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RESULTS OF SURGICAL TREATMENT OF UNCOMPLICATED SUBAXIAL INJURIES USING CORPECTOMY AND TELESCOPIC PROSTHESES: A RETROSPECTIVE COHORT STUDY
Byvaltsev V.A., Sorokovikov V.A., Kalinin A.A., Aliev M.A.
Irkutsk State Medical University, Railway Clinical Hospital at Irkutsk-Passazhirskiy Station, Irkutsk Research Center of Surgery and Traumatology, Irkutsk State Medical Academy of Postgraduate Education – the branch of Russian Medical Academy of Continuous Professional Education, Irkutsk, Russia
The cervical spine (CS) is the most common location of
spinal injuries [1]. Tetraplegia and disability are severe complications of
subaxial injuries, which require for timely diagnosis and treatment [2]. The
main objectives of specialized care for such cases are efficient decompression
of neural structures, recovery of spinal stability, and appropriate
neurological and social rehabilitation [3].
The anatomical and subaxial injuries are cervical
injuries in C3-C7 segments; more than 55 % of them are located at the level of
C5, C6 and C7 vertebrae [4]. The main causes of such injuries are road traffic
accidents, extreme sports, and falling from height [2]. 2-6 % of patients with
blunt spinal injuries have cervical spine injuries, with 10-25 % of clinical
worsening in long term period [5]. It was found that annual CS injuries are
registered in 64 patients per 100,000 of population, with 55 % of such injuries
in combination with the spinal cord injury [6]. The risk of subaxial fractures
is high among men, and the mortality reaches 20 % at older and senile age [7].
The conservative management of uncomplicated injuries
to the lower cervical spine can cause the posttraumatic instability of cervical
segments and chronic pain due to decreasing height of injured vertebrae, progressing
deformation, and decreasing sizes of foraminal passages [3, 8]. The aim of
surgical interventions for patients with traumatic subaxial injuries after
verification of orthopedic instability is decompression of vascular and neural
structures with fixation of spinal segments for prevention of deformation and
secondary liquor-dynamic disturbances [9, 10, 11].
There are not any uniform surgical approach and
techniques for stabilization of injured CS vertebrae. Ventral decompessive
stabilizing interventions are less traumatic, and they promote the direct
visualization of anterior surface of neural structures, and are considered as
surgery of choice in most cases. However, the decrease in quality of formation
of the bone block was noted in multi-level manipulations [9]. Dorsal fixation
in patients with CS injuries is associated with significant dissection of
paravertebral tissues and with quite high risk of postsurgical infectious
complications in contrast to the anterior approach. It causes the high amount of
poor clinical results in the long term postsurgical period [8].
All above-mentioned facts indicate the insufficient state
of knowledge and high social importance of the problem of surgical management
that determined the objectives and the tasks of this study.
Objective – to analyze the
results of surgical treatment of uncomplicated subaxial injuries using
corpectomy and telescopic prostheses.
MATERIALS AND METHODS
Study design
The retrospective cohort multi-center study was conducted.
Acceptance criteria
Inclusion
criteria:
1)
unstable lower cervical spine injuries (5 or more criteria of White and Panjabi
modified scale);
2)
injury severity of E degree (ASIA/ISCSI);
3) a single injury to the subaxial cervical spine – A2
type according to AO Spine [10];
4) absence of neurovisualizational signs of traumatic
changes in the spinal cord;
4) admission < 48 hours from the injury moment.
Exclusion criteria:
1) a subaxial injury as result of osteoporosis;
severity A3, B and C according to AO Spine;
2) complicated spinal injury;
3) subacute or long term period after CS injury;
4) presence of concurrent disease at the stage of
decompensation.
Realization conditions
Surgical
interventions were conducted in the Neurosurgery Center of Irkutsk Railway
Clinical Hospital.
