The Use of Vessel Loop Shoelace Technique for Closure of Wound Dehiscence Caused by Dural Tears Associated with Distractive Flexion Injury of Cervical Spine

STUDY DESIGN: A case report. OBJECTIVES: To report the use of the shoelace technique for treatment of wound dehiscence caused by dural tears. SUMMARY OF LITERATURE REVIEW: It is difficult to treat wound dehiscence caused by dural tears, as it can lead to infection, loss of soft tissue, and need for a long hospital stay. MATERIALS AND METHODS: An 18-year-old male who had been injured in a traffic accident was diagnosed with bilateral facet dislocation of C7-T1, with no neurologic deficit. Clear secretion appeared during the operation, but it disappeared after posterior fusion. The wound began to open about 3 weeks after the operation. We used the vessel loop shoelace technique to suture the wound. RESULTS: The patient had the stitches taken out in the outpatient clinic three weeks after suture. His wounds are healing without complication. CONCLUSIONS: The vessel loop shoelace technique may be a useful treatment for wound dehiscence caused by dural tears.

Delayed Diagnosed Stage 1, 2 Distractive Flexion Injury of the Cervical Spine

STUDY DESIGN: Retrospective study. PURPOSE: To examine the clinical and radiologic characteristics of patients with stage 1 and 2 distractive flexion injury according to Allen's classification and who were not diagnosed immediately after injury, and to analyze the outcomes of surgical treatments. OVERVIEW OF LITERATURE: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, attention should be paid when performing radiographs as well as when interpreting the radiographs. METHODS: The study was conducted on 10 patients (group 1) with stage 1 or 2 distractive flexion injury and who were not diagnosed immediately after injury from January 2003 to January 2009. The control group (group 2), 16 distractive flexion injury patients who were diagnosed immediately were selected. The simple radiographs, the degree of soft tissue swelling and the magnetic resonance imaging findings of the two groups were compared, and the clinical and radiologic results were examined. RESULTS: The degree of the prevertebral soft tissue swelling of group 1 was lower in group 1, and it was statistically significant (p = 0.046). The fusion was achieved in all cases (100%) in group 1, however, re-displacement as well as the loss of reduction occurred in one case, despite of delayed fusion and good clinical result. In group 2, bone fusion was achieved in 15 cases of 16 cases (94%). CONCLUSIONS: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, it is desirable to perform computed tomography if diagnosis is not clear. Even if the diagnosis is delayed, stage 1 and 2 distractive flexion injury could be readily reduced by traction, and the treatment outcomes are considered to be comparable to those of the patients diagnosed immediately after injury.

Efficiency of Anterior Interbody Fusion using Cage Packed with DBM in the Distractive Flexion Injury of Cervical Spine: Demineralized Bone Matrix vs Autoiliac Cancellous Bone

STUDY DESIGN: This is a retrospective study. OBJECTIVES: We wanted to evaluate the effectiveness and safety of a PEEK cage filled with DBM in patients with a distractive flexion injury of the cervical spine. SUMMARY OF LITERATURE REVIEW: AIF of the cervical spine using an autoiliac bone graft and plate fixation is known to be an effective treatment for traumatic injuries. However, the complications arising from the donor site are troublesome, and so fusion with cage is an alternative treatment. MATERIALS AND METHODS: We analyzed 32 cases (22 males and 10 females) with distractive flexion injury of the cervical spine. They underwent anterior decompression and interbody fusion with a PEEK cage and anterior plate fixation. In 18 patients, the cage was filled with autogenous iliac bone (Group I), and for the other 10 the cages were filled with DBM (Group II). RESULTS: All the cases in Group I and Group II achieved fusion except for one case of nonunion in group II. The anterior and posterior vertebral heights of the fused segments of group II were decreased more than those of group I, resulting a statistical difference (p=0.003). The changes of segmental lordosis (p=0.69) and the neurologic status (p=0.22) showed no statistical difference between the two groups. CONCLUSIONS: AIF using a PEEK cage filled with DBM and plate fixation showed no significant clinical differences compared to the case of iliac bone autografting. However, from a radiologic perspective, the time to achieve union was extensive and a case of nonunion was also observed. Therefore, many considerations are necessary when using DBM as a replacement for iliac bone autografting and further research should be done on this subject.

