Case Reports in Orthopedics

Case Reports in Orthopedics / 2020 / Article

Case Report | Open Access

Volume 2020 |Article ID 7578628 | https://doi.org/10.1155/2020/7578628

Mohammad A. Alsofyani, Soufiane Ghailane, Sultan Alsalmi, Sreenath Jakinapally, Louis Boissière, Ibrahim Obeid, Jean-Marc Vital, "Traumatic Fracture: Dislocation of Cervicothoracic Junction—Grand Round Presentation of C7-T1 Instabilities and Different Instrumentation Techniques", Case Reports in Orthopedics, vol. 2020, Article ID 7578628, 6 pages, 2020. https://doi.org/10.1155/2020/7578628

Traumatic Fracture: Dislocation of Cervicothoracic Junction—Grand Round Presentation of C7-T1 Instabilities and Different Instrumentation Techniques

Academic Editor: Eyal Itshayek
Received18 Mar 2020
Revised13 Jun 2020
Accepted24 Jun 2020
Published01 Jul 2020

Abstract

Introduction. Acute traumatic cervicothoracic junction spinal lesions are rare disorders and poorly documented. We report a case of a traumatic cervicothoracic fracture-dislocation. We present our experience in the operative treatment of an unstable fracture-dislocation at the cervicothoracic junction. Materials and Method. A seventy-year-old man was transferred to our hospital. We found paresthesia in the corresponding dermatome of C7 and C8 bilaterally. Initial CT scan shows vertebral body fracture of T1 with retropulsion into the spinal canal and anteroposterior dislocation of cervicothoracic junction type C according to AOSpine subaxial injury. Traumatic disc material at C7-T1 was removed by anterior cervical discectomy and fusion of C6-T2. Fixation was done from C6 to T2 in the prone position. Results. At one-year postoperative follow-up, radiographs revealed bony fusion at the level of C7-T1, and the patient had no major functional disability. Conclusion. We opted for the ventral-dorsal approach in our case for maximum stabilization and to prevent mechanical complications.

1. Introduction

Traumatic injuries at the cervicothoracic junction (CTJ) are a relatively rare event and considered as a significant cause of paraparesis or paraplegia posttraumatic. As young people are most commonly injured, it is considered as a significant economic burden to the family and society. In CTJ injuries, surgical techniques and associated complications have been extensively described in the literature during the past decade, whereas the choice of anterior versus posterior or double-stage fixation has been given little attention [13]. The purpose of this study is to discuss different instrumentation techniques of this rare injury.

2. Case Presentation

A seventy-year-old male was transferred to our hospital after sustaining trauma falling down into a watercourse. The initial Glasgow Coma Scale score was 15. Upon examination, he was hemodynamically stable and breathing spontaneously; we found paresthesia corresponding with dermatomes C7 and C8 bilaterally. The rest of the neurological physical examination was normal, and the patient was categorized grade E based on the American Spinal Injury Association classification.

Cervical spine radiography and two-dimensional reconstructed computed tomography (CT) scans (Figure 1) showed vertebral body fracture of T1 and anteroposterior dislocation of CTJ type C according to AOSpine subaxial injury.

Under general anesthesia, an image intensifier was used, and 16 kilograms of halo traction was applied with full muscle relaxation; the dislocation was irreducible. Iliac crest autogenous bone grafting was harvested. A left long presternocleidomastoid to the midline approach was then made for exposing the T2 vertebral body. Traumatic disc material at C7-T1 was removed by anterior cervical discectomy. Then, as the patient had biarticular dislocation, we placed the Caspar distractor on the medial line. The dislocation was reduced partially by increasing gently the distraction. When the facets were point to point on the oblique fluoroscopic view, we pushed gently on the upper vertebra, and the reduction was achieved on the oblique fluoroscopic. Anterior fusion from C6 to T2 was performed by iliac crest bone graft and anterior plate. This technique of reduction is successful in 34% of uniarticular dislocations and 27% of biarticular dislocations [4].