All
patients (n = 75) were operated by the single surgical team. The left-sided retropharyngeal
approach by Cloward was used. The Caspar retractor (Germany) was used. The optical magnification was
performed with Pentero 900 (Zeiss, Germany). The intrasurgical fluoroscopic
control was realized with the electronic optical converter (Siemens, Germany).
The staged resection of adjacent intervertebral disks, removal of vertebral
body and decompression of vascular and neural formations were conducted. The telescopic
prosthesis ADD-plus (Urlich, Germany) was implanted, and screw fixation to
adjacent vertebrae with in situ distraction were performed.
Study duration
The study group was estimated for clinical neurological and radiological values before the surgery at the moment of discharge, and after 12, 24 and 36 months from the surgery moment. The minimal follow-up was 3 years, the maximal one – 5.9 years.
Study results
Main result
Efficient fixation of the operated level, and recovery of spatial relationships in the cervical spine were achieved after ventral decompression and placement of the telescopic prosthesis.
Additional results
The gender and constitutional features (gender, age, body mass index) of the patients, the parameters of surgical interventions, the postsurgical course (surgery duration, blood loss, activation time, hospital stay), the clinical data (pain intensity in the cervical spine according to VAS, satisfaction with surgery according to Macnab score), results of instrumental methods, and presence of complications were investigated.
Statistical analysis
The statistical findings were received with Microsoft
Excel and Statistica 8. Non-parametrical tests were used for analysis of
significance of differences. P value < 0.05 was considered as the lower
border of confidence. The information is presented as the median and the
interquartile range as Me (25-75 %).
The study was conducted in compliance with the
standards of Good Clinical Practice, and the principles of Helsinki Declare of
the World Medical Association. The study protocol was approved by the ethical
committees of all participating clinical centers. The article does not contain any
restricted data. The patients gave the informed consent before participation in
the study.
RESULTS
The table 1 shows the general data on patients who were included into the study. The analysis showed the prevailing cohort of men of mean age.
Table 1. The distribution of the studied patients by sex, age and constitutional features
|
Criteria |
Study group |
|
Age (years) |
32.5 (28; 56) |
|
Female gender (n, %) |
32 (42.7 %) |
|
BMI (kg/m2) |
24.7 (22.2; 26.9) |
The table 2 shows the parameters of surgical interventions, and the data of postsurgical period. The removal of one vertebral body was realized in 59 (78.7 %) cases, two bodies – in 14 cases (18.7 %), three adjacent vertebral bodies – in 2 (2.6 %).
Table 2. Characteristics of surgical interventions and specificity of the postoperative period of patients of the studied group
|
Criteria |
Study group |
|
Operation time (min) |
160 (120; 205) |
|
Blood loss (ml) |
180 (140; 235) |
|
Activation time (days) |
2 (1; 2) |
|
Terms of hospitalization (days) |
12 (10; 13) |
The catamnesis showed a significant decrease in intensity of pain in the cervical spine from 76 mm (69; 89) to 12.5 mm (6; 24) in the early postsurgical period (p = 0.0007), and to 8.5 mm (5; 17) in the long term period (p = 0.01) (Fig. 1).
Figure 1. Dynamics of the level of pain syndrome on VAS in
the cervical spine in patients of the study group
36 months after the surgery, the patients’
satisfaction according to Macnab score: excellent outcomes – 45 (60 %); good –
27 (37 %); satisfactory – 3 (4 %); poor results – 0 cases.
The fully functional bone block was identified in 12
months in 61 (81.3 %) cases, after 24 months – in 67 (89.3 %), after 36 months
– in 71 (94. %) cases.
The retrospective analysis identified some various
perisurgical complications (the table 3). Microsurgical suturing of a defect
was carried out for intrasurgical injury to dura mater. In case of registration
of intermuscular hematoma, it was drained. Prolonged antibacterial therapy was
carried out for contamination of the surgical wound. The unfavorable
consequences identified in catamnesis were the causes for revision
decompressive stabilizing interventions.
