The Surgical Approach to Subaxial Cervical Spine Injuries

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$Crescent fracture-dislocation of the sacroiliac joint$

Subaxial Cervical Spine Injuries • Dvorak et al 2621 Table 1. Subaxial Injury Classification (SLIC) Scale Points Morphology No abnormality 0 Compression burst 11 2 Distraction (e.g., facet perch, hyperextension) 3 Rotation or translation (e.g., facet dislocation, 4 unstable teardrop or advanced staged flexion compression injury) Discoligamentous complex Intact 0 Indeterminate (e.g., isolated interspinous 1 widening, MRI signal change only) Disrupted (e.g., widening of anterior disk 2 space, facet perch or dislocation) Neurological status Intact 0 Root injury 1 Complete cord injury 2 Incomplete cord injury 3 Continuous cord compression (neuro modifier 1 in the setting of a neurologic deficit) The SLIC scoring system can be used to direct treatment into the broad categories of either surgical or nonsurgical by summing the points in each of the 3 categories outlined in Table 1. Injuries which score 5 or more points on SLIC are all treated surgically, whereas those scoring 3 or less are treated nonsurgically. A score of 4 is considered equivocal. Once the SLIC scoring system suggests that a specific injury should be treated surgically, the surgeon must decide which single or combination of surgical approaches to use. Although the SLIC classification guides the physician to either operative or nonoperative treatment, it does not assist in the choice of surgical approach. Currently, there is no evidence-based algorithm that would provide surgical treatment options and specify which approach should be used. This article focuses on the choice of surgical approach once the decision to operate has already been made. Evidence-based medicine is simply not just the best available systematic research, but must also integrate clinical expertise and the growing realm of patient preference. A systematic review is an exhaustive objective review of the pertinent literature around an a priori research question and is recognized as the optimal design for literature review. Clinical experts can use their experience and knowledge to strengthen and optimize research-generated guidelines. The Spine Trauma Study Group (STSG) is such a group of experts. It is composed of 48 spine surgeons (neurosurgical and orthopaedic) who have committed a substantial portion of their clinical practices and research to the provision of care to spine trauma patients. Finally, and increasingly more importantly, surgeons are relying on patient preference to guide management recommendations and decisions. Patient acceptance of devices such as the halothoracic-vest are an example of this. 12 Patients have been empowered in the treatment decision armed with information around probabilities of outcome, health-related quality of life, complications, and care paths. Although there is a limited amount of published literature that recommends specific surgical approaches for certain injuries, the published articles to date each have 1 or more significant limitations: exclusive reliance on local experience; lack of consideration of the global experience in the literature; and failure to use well-described nomenclature to define the study population. There were 2 principle objectives of the present study: (1) to undertake a qualitative systematic review of the literature on surgical treatment approaches for various subaxial cervical spine injuries; and (2) to integrate this literature review with the consensus opinion of experts from the STSG and the SLIC scoring system to propose an evidence-based algorithm to manage these injuries. This algorithm would be based on the 3 principal morphologic categories, while incorporating the other 2 interrelated SLIC categories, namely, neurology and discoligamentous complex integrity. By building on the foundation of the SLIC scoring system and by adding an evidence-based treatment algorithm which specifically addresses the optimal surgical approach for subaxial cervical injuries, we intend to improve patient outcomes and facilitate education and clinical research. Methods Systematic Review For a given question, it is generally accepted that when homogeneous level 1 studies are not available, quantitative systematic review or meta-analysis cannot be done and a qualitative systematic review becomes the design of choice. This particular study lends itself well to a qualitative review as we are able to apply the various levels of evidence to our broader question around appropriate surgical approaches. Therefore, we categorized these studies according to their level of evidence and their appropriateness to the research question. Unique to this qualitative review is the inclusion of biomechanical studies that are particularly relevant to the question being asked. Inclusion or Exclusion Criteria. The criteria used to include studies in this review were determined a priori and considered the following factors: (1) the population that was studied in the article; (2) the intervention that was being reported on; and (3) the outcome measures that were reported in the article. To be included in this literature review the study had to have adult patients (age 16 years) with subaxial cervical traumatic injuries from C3 to T1 inclusive treated surgically with anterior, posterior, or combined anterior and posterior surgical approaches. The study had to measure the radiographic and/or clinical success of the treatment using validated outcome measures and/or radiographic measures and must have described the surgical approach used. The most common reasons for exclusion of what appeared to be appropriate studies were; failure to specify the surgical approach used in treating a cohort of patients, the use of outdated surgical techniques, which are no longer used or relevant (Cloward Procedure in cervical trauma, sublaminar wires, etc.), failure to adequately describe the injury patterns treated, and the inclusion of a heterogeneous population, i.e., nontraumatic conditions or injuries beyond the subaxial cervical spine. Literature Review. A comprehensive literature search was performed to identify potential studies including any article with an
