Clinical data of 39 cases of cervical dislocation from April 1990 to March 2008. Segments: C1-215 cases, 20 cases of lower cervical segment, and 4 cases of spinal cord injury without obvious fracture dislocation. Among them, there were 10 cases of arthrosis interlocking. Spinal cord injury: 9 cases of grade A, 8 cases of grade B, 5 cases of grade C, 8 cases of grade D, 8 cases of grade E, and 1 case of nerve root symptoms only. 32 cases underwent early, rapid, weight-increasing traction treatment. 17 cases underwent surgery. Results The success rate of traction repositioning was 90%.
The average improvement in spinal cord injury was 0.63 grade. Six cases died, all of which were arthrogryposis interlocked with severe spinal cord injury. Conclusion In the treatment of cervical dislocation by rapid repositioning traction, it is necessary to closely observe the condition and strictly prevent excessive traction. Whether to operate should be considered based on the repositioning situation, MRI performance, spinal cord injury, and general condition and condition.
Cervical dislocation can be combined with different degrees of spinal cord injury. In response to different conditions, timely relief of spinal cord damage by various pathological factors, while grasping the need not to increase the patient’s pain and burden, is a major decision we face. In this paper, we summarize the data of 39 cases of cervical dislocation admitted from April 1990 to June 2007 and discuss with our colleagues in terms of treatment strategy by combining the relevant literature on the notification of critical patients’ conditions, traction methods and complications, mastery of surgical indications, and selection of surgical methods.
1. Clinical data
1.1 General data Among the 39 cases in this group, 29 were male and 10 were female; their ages ranged from 6 to 74 years, with an average of 40 years (average of 26.23 years for C1-2 and 44.13 years for the lower cervical segment). All cases had a history of trauma. Segments: C1-215 cases, C3-41 cases, C4-57 cases, C5-67 cases, C6-75 cases, and 4 cases of spinal cord injury without obvious fracture dislocation. According to Frankel’s classification: 9 cases of grade A, 8 cases of grade B, 5 cases of grade C, 8 cases of grade D, 8 cases of grade E. Only 1 case had nerve root symptoms.
1. 2 The lateral radiographs of the cervical spine showed that the cervical interval (ADI) was >3 mm in adults and >5 mm in children in 15 cases of C1-2 dislocation, including 5 cases of dentition deformity, 1 case of skull base depression and 5 cases of fracture (including 2 cases of dentate fracture). There were 20 cases of dislocation of the lower cervical segment, and the lateral radiographs showed more than 2 mm of anterior displacement of the upper cervical spine, including 10 cases with arthrogryposis locking and 8 cases with fracture. There were 4 cases without obvious fracture and dislocation, and all of them had obvious disc protrusion by MRI examination.
2. Treatment plan
Among the 39 cases, 2 cases were admitted to hospital with respiratory failure and died after resuscitation. The remaining 37 cases were treated with anti-inflammatory, decongestive and neurotrophic therapy, and 32 of the 33 cases with subluxation were treated with traction according to their condition (one case died 30 hours after admission because she did not agree to traction treatment). Traction was performed by occipito-mandibular belt or cranial traction. The weight of cranial traction started from 3-4 kg, and the weight was increased by 2-3 kg each time with an interval of 1-24 h. The maximum weight was 14 kg. 29 cases were successfully repositioned; 15 of them continued traction for 1-3 months after reduction and then changed to cephalothoracic cast or support belt fixation; 12 cases were subsequently treated with surgery; 2 cases died on the second and ninth day after repositioning. 3 cases were unsuccessfully repositioned, and 1 case was changed to surgery; 1 case was One case was discharged automatically; one case died after rapid traction and manual repositioning. 17 cases were treated surgically.
Eight cases were C1-2 dislocations, six of which were treated with posterior decompression and occipitocervical fusion; one with anterior fusion; one with anterior dentate resection and posterior occipitocervical fusion; five cases were treated with lower cervical dislocations, three of which were treated with anterior decompression and bone graft fusion and internal fixation with plates; two were treated with posterior decompression and internal fixation. In four cases without significant fracture dislocation, three of them were treated with anterior discectomy, bone graft fusion and plate internal fixation; one was treated with posterior single-door canal enlargement.
