Spinal fractures, spinal cord injuries, and nerve root injuries are commonly encountered entities for spine surgeon. While many cases have well-researched presentations, outcomes, and standards of care there are many patients for which the appropriate clinical management is less clear. Other patients present with injuries with clear treatment preferences that are impossible to implement based on comorbidities or preference. The authors present a few recent cases of spinal injury where multiple treatment pathways could be considered and individual patient-related factors changed the course of treatment.
Key points
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There is a substantial degree in heterogeneity in spine trauma. Some injury patterns are well recognized and have well defined treatment recommendations but many do not.
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Care often needs to be individualized for patients with “non-standard” injuries, those with major medical co-morbidities, and those where there is no clear consensus on treatment strategy.
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Understanding of pertinent anatomy and the natural history of spinal fractures will help in formulating these treatment plans.
Cases
Case 1: Odontoid Fracture with Subsequent Stable Pseudoarthrosis
A 79 year old man with a past medical history significant for atrial fibrillation and remote history of pulmonary embolus on chronic anticoagulation with apixaban, obstructive sleep apnea, gastro-esophageal reflux disease, and depression presented to the emergency room after stepping on an ice cube on his kitchen floor, falling and striking the back of his head. He experienced severe neck pain after his fall, prompting his emergency room evaluation. Given the presence of his neck pain, he was placed in a rigid cervical collar by emergency room providers and a computed tomographic (CT) scan of his neck was obtained ( Fig. 1 A ) demonstrating a minimally displaced type 2 odontoid fracture (Anderson and D’Alonzo classification) in addition to a unilateral fracture of the posterior arch of C1 and an osteophyte fracture at C6-7. He demonstrated no neurologic deficits on physical examination. Beyond his neck pain, the patient had no neurologic complaints.
He was admitted to the hospital where he was formally seen by the orthotics team to ensure appropriate fitting of his rigid cervical collar. He was evaluated by physical therapy, occupational therapy, and the swallow team and was found to have no issues with dysphagia or swallowing while being managed in the cervical collar. He was trained on appropriate brace donning/doffing and care. Upright AP, lateral, and open mouth views were obtained in his collar and found stable alignment of the cervical spine in the upright position ( Fig. 1 B). He was started on vitamin-D supplementation for his radiographic evidence of osteopenia.
He was discharged from the hospital without complication and was seen in follow-up 6 weeks after his presentation. He continued to have no neurologic deficits and his neck pain was improving. Repeated plain film radiographs at that time again demonstrated normal alignment of the cervical spine and odontoid fracture but with continued lucency along the fracture line of the odontoid fracture ( Fig. 1 C). Due to the radiographic evidence of incomplete healing, the patient was kept in his cervical collar for an additional 6 weeks.
Three months following the injury, a repeat CT scan of his cervical spine ( Fig. 1 D) demonstrated lack of bony fusion at the odontoid, albeit there was some evidence of bone growth along the most posterior aspect of the fracture line. His C1 arch and C6-7 osteophyte fractures had healed. Alignment was maintained. A discussion was had with the patient about his ongoing treatment options including posterior C1-2 fusion, continuing with the cervical collar, or removing the collar and living with stable pseudoarthrosis. The patient elected to continue in the collar.
Four and a half months following the injury, an additional CT scan ( Fig. 1 E) demonstrated no further healing of his odontoid fracture. Dynamic flexion/extension radiographs of his cervical spine were also obtained at this clinic visit to evaluate for abnormal motion at his fracture level ( Fig. 1 F). There were no signs of instability on flexion/extension films. The patient opted to continue nonoperative management and began a gentle range of motion exercises for his neck and was followed again in clinic 6 months following the injury. Follow-up at that time with repeated dynamic cervical radiographs ( Fig. 1 G) demonstrated no abnormal motion and stable pseudoarthrosis. The patient continued to do well clinically and had no significant complaints. He was referred to our institution’s osteoporosis clinic for a formal bone health evaluation. He will be seen again at 1 year following the injury.
