Sub-axial cervical spine injuries: Modified Stellerman's algorithm

Abstract

Background: Global fusion is recommended in sub-axial cervical spine injuries with retrolisthesis, translation rotation injuries associated with end plate or tear drop fractures. We propose a modification of Stellerman's algorithm which we have used where in patients are primarily treated via anterior decompression and fixation. Global fusion was done only in cases where post-decompression traction does not achieve reduction in cases with locked facets.

Materials and methods: Two hundred and thirty consecutive patients with sub-axial cervical spine injuries were studied in a prospective trial over a 7 year period. Seven cases with posterior compression alone were not subjected to our protocol. Of the other 223 cases, 191 cases who on radiological evaluation needed surgery were initially approached anteriorly. Decompression was effected through a corpectomy in 14 cases and a single or multiple level disc excisions were performed in the others. Cases with cervical listhesis (n=36) where on table reduction could not be achieved following decompression were subjected to progressive skeletal traction for 48 h. Posterior facetectomy and global fixation was done for patients in whom reduction could not be achieved despite post-decompression traction (n=11).

Results: Of the 223 cases, 20 cases were managed conservatively, 12 cases expired pre-operatively, and the remaining 191 cases needed surgical intervention. Out of the 154 cases of distraction/rotation/translation injuries on table reduction could be achieved in 118 cases (76.6%). Thirty-six patients had locked facets (23 cases were bifacetal, 13 cases unifacetal) and of these 36 cases reduction could be achieved with post-anterior decompression traction in 25 patients (16.2%); however, only 11 cases (7.1%)-8 bifacetal and 3 unifacetal dislocations-needed posterior facetectomy and global fusion. One hundred and forty-three patients were followed up for a minimum period of 6 months. One hundred and twenty-six patients showed evidence of complete fusion (88.1%) while the remaining 17 (11.8) showed evidence of partial fusion. There were no signs of instability on clinical and radiological evaluation in any of the cases. Reduction of graft height was noted in 18 patients (12.5%). There were eight cases of immediate postoperative mortality and two cases of delayed mortality in our series of cases.

Conclusion: We feel that on table decompression and reduction followed by anterior stabilization can be used as the initial surgical approach to manage most types of cervical injuries. In rotation/translational cases where reduction cannot be achieved, monitored cervical traction on the decompressed spine can safely achieve reduction and hence avoid the need for a posterior facetectomy in a large percentage of cases.

Keywords: Anterior decompression and fusion; Stellerman’s algorithm; sub axial spine injuries.

Figure 1

Stellerman’s algorithm for bifacetal subluxations

Figure 2

Bar chart showing distribution of cases

Figure 3

Flowchart of our cases with their numbers and treatment protocol

Figure 4

(a) Sagittal MRI T2WI of cervical spine in a posttraumatic cervical spine injury showing three level disc herniation. (b) 16 months post-operative X-ray cervical spine (lateral view) after excision, fusion and fixation showing good bony fusion

Figure 5

Proposed algorithm of management of sub-axial cervical spine injuries

Figure 6

X-ray cervical spine (lateral view) showing (a) C5 fracture with subluxation. (b) C5 fracture with subluxation treated with anterior corpectomy, fusion with fixation (21 months post-operative)

Figure 7

(a) Pre-op sagittal MRI T2W image of C6-C7 dislocation in whom reduction could not be achieved despite on-table and post-operative traction. (b) Post-operative X-ray of cervical spine (lateral view) showing posterior facetectomy and global fixation

Figure 8

Follow up radiograph of cervical spine (lateral view) of a case of C4-C5 retrolisthesis showing good fusion and alignment obtained by anterior decompression, fixation, and fusion

Figure 9

X-ray cervical spine lateral view showing (a) Patient with fracture C5 with retrolisthesis. (b) Post-operative X-ray of the patient treated with anterior corpectomy, fusion, and fixation. (c) Follow up film shows good fusion, inferior screws have backed out, and graft height is reduced