Introduction
Spondyloptosis is defined as complete intercorporal displacement which was first described
in cervical spine by Bhojraj and Shahane.[1] Only a few case reports have been documented in literature as described below in
the review of literature.[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23] Being a rare entity, several different management options have been described in
literature ranging from conservative to 540-degree fusions.[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23] In this article, we have done a thorough review of literature on traumatic cervical
spondyloptosis and also included our experience of a case we managed at our center.
Review of Literature
Studies describing cervical spondyloptosis are summarized in [Table 1].
Table 1
Summary of reports of spondyloptosis published in literature
|
Study
|
Age/Sex
|
Level of injury
|
Mechanism of injury
|
Neurology preop
|
Neurology postop (follow-up)
|
Type of reduction
|
Surgery
|
Complications
|
|
Abbreviations: ACDF, anterior cervical discectomy and fusion; ACD-PF-AF, anterior
cervical discectomy and posterior and anterior fusion; ASIA, American Spinal Injury
Association; CSF, cerebrospinal fluid; FFH, fall from height; RTA, road traffic accident;
VA, vertebral artery.
|
|
Bhojraj and Shahane (1992)1
|
8/F
|
C6–7
|
Obstetric palsy
|
ASIA C
|
ASIA B
|
None
|
C5–7 corpectomy + anterior fusion without instrumentation
|
None
|
|
Amacher (1993)17
|
7/M
|
C7-T1
|
|
Neck pain + hyperreflexia
|
Stable
|
|
Anterior cervical fusion C6-T1 + Posterior fixation C6-T3
|
|
|
Sharma (2005)9
|
15/M
|
C4–5
|
Fall from two-wheeler
|
Quadriplegic
|
Grade 3–4 power
|
Closed
|
C4–5 ACDF + plating
|
None
|
|
Lee et al (2007)18
|
65/M
|
C7-T1
|
FFH
|
ASIA D
|
ASIA D
|
Open
|
Anterior C7–T1 discectomy and C7 corpectomy + C7 Laminectomy + facetectomy + C5-T2
instrumented fusion + anterior fusion with Pyra mesh (ACD-PF-AF)
|
Posterior dural injury with CSF leak managed by lumbar drain
|
|
72/M
|
C7-T1
|
FFH
|
ASIA E
|
ASIA E
|
None
|
Conservative
|
Only 3 mo follow-up
|
|
Menku et al (2004)19
|
35/M
|
C6–7
|
RTA
|
ASIA E
|
ASIA E
|
None
|
C5–6 ACDF + plating + C4–6 posterior instrumented fusion (ACD-PF-AF)
|
None
|
|
Tumialán et al (2009)8
|
39/M
|
C7-T1
|
RTA
|
ASIA E
|
ASIA E
|
Closed with 60 lbs
|
C7-T1 ACDF + plating f/b C5-T2 posterior instrumented fusion
|
None
|
|
Acikbas and Gurkanlar (2010)7
|
42/M
|
C7-T1
|
RTA
|
ASIA E
|
ASIA E
|
Closed
|
C7-T1 ACDF + plating f/b C4-T3 posterior instrumented fusion
|
None
|
|
Srivastava et al. (2010)11
|
35/M
|
C3–4
|
FFH 20 ft
|
ASIA E
|
ASIA E
|
Closed with 4 kg
|
C3–4 ACDF + plating
|
None
|
|
Chadha et al (2010)12
|
35/M
|
C6–7
|
FFH 10 ft
|
ASIA A
|
ASIA A
|
Closed with 9.07 kg
|
C6–7 ACDF + plating
|
Dural leak found Poor general condition
|
|
Keskin et al (2013)14
|
51/M
|
C6–7
|
RTA
|
ASIA D
|
ASIA E
|
Closed with 20 kg
|
C6–7 ACDF + plating f/b C6 laminectomy + C4-T2 posterior instrumented fusion
|
Dural leak found + lumbar drain placed postop
|
|
Dahdaleh et al (2013)13
|
61/M
|
C7-T1
|
RTA
|
ASIA A
|
NR
|
Partial closed reduction with 23.6 kg f/b open
|
C3-T3 posterior instrumented fusion
|
Reduced to grade 1
|
|
48/F
|
C6–7
|
Fall from stairs
|
ASIA D
|
ASIA E
|
Open
|
C6–7 ACDF + plating
|
None
|
|
51/M
|
C7-T1
|
RTA
|
ASIA E
|
ASIA E
|
Partial closed reduction with 45 lbs f/b open
|
C4-T2 posterior instrumented fusion + facetectomy
|
None
|
|
48/M
|
C6–7
|
RTA
|
ASIA B
|
ASIA B
|
Partial closed reduction with 18 kg f/b open
|
C4-T1 posterior instrumented fusion + facetectomy
|
None
|
|
42/M
|
C7-T1
|
RTA
|
ASIA C
|
ASIA D
|
Closed
|
C5-T2 posterior instrumented fusion
|
None
|
|
Ramieri et al (2014)20
|
55/M
|
C6–7
|
RTA
|
ASIA E
|
ASIA E
|
Partial closed reduction with 20 lbs f/b open
|
C3-T2 posterior instrumented fusion f/b anterior C6 corpectomy + fusion
|
None
|
|
Ahn et al (2015)21
|
32/M
|
C7-T1
|
FFH 2 m
|
ASIA E
|
ASIA E
|
Failed closed reduction with 27.2 kg f/b open
|
C7-T2 posterior instrumented fusion + facetectomy f/b C7-T1 ACDF + plating
|
None
|
|
Modi et al (2016)22
|
35/M
|
C6–7
|
NR
|
ASIA A
|
ASIA A
|
Failed closed reduction with 30 pounds f/b open
|
C6–7 ACDF
|
None
|
|
8/M
|
C7-T1
|
NR
|
ASIA A
|
NR
|
Conservative
|
Patient not willing
|
Severe spasticity with multiple bed sores and totally dependent
|
|
70/M
|
C7-T1
|
NR
|
ASIA A
|
NR
|
Closed
|
Not operated due to comorbidities and high risk
|
Patient expired due to the multisystem failure
|
|
Wong et al (2017)16
|
49/F
|
C5–6
|
RTA
|
ASIA A
|
ASIA A
|
Partial reduction with 13.6 kg f/b open
|
C5–7 ACDF + plating
|
Left VA dissection + occlusion
|
|
Fattahi and Tabibkhooei (2019)6
|
18/F
|
C5–6
|
RTA
|
ASIA A
|
ASIA A
|
Closed at 25 lbs
|
C5 corpectomy + fusion + plating
|
CSF leak from traction pin site f/b meningitis + hydrocephalus and death
|
|
Kim et al (2019)23
|
60/M
|
C7-T1
|
FFH
|
ASIA A
|
ASIA D
|
Open
|