Discussion
C2 fractures are common traumatic injuries in geriatric populations and are only becoming increasingly common in an aging population with type 2 odontoid fractures representing the most common fracture pattern. , Nonunion in type 2 odontoid fractures is more common among patients aged greater than 50 years. It is also established that surgical fixation yields significantly higher fusion rates (>74–80% depending on the study) compared to those managed in a hard collar or halo device (40%). , As patients advance in age and accrue comorbid conditions that increase the perioperative risks of cervical spine surgery, hesitancy for operative fixation is understandable. Frangen and colleagues documented an 11% mortality rate in their retrospective operative cohort that underwent posterior fusion from cardiac issues, pulmonary failure, or pneumonia. Schoenfeld demonstrated in his retrospective cohort study that type 2 odontoid fractures regardless of management type are associated with high rates of mortality, 39% in all comers within 3 years of presentation. His study did display decreased mortality rates in the operative group compared to the conservatively managed group (both Halo immobilization and rigid collar being included in this group); however, this was not statistically significant. Conversely, systematic review and metanalysis by Alvila and colleagues did demonstrate significance (13.2% mortality in the operative cohort compared to 19% mortality in the nonoperative group). , Unsurprisingly, the operative cohort is more likely to suffer complications such as tracheostomy placement, reintubation, or feeding tube placement. , It should be noted that management of these fractures in cervical collar is not without complications themselves; however, these tend to be less severe (neck pain, stiffness, skin complications, etc.). Any interpretation of this literature must be made with the realization that patients were selected for fusion for a reason, and it is likely patients who were poor surgical candidates were less likely to be selected for operative intervention.
Older age and major comorbid conditions are often cited as the rationale for opting for nonoperative management of these fractures. The authors’ preference in management of C2 fractures in the elderly is to trial a period of immobilization in the absence of gross ligamentous injury (rare in the elderly) and reserve operative fixation for failures of immobilization. Ultimately, engaging patients and their families in clear risk–benefit discussions allowing for them to exercise their autonomy based on their own perceptions and opinions of what constitutes acceptable risk is vital. The patient and his family in our case example were approached multiple times regarding the option of posterior fusion; however, when armed with the best information we could give them in the context of this patient’s constellation of comorbidities, they continued to opt for collar therapy. Stable pseudoarthrosis, although not the ideal outcome, is an acceptable result for many patients who have suffered type 2 odontoid fractures. Harris and colleagues demonstrated in their cohort study that of their patients who underwent collar therapy and who did not achieve bony fusion, none of them had bothersome symptoms. Our patient was extensively counseled not only on the risks during his collar therapy but also the risk of subsequent pannus formation adjacent to a pseudoarthrosis. Given the patient’s experience with his cardiac and pulmonary comorbidities, he greatly favored the risk of a possible cervical myelopathy from a hypothetical pannus formation down the road than to the perioperative risks and loss of motion associated with C1-2 fusion now. Stable pseudoarthrosis, in the setting of continued neurologic stability and lack of troubling symptoms such as pain, may be considered a reasonable endpoint in patients with type 2 odontoid fractures who are felt to be of high surgical risk or who prefer conservative management.
Case 2: C4 Flexion Teardrop Fracture with Significant Ligamentous Injury
A 59 year old man with no significant past medical history was swimming in a pool when he swam into the pool’s wall, striking his head. He was immediately unable to move his limbs after the collision with the wall and was pulled out of the pool by witnesses. Over the course of an hour, he slowly returned to his neurologic baseline. He was brought to an outside facility where a CT scan of the cervical spine was obtained ( Fig. 2 A ) and demonstrated an apparent flexion-teardrop fracture at C4. This was initially interpreted as and presented to our surgery team a “minor teardrop fracture.” Computerized tomographic angiogram (CTA) of the neck also demonstrated bilateral pseudoaneurysms of the carotid arteries secondary to blunt trauma requiring aspirin therapy for stroke prevention. He was transferred to our trauma center and was found to be neurologically intact without any motor or sensory abnormalities. He underwent cervical spine MRI ( Fig. 2 B) based on his history of complete quadriparesis immediately after his injury. His MRI was significant for evidence of disco-ligamentous injury at the C4-5 level with disruption of the anterior longitudinal ligament (ALL) at this level. MRI further demonstrated increased T2 signal intensity within the C5-6 disk space.