Table 3. Characteristics of registered complications in the studied group of patients
|
Criteria |
Study group |
|
Intraoperative complications, n (%) |
1 (1.3 %) |
|
Dural tears |
1 |
|
Nerve root injury |
- |
|
Early postoperative complications, n (%) |
5 (6.7 %) |
|
Formation of hematoma |
3 |
|
Surgical site infections |
2 |
|
Late postoperative complications, n (%) |
6 (8 %) |
|
Degeneration of level adjacent to surgery |
2 |
|
Pseudarthrosis |
3 |
|
Instability of fixing structures |
1 |
The figures 2-5 show a clinical case of surgical
management of a patient with uncomplicated injury to C7 vertebra (A2 type
according to AO Spine) operated with corpectomy and the body-replacing
prosthesis.
Figure
2. Cervical spondylography
before surgery: a) direct projection; damaged vertebra (CVI)
indicated by an arrow; b) lateral projection; damaged vertebra (CVI)
indicated by an arrow
Figure
3. MRI of the cervical spine
prior to surgery: a) sagittal projection, the yellow line indicates the
level of axial sections; b, c) axial sections at the level of
intervertebral disks adjacent to the CVI body
Figure
4. Cervical spondylography 6
months after corpectomy and delivery of the implant at the level of CVI:
a) direct projection; b) lateral projection
Figure
5. MRI of the cervical spine 6
months after surgery: a) sagittal projection, the yellow line indicates
the level of slices; b, c) axial sections at the level of intervertebral
disks adjacent to the CVI body
DISCUSSION
Surgical management of patients with subaxial injury
is non-unique, particularly, in terms of selection of a surgical approach [12].
In 1982, Allen and Ferguson [13] offered a classification of subaxial injures
with six categories in dependence on an injury mechanism according to
radiologic data, but without priority of a surgical technique. In 2007, Vaccaro
et al. created SLIC (Subaxial cervical spine injury classification system) [14]
for selection of management techniques by means of calculation of points
according to three criteria (injury mechanism, presence of an injury to the
disk-ligament complex, neurological status), which present the main and
independent determinants for prediction and treatment of patients.
Cervical corpectomy is a universal procedure for
ventral decompression of the spinal cord [15]. Reconstruction of the anterior
column with removal of the vertebral body is a necessary condition for
restoration of the height of an injured level and sagittal profile of CS [12].
In 2007, based on the systematic review of subaxial
injuries to CS, Elder et al. developed an algorithm for selection of a surgical
approach [16]. Selection of a surgical technique for such patient was based on presence
of an injury to the anterior supporting column and on need for visualization of
neural structures [17].
Yokota et al. [18] studied a possibility for conservative
management of CS injuries. For the period from 9 months to 9.5 years, 13
patients were examined who received the immobilization with rigid collar.
During follow-up, all cases showed the positive time course with disappearance
of neurological symptoms. Moreover, the late period showed an increase in local
kyphotic deformation. According to the authors’ opinion, besides injury
severity, such factors influence on kyphosis progression: young age, injury to
both end plates, and destruction of the posterior supporting complex.
In 2019, a metaanalysis was published, where Wengel
[19] et al. showed a relationship between modern surgical decompression of the
spinal channel and neurological outcomes. Regression of clinical symptoms was
noted after early decompression in 422 patients among 1,058 ones with complete
spinal cord injuries. The improvement in neurological status by 2 degrees and
more (according to ASIA) was 22.6 % as compared to 10.4 % in the group of late
decompression. Conversely, the comparison of groups with early and late
decompression in patients with incomplete spinal cord injuries did not find any
significant differences in degree of clinical improvement.
Khorasanizadeh M. [11] et al. conducted a
metaanalysis and identified a relationship between neurological improvement and
a degree of an injury to the supporting columns, injury level and its
mechanism, and management techniques. An improvement in ASIA by at least 1
degree was in 19.3 % of patients with A type of severity, in 73.8 % – with
degree B, in 87.3 % – with degree C, in 46.5 % – with degree D. Moreover, the
authors indicate that complete regression of neurological symptoms is not
common for degrees A and B, and it was observed in 9.2 % in the group C, and in
46.5 % in the group D.
