Posttraumatic cervical spondyloptosis is usually caused by a high impact force. Road traffic accidents are the most common mechanism of injury. However, unusual mechanisms such as vaginal delivery, intubation, spinal massage or manipulation, and indoor slippage and fall, as in our index case, have been reported.9,11–13 Available data show that the C7-T1 level was the most affected segment.3,14 Six cases of C4-C5 level involvement, similar to our index case, have been reported and are summarized in Table 1. The time of presentation from trauma ranges from a few hours to eight years.2,3,9,13,14 Interestingly, our patient and those reported by Gascol et al.8, Sakta et al.13, and a case reported by Padwal et al.15, all presented eight months following trauma.
Neglected PTCS poses numerous management challenges. These include complications from prolonged immobilisation such as pressure sores, recurrent urinary tract infections, constipation, and joint contractures, as in the present case.14 They are also at an increased risk of progressive neurological deterioration, intraoperative blood loss, damage to neural structures, and residual spinal deformity. This results in a prolonged hospital stay, increased costs, and poor outcomes.6 The paucity of specialist facilities, overlooked or missed diagnoses, ignorance, poverty, and unregulated proliferation of traditional healers have been implicated in delayed presentation.5,13 This is coupled with locoregional challenges such as poor health-seeking attitudes, limited health insurance coverage, reduced manpower from brain drain, limited theatre spaces, and state-of-the-art neurosurgical facilities.16 Our index case initially sought care with a traditional healer before presenting to our facility, thereby exhausting their limited funds before presenting in our facility. Occasionally, unconventional practices in the hands of this shamanist have been noted to worsen a patient's neurological status.13
At present, there is no consensus in management. Various approaches have been described and tailored to patient presentation and neurologic deficit, neuroimaging findings, and surgeon preference. An all-out non-operative approach has been tried, but the outcome appears poor, with a high conversion rate to open reduction, and mortality reported in one.3,17 In our index case, preoperative Gardner well traction was instituted to achieve some degree of reduction before surgery, and ameliorate the associated paraspinal spasms. This was achieved with a reduction to grade one listhesis (Fig. 2). Our observation is in contrast with a previous report8 and recommendation13 on the non-effectiveness of preoperative cervical traction in neglected cervical spondyloptosis.
There is presently no well-designed study to evaluate the outcomes of various approaches. Initially, surgical reduction was thought to be unsafe, and at present, combined anterior and posterior approaches appear to be frequently performed, with proponents advocating better stabilization and cord decompression.12,13,17,18 In our case, an anterior-only approach was chosen to address the marked anterior cord compression and excise the deformed and osteopenic C5 and C6 vertebrae bodies with pseudoarthrosis, to enable adequate decompression and instrumented fusion. A similar application of this procedure has been reported with an excellent outcome.13 Also, anterior fusion stabilises two columns (anterior and middle Dennis column), especially if a bicortical purchase is achieved (see Fig. 4), like in our index case.17 We also considered a shorter operative time due to her reduced lung capacity from previous pulmonary tuberculosis, which a single approach may guarantee compared to a combined approach. The posterior-only approach, the least frequently used option is suited for cases of persistent bilateral facet lock, following failed closed reduction, multi-level cervical fractures and to mitigate the risk of graft migration that could complicate anterior fusion.13,19,20
Her postoperative period was unremarkable, but the following complications have been reported: CSF leak from dural tear and life-threatening vertebral or basilar artery injury, emphasising the need for perioperative CT angiography in the management of this patient.7,14 The outcomes of cervical spondyloptosis are usually noted to be poor; however, within the limits of reported cases, neurological improvement was observed in 40%, with a mortality of 11% recorded.3,21 Our index case had resolution of autonomic dysfunction with motor improvement from AIS C to D as of the 4th week post-operation. We are optimistic about improved motor activity with continued physiotherapy and the surgical release of both knee contractures.