Cervical Trauma Resulting in Quadriplegia
The patient is a 28-year-old male, who, while intoxicated, fell 30-feet after climbing a tree to escape the police. Quadriplegia was immediate on falling. He presented at the emergency room within 20-minutes of falling.
His neurological examination revealed 5/5 bilateral deltoid, 5-/5 bilateral bicep, 4/5 wrist extension, 3/5 finger extension, and 0/5 distal with a C6 sensory level.
Figure 1: Lateral swimmer's view
Figure 3A. Axial CT scan, C5
Figure 3B. Axial CT scan, C6
Figure 3C. Axial CT scan, C7
Figure 3D. Axial CT scan, C7-T1
Figure 4. MRI, C7-T1
Figure 5. Pre-operative stage 1; axial MRI, C7-T1
Residual cervical disc herniation versus small epidural hematoma, with associated subluxation, stenosis, and spinal cord injury at the cervicothoracic junction.
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Intraoperative reduction and C5-T2 instrumentation and fusion with subsequent C7-T1 ACDF performed in an elective fashion.
Figures 6 and 7 (below) are sagittal and axial (C7-T1 level) MR images after posterior reduction, instrumentation and fusion.
Figure 7. Axial MRI, C7-T1
Figure 8: AP x-ray at 6-months
Figure 9. Lateral x-ray at 6-months
This case, of a young male who sustains a cervicothoracic fracture dislocation and profound spinal cord injury, brings up several interesting diagnostic and therapeutic implications.
First of all, the fact that the patient is intoxicated is a potential mixed blessing. Although it may impair our ability to obtain a reliable history and elicit physical examination findings, there is some suggestion that alcohol may have a neuroprotective effect. Depending upon the patient's level of intoxication, he may not be alert enough to consider a closed reduction under traction in the emergency room. Even in a patient with no distal motor sparing on presentation, it is crucial to be able to monitor the patient's neurology during closed reduction to ensure there is no progressive neurological deterioration. For these reasons, I would not favor a closed reduction in this patient.
From my interpretation of the radiographs, particularly figure 3D, which shows empty superior facets, this patient has a bilateral facet dislocation with a traumatic laminectomy, which has enlarged the patient's spinal canal and potentially preserved the spinal cord from severe injury. If the patient is sent to the MRI suite then, there is some risk of spinal manipulation with positioning and variable haemodynamic status, as the patient is not as carefully monitored while in the magnet. An alternative approach would be to proceed urgently to the operating room to perform an open anterior decompression and attempted anterior open reduction.
Figure 2B shows the level of this patient's manubrium and demonstrates that despite the cervicothoracic level of the dislocation, the anterior exposure in this patient would be relatively easy, due to the long thin neck and relatively low sternal notch. Also noting, in the same image, the inferior endplate of C7 that is directly apposed on the superior endplate of T1 suggests that any intervening disc material has to be extruded and separated from these endplates, and is either displaced anteriorly or posteriorly.
Given these findings, it is my opinion that it would be reasonable to proceed directly to the operating room and perform an anterior discectomy, distract the endplates, and remove any disc material from the spinal canal. In most cases, the posterior longitudinal ligament will be traumatically disrupted and the cord can be directly decompressed. Once all disc material has been removed, an open anterior reduction can be performed by removing the distractor from the disc space, applying traction through cranial tongs, gentle controlled flexion, and some dorsally directed pressure on the C7 body. Given the fact that both facets are dislocated and not fractured, an open anterior reduction has a high probability of success.
Once successful, an anterior interbody graft can be inserted followed by anterior plating and supplemental posterior fixation with removal of the fractured lamina. If complete anterior reduction cannot be achieved, then an interbody graft can be inserted with a buttress plate fixed only to C7, and the patient can be flipped to complete the posterior reduction, decompression, and instrumentation.
I would obtain an MRI postoperatively to ensure decompression and inform on the patients prognosis, but I do not believe that the additional risk of obtaining a MRI prior to performing the anterior cervical approach (which will almost certainly be necessary in this case) is warranted, nor do I think the information gained from the MRI would change my surgical approach.
Lali Sekhon, MD, PhD, FRACS, FICS
This is an interesting case of severe spinal cord injury presenting as an ASIA A, with a subluxation and 3-column injury at the cervicothoracic junction.
This scenario is a typical one, which faces many spine surgeons, yet remains a difficult one. No uniform algorithm for treatment exists; yet, obtaining an adequate decompression and subsequent stabilization without causing subsequent secondary injury are the objectives of management. Some surgeons would advocate immediate traction, sometimes even before the MR scan. Others, an anterior decompression and fusion and reassessment, or moving to an immediate posterior approach. Still others would advocate a posterior alone procedure initially citing the difficulty of getting a reduction from an anterior approach. Finally, the last group would perform posterior decompression and stabilization and, as long as disc height was restored, they would be happy to re-image and re-assess for an anterior approach.
There is no one correct answer. The right treatment is an algorithm of experience, familiarity with approaches, comfort levels, and response to initial maneuvers. Differentiating hematoma from disc can be problematic. In this case, I lean toward the latter given no disc space exists on CT.
The author achieved an amazing result with an appropriately long posterior construct providing reduction and stabilization across the cervicothoracic junction and then directly decompressing the C7-T1 interspace anteriorly. The ASIA A patient returned to normal. In my hands, I would have attempted traction to realign then an initial anterior decompression and stabilization with a posterior decompression and stabilization performed in the same sitting.
This case illustrates the complexity of decision-making we, as spine surgeons, sometimes face and how the goals of doing no harm, decompressing and stabilizing can be achieved in a number of ways.