Based on the unexpected MRI results, the patient was treated with a 2 level anterior cervical discectomy and fusion at C4-5 and 5-6. Intraoperatively the patient was confirmed to have complete disruption of the ALL, disk space fractures at both C4-5 and C5-6 and a partial thickness tear of the dura at the C5-6 level secondary to his injury. There was no clear cerebral spinal fluid (CSF) leak from this partial thickness tear; however, the defect was covered with a dural surgical sealant regardless (DuraSeal). The arthrodesis was then completed in the standard fashion. The patient was fitted in a rigid surgical orthosis postoperatively and underwent brace training and evaluation by our physical and occupational therapy teams. He continued to have no neurologic deficits postoperatively and no signs or symptoms of CSF leak. He was discharged on postoperative day 2.
Six weeks following surgery, anterior-posterior (AP) and lateral cervical spine radiographs ( Fig. 2 C) demonstrated no hardware complications and stable alignment. His cervical collar was removed and restrictions were lifted. He has been separately followed for his carotid artery injuries by our neuroendovascular colleagues who have maintained him on aspirin therapy and serial monitoring of his blunt cerebrovascular injuries.
Discussion
Flexion teardrop fractures were initially named by Schneider and Cann and may represent as many as 15% of traumatic cervical spine injuries. According to Torg and colleagues’ biomechanical study evaluating roentgenographic features of these injuries as observed from the National Football Head and Neck Injury Registry, similar appearing anteroinferior body corner fractures may represent either isolated fractures or 3 column, 2 plane fractures associated with sagittal vertebral body fracture, as well as fracture of the posterior elements. Unsurprisingly, 3 column injuries tend to be associated with quadriplegia, whereas isolated fractures tend not to be associated with permanent neurologic deficit. Flexion teardrop fractures are most common at the C5 level questionably secondary due to the stress placed on this vertebra during flexion as a result of its usual lordotic alignment. Splaying of the posterior elements may also be seen. The presence of these fractures should raise alarm for concomitant ligamentous injury and instability across the spinal columns. This was true in our vignette with evidence of complete ligamentous disruption at 2 levels. These fractures may commonly be confused by the extension teardrop fractures given the similar shapes of the fractured bony fragment. Unlike their flexion counterparts, extension teardrop fractures are oftentimes considered more “minor” injuries and are far less associated with neurologic deficits. Extension teardrop fractures are less common than flexion teardrop fractures (∼11.6% of traumatic cervical spine injuries at one institution) and tend to have a clinical history of extension type force on the cervical spine (blow to face or jaw, etc.). They are also more likely to occur at higher cervical spine levels (ie, C2).
Treatment of these fractures varies drastically with flexion teardrop fractures often requiring fixation of an unstable spinal column and extension fractures being treated conservatively. , There is limited literature on the optimal management of these flexion-type fractures, although generally anterior cervical decompression and fusion are generally discussed in the literature with favorable outcomes and minimal complications. , , Alternatives to surgical fixation include halo device placement; however, the latter has been associated with significantly increased mean cervical kyphosis in the halo group compared to their cohorts who underwent anterior corpectomy and plating.
When evaluating so-called “teardrop” type fractures, emphasis should be placed on understanding the exact injury mechanism in addition to close inspection of radiographic features that can clue surgeons into fully understanding injury morphology and spinal stability. While extension teardrop fractures tend to have a more benign course amenable to conservative management flexion, teardrop fractures are highly concerning for unstable 3 column injuries. Surgeons should always interpret radiographic images themselves, have a high index of suspicion for more insidious injury, and take thorough and complete patient histories.
Case 3: Bilateral Jumped Lumbar Facets
The next patient is a 48 year old man with a past medical history of coronary artery disease with the remote placement of cardiac stents on dual antiplatelet therapy who was involved in a logging accident. On arrival, his neurologic examination revealed no deficits. CT scans of his chest and abdomen revealed several rib fractures, a left renal laceration, a splenic laceration, and a hemothorax. His renal and splenic lacerations demonstrated evidence of active extravasation. CT scans of his thoracic spine revealed a nondisplaced fracture of the left T12 pedicle and CT scan of the lumbar spine demonstrated jumped and locked facets bilaterally at L5-S1 with subsequent 1.3 cm anterolisthesis of L5 on S1 ( Fig. 3 A ).
