Tumialán LM, Dadashev V, Laborde DV, Gupta SK. Management of traumatic cervical spondyloptosis in a neurologically intact patient: Case report. Spine (Phila Pa 1976). 2009. 34: E703-8

15. Tumialán LM, Theodore N. Basilar artery thrombosis after reduction of cervical spondyloptosis: A cautionary report. J Neurosurg Spine. 2012. 16: 492-6