Recent Advances in Spine Surgery

Overview

Managing cervical spine fractures and disk lesions was difficult before the development of safe treatment methods. Surgeons mainly used traction, plaster casts, and braces, avoiding surgery whenever they could. Stabilizing abnormal spinal segments was not commonly practiced, and inaccessible areas posed challenges for treating infections and tumors.

Although surgical advancements have enhanced treatment options, traditional methods still have a role. The paper seeks to describe current approaches, leaving their effectiveness to be assessed in the future. Surgeons must consider their skills and the circumstances to determine the optimal approach for each patient.

Benefits of Internal Stabilization for Dislocations, Fractures, and Fracture-Dislocations of the Cervical Spine

The conservative approach to managing cervical spine fractures often neglects patients with unstable spines who haven’t yet experienced cord or root injury. It also fails to address the issue of cervical root pain. Torn ligaments are generally weaker, increasing the risk of late subluxation.

Protecting patients from additional cord injury is crucial, even if most fractures eventually stabilize. Identifying unstable ligaments through X-rays is challenging, and determining the appropriate time to remove protective measures poses a difficult decision.

Potential mechanical instability arises following dislocation, fractures, or fracture-dislocations in the cervical spine, posing risks to important structures. To address this, it is both sensible and safe to internally stabilize the affected spinal segments using wires and bone grafts after precise reduction.

This approach safeguards the spinal cord by establishing stability through the use of stabilized bone. Neglecting to treat unreduced or unstable injuries and persistent root pains is not advisable.

However, it is crucial to assess each case individually and contemplate surgical interventions that restrict head and neck movements based on specific indications. Collaborative efforts between neurologic and orthopedic surgeons can yield improved outcomes when managing these intricate concerns.

Management of Fractures and Dislocations in the Cervical Spine

Handling the Patient

The physician in charge takes great caution when dealing with a patient suspected of having a cervical spine injury, as the precise level of instability is unknown. Before conducting radiographic examinations, the patient’s head is supported with five to ten pounds of head-halter traction, a brace, or other external support in a neutral position.

If there are clear indications of spinal cord damage, skull tongs should be promptly applied under local anesthesia. Traction should be applied straight, at approximately 10 to 15 pounds, until X-rays are obtained.

Roentgenograms

When dealing with a patient in the emergency room, it is of utmost importance to minimize their movement while obtaining X-rays (roentgenograms). The responsible physician must carefully maintain the alignment of the head and body during the imaging process. To ensure accurate visualization of the vertebrae, it is necessary to obtain clear anteroposterior, lateral, oblique, and open mouth views.

Typically, this can be achieved by positioning the patient’s upper extremities alongside their body, applying gentle traction, and exerting straight traction on the head to bring the shoulders downward.

Mechanism of Injuries

By meticulously assessing the patient’s medical background, scrutinizing head injuries, and examining X-ray results, it becomes feasible to ascertain the precise mechanism of injury and discern the ligaments that have been impacted. Evidently, anterior compression fractures and dislocations manifest themselves more prominently, whereas hyperextension injuries may be less visibly discernible.

Flexion injuries commonly exhibit anterior fragmentation and compression, while vertical and extension injuries tend to result in lateral mass fragmentation and alterations in the angles of the affected facets, which can occasionally resemble flexion injuries.

Skeletal Traction

In situations of uncertainty, employing skull traction is a beneficial approach to safeguard the spinal cord. The use of tongs is warranted for fractures, dislocations, or destructive lesions that result in angulation or subluxation of the cervical vertebrae, particularly when spinal cord or root damage is present.

The application of tongs can be conveniently performed under local anesthesia, without the need for patient movement. To ensure a sterile environment, the tongs can be securely maintained in position for an extended duration. Managing patients in skull traction is best accomplished using turning beds, as they allow for more convenient care.

In cases of flexion fractures accompanied by bilateral facet dislocations, disengagement typically necessitates 25 to 40 pounds of traction, followed by reduction using a lighter traction force. For extension, hyperextension, and vertical injuries, 20 pounds of straight traction often proves sufficient for reduction, with a subsequent reduction to 10 pounds for maintenance purposes.

Open Reduction and Fusion without Laminectomy

Reducing unilateral facet dislocation, which involves a combination of flexion and rotation, proves challenging when employing skull traction and can go unnoticed without clear oblique views.

Early implementation of the Rogers’ method for open reduction is recommended, especially in cases with noticeable severe root pain. If reduction is successful and there is improvement in neurological signs without any spinal fluid blockage, a nonoperative approach becomes a feasible choice. Sustaining traction until reaching maximum improvement permits subsequent stabilization through the application of a head-body cast.

Employing internal fixation using the Rogers’ method offers various advantages, such as decreased deformity, alleviated pressure on the spinal cord and nerve roots, earlier recovery of mobility, and improved safeguarding of the spinal cord and related structures.

Post-reduction and Laminectomy Stabilization

When reduction is unsuccessful and symptoms persist, including nerve root pain, lack of spinal cord recovery, worsening spinal cord signs, or quadriplegia, a nonoperative approach provides minimal prospects for patient improvement. Laminectomy, open reduction, and internal stabilization are the preferred choices when they can be performed.

Internal stabilization enhances nursing care by alleviating traction on nerve roots and permits earlier removal of external support, thereby uplifting psychological well-being. Internal stabilization diminishes the risk of subluxation and additional spinal cord damage. Although there may be a possibility of increased mortality among operated quadriplegics, the advantages of this approach outweigh the potential risks.

Occipitocervical Fusion

Fractures affecting the odontoid process commonly exhibit suboptimal healing and are susceptible to effortless shifting, leading to a significant likelihood of neurological complications.

Although the use of traction can aid in reducing the injury, there is a higher probability of subsequent dislocation in comparison to injuries that require less uncomplicated reduction. Occipitocervical fusion is necessary for tumors in specific instances. Forsythe noted that incorporating C-3 into the fusion procedure improves the stability of occipital fractures.

Anterior Cervical Fusion

Over the past two decades, a range of established procedures have emerged to tackle pain and neural issues associated with cervical vertebrae conditions. These encompass foramenotomy or posterior unroofing for root pain caused by cervical disk protrusion, laminectomy and dentate ligament sectioning for spinal cord compression, and posterior fusion for pain arising from neck instability.

Additionally, anterior cervical fusion is a common procedure for patients experiencing neck pain, radiating symptoms, and signs of disk degeneration. Optimal results have been noted in cases confined to one or two segments of the lower cervical vertebrae.

The procedure is performed under general anesthesia with endotracheal intubation. An incision is made above the left clavicle to reach the cervical vertebrae. Lumbar puncture needles are used to evaluate the condition of the affected disk spaces.

Degenerated material is removed and a graft from the iliac crest is inserted to repair the disks. The incision is closed, and the patient is kept in a supine position for 24 hours. Ambulation is allowed after 48 hours, and a cervical brace is worn for three months. Complications are infrequent and can be prevented with meticulous surgical technique.

Anterior Cervical Spine Biopsy, Excision Of Spurs, And Curettage

Access to the entire cervical vertebrae is achievable through the longitudinal incision technique described. This approach allows for various procedures such as cleaning infections, excising tumors, and performing drainage. Excision of localized tumors in the C1 and C2 vertebrae can be conducted via the pharynx. Removing spurs can provide relief from dysphagia caused by cricopharyngeus interference.

Thorough examination and imaging are vital for confirming the association between the spur and swallowing difficulties. Effective management necessitates collaboration among otolaryngologists, radiologists, and orthopedic surgeons.

Do you have more questions?