Indian Journal of Neurotrauma 2019; 16(01): 45-48
DOI: 10.1055/s-0039-1700313
Invited Article
Neurotrauma Society of India

Traumatic Cervical Spondyloptosis: Review of Literature and Case Report

Hitesh Inder Singh Rai
1  Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
,
Kanwaljeet Garg
1  Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
› Author Affiliations
Further Information

Address for correspondence

Kanwaljeet Garg, MBBS, MCh
Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences
New Delhi 110029
India   

Publication History

Publication Date:
23 October 2019 (online)

 

Introduction

Spondyloptosis is defined as complete intercorporal displacement which was first described in cervical spine by Bhojraj and Shahane.[1] Only a few case reports have been documented in literature as described below in the review of literature.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] Being a rare entity, several different management options have been described in literature ranging from conservative to 540-degree fusions.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] In this article, we have done a thorough review of literature on traumatic cervical spondyloptosis and also included our experience of a case we managed at our center.


#

Review of Literature

Studies describing cervical spondyloptosis are summarized in [Table 1].

Table 1

Summary of reports of spondyloptosis published in literature

Study

Age/Sex

Level of injury

Mechanism of injury

Neurology preop

Neurology postop (follow-up)

Type of reduction

Surgery

Complications

Abbreviations: ACDF, anterior cervical discectomy and fusion; ACD-PF-AF, anterior cervical discectomy and posterior and anterior fusion; ASIA, American Spinal Injury Association; CSF, cerebrospinal fluid; FFH, fall from height; RTA, road traffic accident; VA, vertebral artery.

Bhojraj and Shahane (1992)1

8/F

C6–7

Obstetric palsy

ASIA C

ASIA B

None

C5–7 corpectomy + anterior fusion without instrumentation

None

Amacher (1993)17

7/M

C7-T1

Neck pain + hyperreflexia

Stable

Anterior cervical fusion C6-T1 + Posterior fixation C6-T3

Sharma (2005)9

15/M

C4–5

Fall from two-wheeler

Quadriplegic

Grade 3–4 power

Closed

C4–5 ACDF + plating

None

Lee et al (2007)18

65/M

C7-T1

FFH

ASIA D

ASIA D

Open

Anterior C7–T1 discectomy and C7 corpectomy + C7 Laminectomy + facetectomy + C5-T2 instrumented fusion + anterior fusion with Pyra mesh (ACD-PF-AF)

Posterior dural injury with CSF leak managed by lumbar drain

72/M

C7-T1

FFH

ASIA E

ASIA E

None

Conservative

Only 3 mo follow-up

Menku et al (2004)19

35/M

C6–7

RTA

ASIA E

ASIA E

None

C5–6 ACDF + plating + C4–6 posterior instrumented fusion (ACD-PF-AF)