Secondly, for increasing the stability of CTJ, the patient was turned to the ventral position. Fixation was done without facetectomy associated with instrumentation from C6 to T2. Screws were placed in the lateral mass of C6 and pedicular screws from C7 to T2. Cervical spine radiography (Figure 2) and computed tomography (CT) scans (Figure 3) postoperative showed complete reduction of CTJ. In the immediate postoperative period, the patient complained of transient paraplegia; postoperative magnetic resonance imaging (MRI) (Figure 4) did not show mechanical compression or epidural hematoma. The transient paraplegia disappeared on the first postoperative day. The patient was discharged to the rehabilitation center with an immobilisation collar for 2 months.

At one-year follow-up, cervical spine radiography (Figure 5) revealed a well-reduced CTJ with bone graft healing; the patient had no major functional trouble.

3. Discussion

CTJ is a region in the vertebral column where biomechanically, it represents a region where there is an inflection from mobile cervical lordosis to rigid thoracic kyphosis. Radiographically, it is not easy to visualize especially in traumatic cases. Traumatic injuries to the CTJ usually include fracture-dislocation or isolated fracture [57]. Immediate treatment includes closed reduction, followed by surgical fixation [6, 8]. The different anatomical features of CTJ [3, 9], with the peculiar biomechanical characteristics [10], require the need of a suitable surgical technique for maximum stabilization.

Nichols et al. [11] reported a 9% incidence of CTJ injury, described as unilateral and bilateral facet dislocations or true fracture-subluxation of C7-T1. Evans [12] in 1983 published one of the largest reviews to date, where he investigated 14 cases determined from 587 cervical spinal cord injuries (SCIs) during a 26-year period, providing an incidence of 2.4% of cervical SCIs.

Dislocations of the CTJ are frequently missed especially in simple cervical trauma cases visiting the emergency department. Evans [12] confirms that almost two-thirds were not well diagnosed on admission. Similar arguments have already been focused and discussed in a series of three-hundred cervical spine traumas by Bohlman [13], published over forty years ago. Traumatic lesions at the CTJ are easily missed, due to poor visualization in this area; other imaging studies such as swimmer’s view, CT reconstruction, or MRI should be carried out in suspicious cases [7].

Following trauma at CTJ, neurological problems are commonly seen. This may be due to the anatomical features of the upper thoracic spine through the small canal size, even though vascular insufficiency through the low blood supply of the lower cervical spine makes it more susceptible to ischemic injury.

A large and growing body of literature has investigated the successful results for anterior instrumentation for pathological fractures of the CTJ; the reported results of anterior instrumentation for traumatic fractures and dislocations are limited [14]. More recent attention has focused on biomechanical features regarding the adequacy of anterior instrumentation for stabilizing posterior element injuries of the cervical spine [15, 16]. Bueff et al. [17] reported in a cadaveric study that anterior fixation techniques had less stiffness than posterior fixation, especially in resisting flexion-distraction forces. Boockvar et al. [2] demonstrated that anterior instrumentation alone may not be enough biomechanically for CTJ and that combined anterior-posterior fixation and fusion may be considered to increase stabilization for fusion success.

Anterior approaches can be practically classified into a low anterolateral cervical approach, a transmanubrial-transsternal approach, and a thoracotomy [14]. The way of choosing the approach depends on the level of lesion and the surgeon’s experience. The low cervical approach is widening of the classical cervical approach medial to sternocleidomastoid (SCM); this allows access to the first and the second thoracic vertebral body [14, 18]. The transmanubrial-transsternal approach is required for the lesion down to T3 [14]. It can be done with low cervical approach for accessing the lower cervical spine. Several modifications were done for decreasing the high risk of morbidity by this approach [14]. Pointillart et al. [19] modified the approach by extending the standard anterolateral cervical approach caudally. Preoperative planning of MRI sagittal slices is mandatory as described by Sharan et al. [20]. If the sternum restricts the access, a median manubriotomy gives adequate access to the spine. The advantages of this modified approach are to protect the clavicles, sternoclavicular joints, and sternal body. If the lesion is below the T4 level, a thoracotomy has to be performed.