Our study analyzed only patients with uncomplicated
unstable A2 subaxial fractures. The main aims of surgery were restoration of
the sagittal profile of CS, prevention of kyphotic deformation and of
development of neurological symptoms.
Amer M. et al. published the data on surgical
management of 20 patients with subaxial injuries [15]. The authors performed
corpectomy from the anterior approach and installed PEEK prostheses. 80 % of
cases showed the clinical improvement in mJOA score. Interbody fusion was achieved in all cases. Jain
V. et al. [3] observed the course of the postsurgical period in patients with
two-level corpectomy of the cervical spine and with stabilization using
Mesh-cage and the anterior plate. Spondylodesis was achieved in 91.3 % of cases.
Pseudoarthrosis was verified in 8.69 %.
A study by Belirgen et al. [20] showed that the
anterior approach (in comparison with the posterior one) caused lower values of
intrasurgical blood loss, better ASIA, and recovery of spatial relationships in
CS.
The potential complications of ventral interventions include
neurological disorders, vascular injuries, esophagus injuries, infections of
surgical site, and intermuscular hematomas [11]. Tasiou et al. [1] conducted a
retrospective case-control study and reported on 15 (13.1 %) cases with poor
outcomes in 114 patients with surgery from the anterior approach. All cases were
distributed into early and late. The early complications included dysphagia, liquorrhea,
soft tissue edema, intermuscular hematoma (each complication in 1.75 % of
cases); clinical worsening, recurrent laryngeal nerve injury, esophagus
perforation, superficial wound infection (each in 0.88 %). The long term
postsurgical period included degeneration, adjacent segment lesion (2.63 %); tracheoesophageal
fistula, implant malposition (each in 0.88 %).
Cervical Spine Research Society presented the data on 5,356 patients
with the most common spine abnormalities. The rate of complications after use
of the anterior approach was 0.64 %, after posterior one – 2.18 % [21].
Moreover, Aarabi et al. reported that a degree of ventral compression confirmed
by postsurgical MRI highly influenced on the long term functional outcome [22].
Telescopic constructs are widely used for CS prosthetics after
corpectomy. These implants are uniform and can be extended in situ within the
bone defect, recovering the required configuration of CS [15]. The
complications of their use include fractures of adjacent vertebrae, and
technical difficulties when installing the prostheses [13]. Some authors report
on fine results of spondylodesis formation in 93-100 % when using the
telescopic implants, as well as ADD-plus [20, 22].
The selection of the vertebral body-replacing prosthesis in
decompressive stabilizing surgery is determined by both indications for
surgical intervention, and also by material resources in a medical facility and
preferences by a surgeon. A construct type and functional capabilities are
determined individually in dependence on primary goals [18, 20].
Currently, the telescopic implants can be considered as the most perfect
and efficient for anterior approaches. When estimating such constructs, one
should estimate the ability to change their vertical size. But from other side,
distraction of endoscopic prostheses is associated with “the filling defect”,
which may prevent the appropriate spondylodesis in the postsurgical period
[17].
After review of some articles by other authors, we did not find any
principal differences between anterior decompression and implantation of
telescopic prostheses in uncomplicated subaxial injuries (the table 4). We
found improvement in long term postsurgical period with high incidence of
interbody bone block with low risk of perisurgical complications.
CONCLUSION
The retrospective study confirmed the high clinical efficiency of the anterior decompression and implantation of the telescopic prosthesis for treatment of patients with uncomplicated subaxial injuries. Moreover, the high values of bone block formation were found along with the low rate of symptomatic perisurgical complications.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the
absence of any clear or potential conflicts of interests relating to
publication of this article.
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