C7-T1 discectomy via posterior approach + C6-T1 posterior instrumented fusion
|
None
|
|
39/M
|
C7-T1
|
FFH
|
ASIA D
|
ASIA E
|
Open
|
C6-T2 posterior instrumented fusion
|
None
|
|
Our case
|
33/M
|
C5–6
|
FFH
|
ASIA B
|
ASIA B
|
Partial reduction with 4 kg f/b open
|
C5–6 ACDF
|
Dural leak found
|
Case Report
A 33-year-old male had a fall from 12 to 15 feet height and sustained neck injury
following which he became quadriplegic. He presented to our hospital, a tertiary level
trauma center. His Glasgow Coma Scale was 15 and he was quadriplegic below the C5
level with intact sensations (American Spinal Injury Association [ASIA]-B). After
initial resuscitation and securing patient’s airway, he was screened for other injuries
which revealed a left-sided hemothorax, for which an intercostal drain was inserted.
X-ray cervical spine showed no head injury and grade 4 anterolisthesis of C5 over
C6 with spinal canal compromise ([Fig. 1A]). Computed tomography angiography of neck showed left-sided vertebral artery injury.
Fig. 1 Preoperative, intraoperative, and postoperative X-ray cervical spine showing spondyloptosis
(A), intraoperative manipulation being done (B), and postoperative X-ray showing complete reduction and fixation using polyetheretherketone
(PEEK) cage and anterior cervical plate (C).
He was admitted in the intensive care unit for further management. He was in acute
renal failure and was not fit to be taken up for surgery. He was on inotropes which
were gradually weaned off the next few days and implantable cardioverter defibrillator
was removed after the lung expanded. When his vitals became stable and he was off
inotropes, he was planned for surgery. X-ray neck lateral view was done before surgery
which showed C5–6 spondyloptosis.
On the day of surgery, intraoperative cervical traction was applied with a 4-kg weight
which reduced the listhesis to grade 3. After confirming the C5–6 level with image
intensifier, anterior cervical approach was used. C5–6 discectomy was done. After
freeing the uncovertebral joints bilaterally and adequate soft tissue release, listhesis
was reduced completely by intraoperative manipulation ([Fig. 1B]). Cerebrospinal fluid (CSF) leak was seen (noniatrogenic), which was plugged with
tissue glue. C5–6 anterior cervical discectomy and fusion (ACDF) using polyetheretherketone
cage was done and plating done thereafter ([Fig. 1C]). A posterior surgery was planned to be done few days later as the patient’s general
condition was so good that he can tolerate anterior and posterior surgery in one go.
Postoperatively, he was on ventilator support with no changes in neurological examination.
After a week of surgery, the patient developed meningitis for which appropriate antibiotics
were started. Subsequently, he developed hydrocephalus for which external ventricular
drain was placed. But the patient could not recover and died few weeks after surgery.
Discussion
Spondyloptosis represents the highest grade of instability with three-column involvement
and complete segmental disruption. Cervical spondyloptosis is a rare entity that can
be caused by trauma, congenital causes, or tumors of the spine.[2]
[3] Several management strategies have been described in the literature.
Due to the severe nature of injury and dislocation, most patients present with deficits
with very few having intact neurology as first described by Ozdogan et al in 1999.[4] Our patient presented with complete loss of motor power and the sensation was intact
below the C5 level (ASIA-B).
Preoperative reduction of dislocation with traction has been utilized by most of the
surgeons but with only a few achieving complete closed reduction[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12] while others have to do open reduction. We could only achieve partial reduction
till grade 3 on applying traction preoperatively. However, Dahdaleh et al have given
an algorithm to use closed reduction method only if there is no anterior compression
on the spinal cord, otherwise patient can have increased neurological deficits.[13]
While attempting open reduction after failed/partial closed reduction, all the authors
have used posterior approach to release the muscle/ligaments ± facetectomies. We have
used only anterior single-step approach to reduce the listhesis completely and then
did ACDF.
Regarding complications, CSF leaks due to high-grade dislocation (noniatrogenic) have
been seen by few authors including us but none of the authors reported meningitis
or wound leaks afterwards.[12]
[14] Our patient had meningitis which led to hydrocephalus and subsequent septicemia
leading to death of the patient.
Basilar artery thrombosis[15] and vertebral artery thrombosis[16] have also been reported. Our case also had left vertebral artery thrombosis preoperatively
which was managed on anticoagulants postoperatively without any posterior fossa ischemic
events.