Posterior approach to the CTJ has been performed largely because of the technical difficulty of the anterior approach. Practically posterior instrumentation of the CTJ should always be fused, because of the instability of the CTJ. In the cervical spine, lateral mass screws are often performed in the posterior fixations. The thickness of the lateral mass is decreased from C5 to C7 from 11 to 8.7 mm [21]. Inversely, the size of the pedicle increases progressively from the low cervical spine to the thoracic spine. The pedicle width increases from C5 to C7 from 5.2 mm to 6.5 mm [21]. The angle decreases from 4 to 6 in each level from C5 to T1 between the vertebral body and the axis of the pedicle, decreasing from 50 at the C5 to 34 at the T1 [21]. Instrumentation of pedicle screws must estimate these differences in angulation. Posterior instrumentation can bring back most of the stability in a two-column but not a three-column injury [22].

Collectively, in our case, we started with the anterior approach to reduce the dislocation from the front as it is less invasive comparing with posterior facetectomy and we have direct exposure of the body and disc. Then, we have instrumented the cervical spine posteriorly to decrease the risk of instability and mechanical complications as the patient had a three-column injury of CTJ. Our case report with the grand round presentation of the literature outlines the importance of anterior versus posterior or double-stage fixation at the CTJ. Our case presented with a three-column injury and has shown the importance of previous literature for understanding the stability at this unique region [1517, 22].

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

The authors contributed equally to this work.

Acknowledgments

We would also like to show our gratitude to the 5th International Conference on Spine and Spinal Disorders and the 15th International Conference and Exhibition on Alzheimers Disease, Dementia & Ageing which were held in Rome from April 22 to 23, 2019, for giving us a chance to present this case report.

