C1-C2 Wiring With Timed Self-Obsolescence for Complex C2 Body Fracture

BACKGROUND AND IMPORTANCE Fractures of C2 are typically managed nonoperatively with good rates of healing. Management decisions are complicated, however, when there are additional fractures in the axis possibly leading to increased instability. Additionally, the techniques used for treating these unstable axis fractures can have either significant complications or permanent loss of range of motion. Here, we present a novel technique for the reduction and stabilization of complex C2 body fracture. CLINICAL PRESENTATION A 34-yr-old woman with a complex C2 body fracture, which included a right pars and left lateral mass fracture, presented after a water slide accident. It was felt that this fracture was both unstable and would not heal in an anatomically acceptable way so an open surgical reduction was needed. After consideration of more traditional fusion and osteosynthesis techniques, we chose to perform a C1-C2 internal stabilization with C1 sublaminar and C2 spinous process wiring. The patient was then instructed to wear a Miami J collar for 3 mo. CONCLUSION The outcome was favorable with good approximation and healing with preserved range of motion.

Management of Acute Unilateral Nondisplaced Subaxial Cervical Facet Fractures

BACKGROUND Few studies have focused on the management of patients with nondisplaced cervical facet fractures. OBJECTIVE To determine the rate of successful nonoperative management and risk factors for instability in patients with acute traumatic, unilateral, nondisplaced cervical facet fractures. METHODS We reviewed patients with single or multilevel unilateral nondisplaced or minimally displaced subaxial cervical facet fractures between 2008 and 2014. Facet fractures were classified as type A1 fractures: superior facet fracture of caudal vertebra; type A2: inferior facet fracture of rostral vertebral; and type A3: floating lateral mass (fracture of pedicle and vertical laminar fracture). All patients were given a trial of nonoperative management with external immobilization using a hard cervical collar. Follow-up clinical data and cervical spine radiographs were analyzed to determine factors associated with instability. RESULTS Thirty-five patients (34 males, mean age 40.2 ± 2.4 yr) were reviewed. The mean follow-up duration was 2.7 ± 0.4 mo. The distribution of fracture types was type A1 (n = 15), type A2 (n = 4), type A3 (n = 5), type A1 and A2 fractures (n = 10), and type A1 and A3 fractures (n = 1). Nonoperative management was successful in 29 patients (82.9%), and 6 patients developed instability requiring surgery. All patients who failed nonoperative management had associated injuries suggesting a more severe mechanism of injury. No significant association was found between the type of facet fracture and outcome (Fisher's exact test, P = .18). CONCLUSION In our series, more than 80% of the patients with unilateral, nondisplaced cervical facet fractures underwent successful nonoperative management in the short term.

Risk factors for intraoperative lateral mass fracture of lateral mass screw fixation in the subaxial cervical spine

ObjectAlthough lateral mass screw fixation for the cervical spine is a safe technique, lateral mass fracture during screw fixation is occasionally encountered intraoperatively. This event is regarded as a minor complication; however, it poses difficulties in management that may affect fixation stability and clinical outcome. The purpose of this study is to determine the incidence and etiology of lateral mass fractures during cervical lateral mass screw fixation.MethodsA retrospective clinical review of patient records was performed in 117 consecutive patients (mean age 57 years, range 15–86 years) who underwent lateral mass screw fixation using a modified Magerl method from 1997 to 2010 at a single institution. A total of 555 lateral masses were included in this study. The outer diameters of the screws were 3.5 or 4.0 mm. In the retrospective clinical analysis, the incidence of intraoperative lateral mass fractures was reviewed. Potential risk factors for this complication were assessed using multivariate analysis.ResultsThe incidence of lateral mass fractures during cervical lateral mass screw fixation was 4.7% (26 lateral masses) among all cases. Among the disorders, the incidence was highest in patients with destructive spondyloarthropathy (DSA) (18.8%, 12 lateral masses). There was no significant difference with respect to lateral mass fracture between the use of 4.0-mm screws (5.6%) and 3.5-mm screws (3.6%). Independent risk factors identified by logistic regression were DSA (OR 7.89, p < 0.001) and screw insertion in the C-6 lateral masses (OR 2.80, p = 0.018).ConclusionsThe overall incidence of lateral mass fracture during cervical lateral mass screw fixation was 4.7%. Destructive spondyloarthropathy as an underlying cause of morbidity and screw placement in the C-6 lateral mass were identified as independent risk factors. Use of a 4.0-mm screw in patients with DSA may be a principal risk factor for this complication.