3, Results
Among the 39 patients, 6 died, all of them were dislocated lower cervical segment with arthroplasty, and the spinal cord injury was grade A. 25 cases were followed up for 3-36 months, including 3 cases of grade A to grade B, 1 case; 6 cases of grade B to grade C, 4 cases; 3 cases of grade C to grade D, 2 cases; 7 cases of grade D to grade E, 5 cases; the average improvement was 0.63 grade. 6 cases of grade E had no change.
4, Discussion
4.1 Treatment of critically ill patients, critical condition must first inform the family to obtain their support and understanding Cervical dislocation varies greatly. Arthrosis interlocking is often combined with spinal cord injury, and the condition is critical, and the injured segment above C4 can be life-threatening. In this group, there are 2 patients who were admitted to the hospital with respiratory failure and died after immediate resuscitation. For such patients, in addition to active resuscitation, failure to take other effective treatment has basically become a consensus. However, for patients with severe spinal cord injury, but whose general condition and vital signs were stable at the time, how to treat them was a major decision for the medical staff.
This is the period of inflammatory edema after spinal cord injury, and the continued spread of traumatic inflammation can be life-threatening. (In one case in this group, the family did not agree to cranial traction treatment with surgery and died of respiratory failure 30 hours after admission.) On the other hand, in terms of treatment principles, spinal cord compression must be resolved as soon as possible, and any moving, throwing light, traction, anesthesia and surgery may affect spinal stability and stimulate the spinal cord. The two are intertwined and to some extent influence the decisive decisions of the medical staff. Cases of exacerbation and death during consultation and treatment have also been reported in the literature
. It has been suggested that surgery is best performed after one week. At this time, surgery is subject to greater risk, and in addition to being conscientious and responsible, the family must be informed of the severity and complexity of the condition to obtain their understanding and support and avoid doctor-patient disputes.
4. 2 Choice of traction method and prevention of complications The choice of traction method varies according to the condition. For crico-pivotal cone subluxation without spinal cord injury, occipitomandibular band traction is generally performed. It has been reported [2] that the addition of orthopedic manipulation is more effective, and attention should be paid to the correct technique. For obvious dislocation, cranial traction is performed. In the past, traction weight of 3-4 kg was used, and the weight was increased by 2-4 kg day by day with daily photo review, and generally 10-12 kg can be reset.
After successful repositioning, the weight was reduced to 2-4 kg in the over-extended position, and the traction was maintained for 1-3 months and then changed to external fixation. This method takes too long, and failure to understand the successful reset and reduce the amount in time may cause serious consequences, and there are two cases in this paper. In recent years, many scholars have adopted the method of rapid repositioning by increasing the weight one by one for those with interlocking synapses, so as to know whether the repositioning is successful in time. There are also reports of rapid repositioning with manipulation.
The method is used every 30 minutes, with additional manipulation when the articular eminence is on top of the eminence. It should be noted that the rapid repositioning method of traction should be more closely monitored for vital signs and neurological function changes, to prevent decoupling and overdrawing, and the rapid repositioning method is also used in this paper, with relevant personnel according to emergency surgery before treatment. This requires a renewal of concepts and the support of the relevant departments and leaders.
4.3 Indications for surgery
4.3.1 Whether to operate immediately for arthrogryposis interlocking and severe dislocation Expert opinion is divided, but the traditional method still prefers cranial traction and does not urgently require immediate surgery. Traction can be performed immediately at the bedside and has a positive effect on rapidly improving the effective space of the spinal canal. In this paper, in addition to the fatal cases, 6 out of 8 cases were successfully repositioned. As described earlier, the use of large-weight rapid traction and adjunctive manipulation resulted in shorter treatment times and higher success rates.
Even total dislocation cases were reported with six successful cases of cranial traction immediately after admission [7]. However, the success rate of repositioning is low for those with single synovial interlock, and the efficacy of advocating direct surgery has been demonstrated [3]. It has been suggested [8, 9] that for severe dislocations, the risk is too high due to the need for large weight traction, especially supplemented with manual repositioning. It is better to use tracheotomy with small traction volume and direct anterior or anterior and posterior surgery.