2622 Spine • Volume 32 • Number 23 • 2007 English language abstract. Electronic database searches of MEDLINE (1966 to November 2006) and EMBASE (1980 to November 2006) were performed using both medical subject headings and text word searching. Terms used included fracture, cervical, spine fractures, fracture fixation—internal, cervical vertebra. A search of the electronic database of CINAHL (1982 to November 2006) was conducted using the same text word search. Both the Database of Abstracts of Reviews of Effects and the Cochrane Database of Systematic Reviews were searched using text words. Reference lists from relevant articles were hand searched for additional citations. Content experts from the STSG were sought and questioned as to possible additional references. Study Selection. Two reviewers, both experienced spine surgeons, one with advanced epidemiology training, used a standardized process to evaluate the eligibility of each article. Articles were excluded based on abstract review; otherwise, all the remaining studies were assessed using the complete articles. Any disagreements between the 2 reviewers were resolved using a consensus approach. A qualitative synthesis of the published literature was performed and the conclusions drawn from this literature were used to construct the surgical approaches algorithm. The proposed algorithm, including a draft of this article, was then presented to the membership of the STSG by email for their opinion on the content and face validity of the new evidence-based treatment options. All members of the STSG were asked if they agree with the surgical approaches recommended by this algorithm and were in agreement with the content of the article or if they had major disagreements with the algorithm or the article. STSG members were further invited to propose changes to the article. After the email feedback, the algorithm was presented to the STSG members at the STSG semiannual meeting along with several representative radiographs and cases. They were discussed to assess the face validity, whether the algorithm looks valid and seems reasonable, by the STSG members of this algorithm. The consensus of the majority of members of the STSG was obtained and none of the members had disagreements with the algorithm although significant input regarding the methodology was obtained. Results In the literature search that was performed in November 2006, we identified 665 articles of potential relevance. The study selection process eliminated 526 articles by a review of the abstracts alone. An additional 113 articles were excluded after a review of their methodology and results sections. Most of these were excluded because of relevance and methodologic issues. This left a total of 26 articles that met all inclusion criteria. Of these 26 articles, 1 article presented level I evidence based on its methodology and primary question. 13 There were 3 level II articles 14–16 and 7 level III articles, 12,17–22 which are presented in Table 2. A further 15 articles 2–10,23–28 were considered as level IV evidence relevant to the question of surgical approach for Table 2. Subaxial Cervical Trauma: Surgical Approaches Paper Author Description Level of Evidence of Primary Question Topic and Conclusions Kwon et al 13 Brodke et al 14 Do et al 15 Ianuzzi et al 16 Prospective randomized trial of anterior vs. posterior surgery for unilateral facet fractures, appropriately powered Prospective randomized (by day of admission). Trial of anterior vs. posterior surgical approach, not appropriately powered Biomechanics study comparing anterior and posterior fixation Biomechanics study comparing anterior and posterior fixation I II II II 42 patients randomized to anterior or posterior fusion for facet fracture without spinal cord injury, no significant difference in time to discharge but differences in secondary outcomes 52 patients with spinal cord injury assigned to anterior or posterior surgery with no difference between groups Biomechanical comparison of modern anterior/posterior/and combined fixation in flexion distraction and corpectomy models; anterior plating was inferior to posterior Biomechanical study comparing anterior and posterior fixation following three column injury; all fixation constructs were stiffer than the intact spinal segment Beyer et al 12 Retrospective comparative study III 36 patients with unilateral facet injuries treated non-operatively and operatively; surgical treatment had better results Elgafy et al 17 Retrospective case-control study III 65 patients with cervical fracture dislocations treated with posterior fixation; radiographic failure correlated with ligamentous bilateral facet subluxations and high degree of kyphosis at injury Fisher et al 18 Retrospective comparative study III 45 patients with teardrop fractures treated in halo and with corpectomy and anterior plate. Improved radiographic outcomes in the surgical group Hadley et al 19 Qualitative systematic review of class III and IV studies III Guidelines for management of subaxial cervical injuries suggest that anterior and posterior fixations are both valid treatment options Johnson et al 20 Retrospective case-control study III 87 patients with facet injuries treated with anterior plating: radiographic failure tended to occur in patients with endplate fractures and facet fractures Lifeso and Colucci 21 Retrospective comparative study III 29 retrospective controls and 18 prospective patients suggesting anterior fusion has improved outcomes over posterior or nonsurgical Toh et al 22 Retrospective comparative study III 31 burst fractures and teardrop fractures treated anteriorly and posteriorly. Anterior fusion was preferred for spinal canal decompression
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