Management of Facet Joint Fracture-Dislocation of the Lower Cervical Spine with Reduction Failure / 대한정형외과학회잡지

PURPOSE: This study examined the obstacles preventing a decrease in a facet joint fracture-dislocation of the lower cervical spine after skeletal traction to determine suitable treatment guidelines. MATERIALS AND METHODS: This study examined 19 fracture-dislocation cases of the facet joint in the lower cervical spine who failed closed reduction through skeletal traction. The following parameters were analyzed: obstacles preventing reduction, neurological recovery, complications and body to canal ratio of the injured site. RESULTS: The obstacles found on MRI were herniated discs in 17 cases and joint capsule in 2 cases. The surgical decision was based on an analysis of the size and location of the disc, the degree of spinal canal stenosis and damage of the posterior structures. Anterior reduction/fusion and posterior fusion after anterior reduction/fusion, anterior fusion after posterior reduction/fusion and posterior reduction/fusion was performed in 9, 2, 6 and 2 cases, respectively. There was significant neurological recovery at the final follow-up (p=0.000). The body to canal ratio also increased significantly after surgery (p=0.000). CONCLUSION: For the treatment of unreducible facet joint fracture-dislocation of the cervical spine, pre-reduction MRI is essential for a thorough evaluation of the various underlying pathologies. In addition the surgical methods should be determined according to not only the neurological status, obstacles and pathologic structures preventing reduction, but also the surgeon's experience.

Efficiency of Anterior Interbody Fusion using Cage and Plate in the Distractive Flexion Injury of Cervical Spine : Cage vs Tricortical Autoiliac Bone / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study OBJECTIVES: We wanted to evaluate the effectiveness and safety of anterior interbody fusion (AIF) using cage and plate fixation for treating distractive flexion injury of the cervical spine according to the radiological and clinical outcomes. SUMMARY OF THE LITERATURE REVIEW: AIF of the cervical spine using autoiliac bone and plate fixation is known as an effective method for treating not only degenerative disease, but also trauma as well. However, the problem lies in the complications that occur at the donor site. To avoid these complications, the fusion method using a cage is becoming more frequently used, but there are not many reports on using a cage and plate for treating trauma in the cervical spine. MATERIALS AND METHODS: We retrospectively analyzed 47 patients with distractive flexion injury of the cervical spine and who underwent anterior decompression and interbody fusion with a autoiliac bone graft and plate fixation (Group I, 32 patients) or who underwent anterior decompression and interbody fusion with cage and plate fixation (Group II, 15 patients). We statistically analyzed the changes of the segmental lordosis, the fused segmental body height, the fusion rate on plain radiography and the neurologic recovery with using an ASIA scoring system. RESULTS: All the cases were fused by 12.6+/-2.5weeks after operation. The changes of segmental lordosis shows no statistical difference between the two groups (p=0.69). The anterior and posterior vertebral heights of the fused segments of Group I were more decreased than those of Group II, and there was a statistical difference between the two groups (p=0.03, 0.04). The initial and last follow up neurologic statuses were not statistically difference between the two groups (p=0.11) CONCLUSIONS: For the treatment of fracture-dislocation injury in the cervical spine, AIF using a PEEK cage filled with autoiliac bone and plate fixation is an effective method with the least possibility of complications at the donor site, and at the same time, this surgical method shows equally satisfactory results, both radiologically and clinically, as fusion with using a tricortical autoiliac bone graft.

Treatment of Distractive Flexion Injury in Lower Cervical Spine using Anterior Cervical Fusion / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the availability of anterior cervical plating in the treatment of distractive flexion injury of the lower cervical spine and the relationship between the neurologic findings, types of dislocation, and disc herniation. SUMMARY OF LITERATURE REVIEW: Anterior stabilization of unstable cervical spine injuries is increasing. However, the stability of anterior stabilization only is controversial for the treatment of bilateral dislocation of the cervical spine. MATERIAL AND METHODS: We retrospectively analyzed 32 patients treated with anterior decompression, auto-iliac bone graft, and anterior cervical plating, who suffered from distractive flexion injury in the lower cervical spine from Feb. 1999 to Feb. 2006. Unilateral dislocation occurred in 21 cases, bilateral dislocation in 11 cases, with evaluation of disc status at the injured level conducted after closed reduction by MRI. We statistically analyzed changes in vertebral body height, disc angle, fusion rate, neurologic recovery, and complications. RESULTS: All cases were fused by 12.3+/-2.7 weeks after operation, and the loss of anterior and posterior vertebral body height were statistically significant (p=0.00, 0.00), changes in the disc angle were not (p=0.53). Herniation of the disc was more frequent in unilateral dislocation (p=0.02). Clinically 21 (65%) patients had neurologic deficits, but nerve root injuries recovered in all cases, with the original average ASIA motor score of 55.2 improving to 68.3 at last follow up. CONCLUSIONS: Anterior decompression, bone grafting, and metallic osteosynthesis were effective treatment modalities for distractive-flexion injuries of the lower cervical spine, causing slight vertebral body height decreases but no loss of reduction or neurologic compromise.