4.3.2 Whether surgery is needed after repositioning The traditional method is to switch to posterior surgery after traction failure. For successful cases of repositioning, cranial traction is mostly continued with external fixation. In recent years, due to the development of medical imaging, MRI shows that there are often disc herniation, vertebral body posterior margin bone and fracture, and posterior longitudinal ligament rupture on the dislocated segment. Most scholars advocate the use of anterior surgery.
In this paper, surgery was used in 12 of the 29 cases with successful repositioning. Shi reported [4] 30 cases of arthroglossal interlocking, 15 of which were successfully repositioned with MRI-confirmed disc herniation and underwent anterior surgery. Yu and Wang [1, 6] concluded that as long as there is interlocking of the articular processes, surgery is indicated regardless of successful repositioning, because the posterior tension band structure of the vertebral body, the small joint capsule, the anterior longitudinal ligament and the intervertebral disc have been damaged, and stabilization surgery is necessary. In addition, it has been suggested [10] that old lower cervical fractures and dislocations without spinal cord injury should also be operated early because of poor stability and the possibility of secondary injury.
4.3.3 Whether patients with cervical dislocation end up with indications for surgery Some scholars made a comparison between patients with fracture dislocation with primary spinal cord injury by surgery and non-surgery (family members did not agree to surgery) in 26 cases each and followed up after one year, and concluded that although the reset rate of surgery on fracture and dislocation was higher than that of the non-surgery group, there was no significant difference in the recovery of spinal cord function, which is extremely important for patients, with a P value greater than 0.05.
Whether surgery is necessary to take huge risks and high medical costs, experts’ opinions are well grounded in theory and practice. The final decision of whether to operate for cervical dislocation should be considered based on the reset, MRI performance, spinal cord injury and systemic condition.
4.4 The choice of the operation style When the interlocked articular processes are not successfully repositioned, the posterior approach is mostly used to reposition the articular processes after prying or partial resection, with wire or titanium cable fixation under the vertebral plate or lateral block plate or screw fixation. In recent years, it is advocated to perform anterior resection and decompression of intervertebral disc and injured vertebrae on the basis of posterior approach, bone grafting with locking plate internal fixation, or autologous bone grafting with bone cage and autologous bone implantation with titanium mesh.
For those with successful repositioning and MRI showing anterior disc herniation, anterior related surgery is mostly advocated.
For spinal cord injury without fracture dislocation, posterior open spinal canal enlargement and plasty or anterior surgery is feasible.
For old lower cervical fracture dislocation without spinal cord injury, combined anterior and posterior surgery is performed early. The posterior approach is performed first to release the posterior column factors obstructing the repositioning and fixation with spinal wires, and then the intervertebral scar is released through the anterior approach, and repositioning, decompression, single gap intervertebral implant and plate internal fixation are performed under direct vision.
In cases where C1-2 dislocation has been repositioned by traction, internal fixation by lateral block articular screws plus implantation of the posterior arch of the circumflex pivot; for those who can be repositioned by traction or intraoperative traction plus lifting of the posterior arch of the circumflex pivot, fixation by titanium cable; for those who do not have significant preoperative spinal stenosis and can be repositioned by traction intraoperatively, internal fixation by lateral block of the circumflex pivot, pedicle screws, and lateral block plates; for those with severe deformity of the cervical-occipital region and spinal cord compression In the case of severe cervical-occipital deformity and spinal cord compression, posterior arch resection, occipitocervical bone graft fusion, and internal fixation of the nail plate system were performed, and partial restoration was possible after surgery. In this group, there was one case of dislocation with free dentition, and an anterior transoral dentate resection and posterior occipitocervical fusion were performed.
Cervical dislocation varies greatly, and the choice of various treatment methods is very important. The constant advancement of innovative technologies requires medical staff to update their concepts and take higher medical risks. The various regulations and laws are sound and add a certain amount of pressure to the medical staff. How do we face this format, put the patient’s interests first, carefully analyze the condition, and solve the difficult decision making problems in treatment?