References

  1. V. Krishnamoorthy, Surgical management of traumatic cervico thoracic junction fracture subluxation – a single centre experience, International Journal of Current Research, 2015.
  2. J. A. Boockvar, M. F. Philips, A. E. Telfeian, D. M. O'Rourke, and P. J. Marcotte, “Results and risk factors for anterior cervicothoracic junction surgery,” Journal of Neurosurgery, vol. 94, no. 1, pp. 12–17, 2001. View at: Publisher Site | Google Scholar
  3. V. Y. Wang and D. Chou, “The cervicothoracic junction,” Neurosurgery Clinics of North America, vol. 18, no. 2, pp. 365–371, 2007. View at: Publisher Site | Google Scholar
  4. J. M. Vital, O. Gille, J. Sénégas, and V. Pointillart, “Reduction technique for uni- and biarticular dislocations of the lower cervical spine,” Spine, vol. 23, no. 8, pp. 949–954, 1998, discussion 955. View at: Publisher Site | Google Scholar
  5. A. Amin and A. Saifuddin, “Fractures and dislocations of the cervicothoracic junction,” Journal of Spinal Disorders & Techniques, vol. 18, no. 6, pp. 499–505, 2005. View at: Publisher Site | Google Scholar
  6. J. R. Chapman, P. A. Anderson, C. Pepin, S. Toomey, D. W. Newell, and M. S. Grady, “Posterior instrumentation of the unstable cervicothoracic spine,” Journal of Neurosurgery, vol. 84, no. 4, pp. 552–558, 1996. View at: Publisher Site | Google Scholar
  7. G. Sapkas, S. Papadakis, P. Katonis, N. Roidis, and G. Kontakis, “Operative treatment of unstable injuries of the cervicothoracic junction,” European Spine Journal, vol. 8, no. 4, pp. 279–283, 1999. View at: Publisher Site | Google Scholar
  8. P. Korovessis, P. Katonis, A. Aligizakis et al., “Posterior compact Cotrel-Dubousset instrumentation for occipitocervical, cervical and cervicothoracic fusion,” European Spine Journal, vol. 10, no. 5, pp. 385–394, 2001. View at: Publisher Site | Google Scholar
  9. T. Vanden Hoek and D. Propp, “Cervicothoracic junction injury,” The American Journal of Emergency Medicine, vol. 8, no. 1, pp. 30–33, 1990. View at: Publisher Site | Google Scholar
  10. V. K. Goel, C. R. Clark, D. McGowan, and S. Goyal, “An in-vitro study of the kinematics of the normal, injured and stabilized cervical spine,” Journal of Biomechanics, vol. 17, no. 5, pp. 363–376, 1984. View at: Publisher Site | Google Scholar
  11. C. G. Nichols, D. H. Young, and W. R. Schiller, “Evaluation of cervicothoracic junction injury,” Annals of Emergency Medicine, vol. 16, no. 6, pp. 640–642, 1987. View at: Publisher Site | Google Scholar
  12. D. K. Evans, “Dislocations at the cervicothoracic junction,” Journal of Bone and Joint Surgery. British Volume, vol. 65, no. 2, pp. 124–127, 1983. View at: Google Scholar
  13. H. H. Bohlman, “Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature,” The Journal of Bone and Joint Surgery. American Volume, vol. 61, no. 8, pp. 1119–1142, 1979. View at: Publisher Site | Google Scholar
  14. R. A. Kaya, O. N. Türkmenoğlu, Ö. N. Koç et al., “A perspective for the selection of surgical approaches in patients with upper thoracic and cervicothoracic junction instabilities,” Surgical Neurology, vol. 65, no. 5, pp. 454–463, 2006. View at: Publisher Site | Google Scholar
  15. Y. Do Koh, T. H. Lim, J. Won You, J. Eck, and H. S. An, “A biomechanical comparison of modern anterior and posterior plate fixation of the cervical spine,” Spine, vol. 26, no. 1, pp. 15–21, 2001. View at: Publisher Site | Google Scholar
  16. P. C. McAfee, H. H. Bohlman, T. B. Ducker, S. M. Zeidman, and J. A. Goldstein, “One-stage anterior cervical decompression and posterior stabilization. A study of one hundred patients with a minimum of two years of follow-up,” The Journal of Bone & Joint Surgery, vol. 77, no. 12, pp. 1791–1800, 1995. View at: Publisher Site | Google Scholar
  17. H. U. Bueff, J. C. Lotz, O. K. Colliou et al., “Instrumentation of the cervicothoracic junction after destabilization,” Spine, vol. 20, no. 16, pp. 1789–1792, 1995. View at: Publisher Site | Google Scholar
  18. D. K. Resnick, “Anterior cervicothoracic junction corpectomy and plate fixation without sternotomy,” Neurosurgical Focus, vol. 12, no. 1, article E7, 2002. View at: Publisher Site | Google Scholar
  19. V. Pointillart, N. Aurouer, N. Gangnet, and J.-M. Vital, “Anterior approach to the cervicothoracic junction without sternotomy: a report of 37 cases,” Spine, vol. 32, no. 25, pp. 2875–2879, 2007. View at: Publisher Site | Google Scholar
  20. A. D. Sharan, G. J. Przybylski, and L. Tartaglino, “Approaching the upper thoracic vertebrae without sternotomy or thoracotomy: a radiographic analysis with clinical application,” Spine, vol. 25, no. 8, pp. 910–916, 2000. View at: Publisher Site | Google Scholar
  21. A. B. Bayoumi, I. E. Efe, S. Berk, E. M. Kasper, Z. O. Toktas, and D. Konya, “Posterior rigid instrumentation of C7: surgical considerations and biomechanics at the cervicothoracic junction. A review of the literature,” World Neurosurgery, vol. 111, pp. 216–226, 2018. View at: Publisher Site | Google Scholar
  22. J. L. Kreshak, D. H. Kim, D. P. Lindsey, A. C. Kam, M. M. Panjabi, and S. A. Yerby, “Posterior stabilization at the cervicothoracic junction: a biomechanical study,” Spine, vol. 27, no. 24, pp. 2763–2770, 2002. View at: Publisher Site | Google Scholar

Copyright © 2020 Mohammad A. Alsofyani et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


More related articles

 PDF Download Citation Citation
 Download other formatsMore
 Order printed copiesOrder
Views292
Downloads112
Citations

Related articles

We are committed to sharing findings related to COVID-19 as quickly as possible. We will be providing unlimited waivers of publication charges for accepted research articles as well as case reports and case series related to COVID-19. Review articles are excluded from this waiver policy. Sign up here as a reviewer to help fast-track new submissions.