Availability of Anterior Cervical Plating in Distractive Flexion Injury in Lower Cervical Spine: Radiologic Aspects / 대한척추외과학회지

STUDY DESIGN: A retrospective clinical and radiological analysis. OBJECTIVES: To evaluate the availability of anterior cervical plating in the treatment of distractive-flexion injuries of the lower cervical spine. SUMMARY OF LITERATURE REVIEW: Surgical approaches for distractive-flexion injuries of the lower cervical spine have included the anterior approach, the posterior approach, and the combined anterior and posterior approach. However, which approach is the most useful remains a controversial issue. MATERIALS AND METHODS: We reviewed the outcomes of 30 patients, who were followed-up for an average of 16 months (range, 12-43 months) after undergoing fusions with anterior cervical plating for distractive-flexion injuries of the lower cervical spine from July 1995 to July 2004. The average age of these patients was 52.9 years (range 24-77 years) and male-to-female ratio was 26:4. Group A consisted of 19 cases that were composed of unilateral dislocations and Group B consisted of 11 cases that were composed of bilateral dislocations based on Allen s classification. Group A1 (9 cases) and B1 (8 cases) were composed of cases that had fractures on the superior end plates or facet joints of the lower cervical spine in each group. Group A2 (10 cases) and B2 (3 cases) were composed of cases without fractures in each group. Neurologic symptoms were evaluated by the Frankel classification; and the angle of lordosis, disc height, and duration of bony union were analyzed postoperatively and with the last follow-up roentgenograms. RESULTS: Clinically, 22 (73%) patients had neurologic deficits, which were composed of 9 (41%) cases of complete injury, 7 (32%) cases of incomplete injury, and 6 (27%) cases of nerve root injury. The nerve root injuries recovered in all cases and the incomplete injuries had an average 1.7 grade recovery by the Frankel classification. Radiologically, the loss of lordosis was 2.2+/-1.7degrees in group A, 3.1+/-2.8degrees in group B (p=0.359), 3.0+/-1.6degrees in group A1, 1.5+/-1.5degrees in group A2 p=0.048), 3.5+/-3.1degrees in group B1, and 2.1+/-1.7degrees in group B2. Loss of disc height was 1.7+/-1.1 mm in group A, 2.2+/-0.9 mm in group B( p=0.201), 2.2+/-0.9 mm in group A1, 1.2+/-1.0 mm in group A2 (p=0.046), 2.5+/-0.6 mm in group B1, and 1.2+/-1.1 mm in group B2. The duration for bony union was 12.9+/-2.8 weeks in group A, 14.1+/-2.7 weeks in group B (p=0.044), 13.9+/-2.1 weeks in group A1, 11.9+/-3.0 weeks in group A2 (p=0.046), 14.4+/-2.9 weeks in group B1, and 13.3+/-2.3 weeks in group B2. There was no graft displacement, nonunion or metal failure. CONCLUSION: Anterior cervical plating was an effective treatment modality for distractive-flexion injuries of the lower cervical spine. and more firm method was necessary to surgical treatment in case of fractures on superior end plate or facet joint.

Availability of Anterior Cervical Plating According to the Severity of Injury in Distractive Flexion Injury in Lower Cervical Spine / 대한정형외과학회잡지

PURPOSE: To evaluate the availability of anterior cervical plating in the treatment of distractive-flexion injury in lower cervical spine comparing the result of circumferential fusion with the one of anterior cervical plating alone and fusion. MATERIALS AND METHODS: We retrospectively analysed 50 consecutive patients treated with surgically, who suffered from distractive flexion injury in lower cervical spine. Group A, 28 cases were composed of unilateral dislocation (Allen stage I or II) and anterior plating and fusion. Group B, 10 cases were composed of bilateral dislocation (Allen stage III) and anterior plating and fusion. Group C, 5 cases were composed of unilateral dislocation and circumferential fusion. Group D, 7 cases were composed of bilateral dislocation (Allen stage III or IV) and circumferential fusion. We statistically analysed the results such as the change of vertebral height and Cobb' angle, fusion time, neurologic recovery, fusion rate, operation time, and complications. RESULTS: The mean fusion time of each groups were 3.75+/-2.10 months in A, 6.00+/-2.82 months in B, 3.60 +/-1.34 months in C, 3.85+/-2.26 months in D and a significant difference shows between group B and A, D (Mann-Whitney U test, p=0, 012, p=0.014). In operation time, a significant difference shows between A, B and C, D. No significant difference shows the changes of vertebral height and Cobb's angle, fusion rate, neurologic recovery. In complications, distal screw loosening was 2 in A, 1 in B and delayed union was 2 in A, 1 in B. No complication was in C and D. CONCLUSION: Combined anterior posterior fixation and fusion was superior to anterior fusion alone in respect of stability and fusion rate, but it caused the increase of morbidity by long operation time. Anterior plating and fusion in bilateral dislocation shows the increase of fusion time, but there were no difference in the clinical outcome such as neurologic recovery and complications. So Anterior fusion alone could be recommended as an alternative surgical method for the treatment of bilateral facet dislocation in the lower cervical injury.