None

Tumialán et al (2009)8

39/M

C7-T1

RTA

ASIA E

ASIA E

Closed with 60 lbs

C7-T1 ACDF + plating f/b C5-T2 posterior instrumented fusion

None

Acikbas and Gurkanlar (2010)7

42/M

C7-T1

RTA

ASIA E

ASIA E

Closed

C7-T1 ACDF + plating f/b C4-T3 posterior instrumented fusion

None

Srivastava et al. (2010)11

35/M

C3–4

FFH 20 ft

ASIA E

ASIA E

Closed with 4 kg

C3–4 ACDF + plating

None

Chadha et al (2010)12

35/M

C6–7

FFH 10 ft

ASIA A

ASIA A

Closed with 9.07 kg

C6–7 ACDF + plating

Dural leak found Poor general condition

Keskin et al (2013)14

51/M

C6–7

RTA

ASIA D

ASIA E

Closed with 20 kg

C6–7 ACDF + plating f/b C6 laminectomy + C4-T2 posterior instrumented fusion

Dural leak found + lumbar drain placed postop

Dahdaleh et al (2013)13

61/M

C7-T1

RTA

ASIA A

NR

Partial closed reduction with 23.6 kg f/b open

C3-T3 posterior instrumented fusion

Reduced to grade 1

48/F

C6–7

Fall from stairs

ASIA D

ASIA E

Open

C6–7 ACDF + plating

None

51/M

C7-T1

RTA

ASIA E

ASIA E

Partial closed reduction with 45 lbs f/b open

C4-T2 posterior instrumented fusion + facetectomy

None

48/M

C6–7

RTA

ASIA B

ASIA B

Partial closed reduction with 18 kg f/b open

C4-T1 posterior instrumented fusion + facetectomy

None

42/M

C7-T1

RTA

ASIA C

ASIA D

Closed

C5-T2 posterior instrumented fusion

None

Ramieri et al (2014)20

55/M

C6–7

RTA

ASIA E

ASIA E

Partial closed reduction with 20 lbs f/b open

C3-T2 posterior instrumented fusion f/b anterior C6 corpectomy + fusion

None

Ahn et al (2015)21

32/M

C7-T1

FFH 2 m

ASIA E

ASIA E

Failed closed reduction with 27.2 kg f/b open

C7-T2 posterior instrumented fusion + facetectomy f/b C7-T1 ACDF + plating

None

Modi et al (2016)22

35/M

C6–7

NR

ASIA A

ASIA A

Failed closed reduction with 30 pounds f/b open

C6–7 ACDF

None

8/M

C7-T1

NR

ASIA A

NR

Conservative

Patient not willing

Severe spasticity with multiple bed sores and totally dependent

70/M

C7-T1

NR

ASIA A

NR

Closed

Not operated due to comorbidities and high risk

Patient expired due to the multisystem failure

Wong et al (2017)16

49/F

C5–6

RTA

ASIA A

ASIA A

Partial reduction with 13.6 kg f/b open

C5–7 ACDF + plating

Left VA dissection + occlusion

Fattahi and Tabibkhooei (2019)6

18/F

C5–6

RTA

ASIA A

ASIA A

Closed at 25 lbs

C5 corpectomy + fusion + plating

CSF leak from traction pin site f/b meningitis + hydrocephalus and death

Kim et al (2019)23

60/M

C7-T1

FFH

ASIA A

ASIA D

Open

C7-T1 discectomy via posterior approach + C6-T1 posterior instrumented fusion

None

39/M

C7-T1

FFH

ASIA D

ASIA E

Open

C6-T2 posterior instrumented fusion

None

Our case

33/M

C5–6

FFH

ASIA B

ASIA B

Partial reduction with 4 kg f/b open

C5–6 ACDF

Dural leak found


#

Case Report

A 33-year-old male had a fall from 12 to 15 feet height and sustained neck injury following which he became quadriplegic. He presented to our hospital, a tertiary level trauma center. His Glasgow Coma Scale was 15 and he was quadriplegic below the C5 level with intact sensations (American Spinal Injury Association [ASIA]-B). After initial resuscitation and securing patient’s airway, he was screened for other injuries which revealed a left-sided hemothorax, for which an intercostal drain was inserted.

X-ray cervical spine showed no head injury and grade 4 anterolisthesis of C5 over C6 with spinal canal compromise ([Fig. 1A]). Computed tomography angiography of neck showed left-sided vertebral artery injury.

Zoom Image
Fig. 1 Preoperative, intraoperative, and postoperative X-ray cervical spine showing spondyloptosis (A), intraoperative manipulation being done (B), and postoperative X-ray showing complete reduction and fixation using polyetheretherketone (PEEK) cage and anterior cervical plate (C).

He was admitted in the intensive care unit for further management. He was in acute renal failure and was not fit to be taken up for surgery. He was on inotropes which were gradually weaned off the next few days and implantable cardioverter defibrillator was removed after the lung expanded. When his vitals became stable and he was off inotropes, he was planned for surgery. X-ray neck lateral view was done before surgery which showed C5–6 spondyloptosis.

On the day of surgery, intraoperative cervical traction was applied with a 4-kg weight which reduced the listhesis to grade 3. After confirming the C5–6 level with image intensifier, anterior cervical approach was used. C5–6 discectomy was done. After freeing the uncovertebral joints bilaterally and adequate soft tissue release, listhesis was reduced completely by intraoperative manipulation ([Fig. 1B]). Cerebrospinal fluid (CSF) leak was seen (noniatrogenic), which was plugged with tissue glue. C5–6 anterior cervical discectomy and fusion (ACDF) using polyetheretherketone cage was done and plating done thereafter ([Fig. 1C]). A posterior surgery was planned to be done few days later as the patient’s general condition was so good that he can tolerate anterior and posterior surgery in one go.

Postoperatively, he was on ventilator support with no changes in neurological examination. After a week of surgery, the patient developed meningitis for which appropriate antibiotics were started. Subsequently, he developed hydrocephalus for which external ventricular drain was placed. But the patient could not recover and died few weeks after surgery.

Discussion

Spondyloptosis represents the highest grade of instability with three-column involvement and complete segmental disruption. Cervical spondyloptosis is a rare entity that can be caused by trauma, congenital causes, or tumors of the spine.[2] [3] Several management strategies have been described in the literature.

Due to the severe nature of injury and dislocation, most patients present with deficits with very few having intact neurology as first described by Ozdogan et al in 1999.[4] Our patient presented with complete loss of motor power and the sensation was intact below the C5 level (ASIA-B).

Preoperative reduction of dislocation with traction has been utilized by most of the surgeons but with only a few achieving complete closed reduction[5] [6] [7] [8] [9] [10] [11] [12] while others have to do open reduction. We could only achieve partial reduction till grade 3 on applying traction preoperatively. However, Dahdaleh et al have given an algorithm to use closed reduction method only if there is no anterior compression on the spinal cord, otherwise patient can have increased neurological deficits.[13]

While attempting open reduction after failed/partial closed reduction, all the authors have used posterior approach to release the muscle/ligaments ± facetectomies. We have used only anterior single-step approach to reduce the listhesis completely and then did ACDF.

Regarding complications, CSF leaks due to high-grade dislocation (noniatrogenic) have been seen by few authors including us but none of the authors reported meningitis or wound leaks afterwards.[12] [14] Our patient had meningitis which led to hydrocephalus and subsequent septicemia leading to death of the patient.

Basilar artery thrombosis[15] and vertebral artery thrombosis[16] have also been reported. Our case also had left vertebral artery thrombosis preoperatively which was managed on anticoagulants postoperatively without any posterior fossa ischemic events.


#
#

Conflicts of Interest

None declared.


Address for correspondence

Kanwaljeet Garg, MBBS, MCh
Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences
New Delhi 110029
India   


Zoom Image
Fig. 1 Preoperative, intraoperative, and postoperative X-ray cervical spine showing spondyloptosis (A), intraoperative manipulation being done (B), and postoperative X-ray showing complete reduction and fixation using polyetheretherketone (PEEK) cage and anterior cervical plate (C).