Upper cervical spine injuries: a management of a series of 70 cases

Traumatic injuries of the upper cervical spine are often encountered, and may be associated to severe neurological outcome. This is a retrospective study of 70 patients, admitted over a 14 years period (1996 to 2010), for management of upper cervical spine injuries. Data concerning epidemiology, radiopathology and treatment was reviewed, and clinical and radiological evaluation was conducted. Men are more affected than women, with traffic accidents being the major traumatic cause. A cervical spine syndrome of varied intensity was found in about 90% of patients; neurological deficit was noted in 10 patients (21%). Radiological analysis discovered varied and many combined lesions: C1-C2 dislocation (7 cases), C2-C3 dislocation (9 cases), C1 fracture (10 cases) and C2 fracture (44 cases) including 28 odontoid fractures. Orthopedic treatment was carried out exclusively for 31 patients, and surgical treatment for 38 patients. One patient died before surgery because of a polytraumatisme. Posterior approach was performed in 29 cases including hooks and rods in 18 patients, wiring in 9 cases, and 2 transarticular screw fixations. In 9 cases anterior approach was performed: 5 odontoid screwing and 4 cases of C2-C3 discectomy with bone graft. Nearly all patients were improved in post-operative. Elsewhere, the operating results were marked by a persistent neurological deficit in 2 cases, and infection in 2 cases controlled by medical treatment. Mean follow-up was 23 months and showed good clinical and radiological improvement. Early management of cervical spine injuries can optimize outcome. Treatment modalities are well codified; however controversy remains especially with type II odontoid fractures.


Introduction
Upper cervical spine injuries are frequent due to increasing number of road accidents and falls. These lesions are often serious but neurologic complications are rare in emergency; this is due to the fact that C1-C2 medullar injuries are fatal. In survivors, those lesions may cause chronic instability with pseudarthrosis or delayed neurologic complications. Consequently, every trauma patient needs X-ray and adequate treatment. Authors establish therapeutic indications of upper cervical spine injuries according to clinical and radiological information and assess long term prognosis of instability and neurological injuries.

Methods
This is a retrospective study of patients with upper cervical spine injuries managed at the neurosurgical department in IBN SINA hospital at Rabat between 1996 and 2010. We also included patients who had other lesions in polytrauma context. Neurological deficit was assessed by Frankel scale. Imaging was used to classify the types of fracture. The treatment has included orthopedic and surgical methods. The rates of fusion and neurological recovery were analyzed long-term.

Results
70 cases were included in the study. Young adults were concerned in 66% with range from 16 to 65 years. Sex ratio (M/F) was 4. Road accidents were the most frequent cause with often hyperflexion mechanism. Clinically, cervical spine syndrome was found in 90% of cases, neurological deficit was present in 14 cases (21%). Most patients were admitted with 24 hours delay (83%). Disorders of consciousness concerned 7 cases of serious polytrauma.

Radiological analysis included standard X-ray and CT scan with
Multiplanar reconstruction in all patients. MRI was performed in 11 cases. Radiological lesions are various and sometimes associated as shown in Table 1.
A lower cervical spine injury was associated in 11 cases, and 20 upper cervical spine injuries were diagnosed in a polytrauma. One patient with C2-C3 dislocation died from hemodynamic instability before surgery. Patients with neurological deficits admitted in 6 hours delay had corticosteroids. A transcranial traction was performed in emergency in all cases to avoid secondary displacement. Reduction was obtained in all cases. It was incomplete in 5 cases (4 C2-C3 dislocations and a C1-C2 dislocation).
Orthopedic treatment was performed in 31 cases of stable fractures using Minerva with triple support ( Table 2). 38 patients were operated on. 29 cases with posterior approach including hooks and rods in 18 patients, wiring in 9 cases, and 2 transarticular screw fixation. In 9 cases anterior approach was performed: 5 odontoid screwing and 4 cases of C2-C3 discectomy with bone graft.
Neurologic improvement was found in 74% cases postoperatively without post-operative death. The fusion rate was 94% in operated patients along a mean period of 23 months (Table 3). Orthopedic treatment provides pseudarthrosis in 22% of cases with neurologic improvement in 93% of cases.  [19,20] use the halo vests to manage upper cervical spine fractures; its place is well defined; however, it is more cluttering and uncomfortable for the patient; it also takes more time for fracture healing and expose to the risk of pseudarthrosis. Surgical treatment will be indicated in this case.

Conclusion
Clinico-radiological analysis of upper cervical spine injuries leads to better therapeutic indications and improves long-term outcome in terms of spine stability and biomechanics; thus fusion is needed in every unstable lesion, because orthopedic treatment alone leads to pseudarthrosis in many cases.

Competing interests
The authors declare no competing interests.

Authors' contributions
All authors contributed equally to this work. All authors read and approved the final version of the manuscript. Table 1: findings in CT scan examination Table 2: patients who underwent orthopedic treatment Table 3: post operative evolution