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| EDITORIAL |
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| Year : 2022 | Volume
: 5
| Issue : 1 | Page : 1-3 |
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Cervical spine injury: A historical perspective
Manish Chadha, Rajesh Arora, Anil K Jain
Department of Orthopaedics, University College of Medical Sciences & GTB Hospital, Delhi, India
| Date of Submission | 30-Dec-2021 |
| Date of Acceptance | 30-Dec-2021 |
| Date of Web Publication | 02-Feb-2022 |
Correspondence Address:
Manish Chadha
Department of Orthopaedics, University College of Medical Sciences & GTB Hospital, Delhi 110095.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ISJ.ISJ_111_21
How to cite this article:
Chadha M, Arora R, Jain AK. Cervical spine injury: A historical perspective. Indian Spine J 2022;5:1-3 |
Cervical spine, apart from protecting the spinal cord, supports and provides mobility to the head. This mobility comes from a compromised, less osseous, and more ligamentous stability of cervical spine. Neck is a narrow connector, housing all vital structures, between the head and the torso. Hence, this segment of spine is of critical importance. Injury to cervical spine is potentially lethal and can lead to quadriplegia with a permanent disability.[1],[2] Therefore, all trauma guidelines emphasise securing cervical spine and evaluating it for its injury along with the all-important cardiorespiratory system. The management of these injuries has reformed over the years from largely leaving the patient on bed rest/cast to the rudimentary decompression surgeries to the current state-of-the-art treatment protocols.[1],[2],[3]
The earliest description can be found in Egyptian scriptures dating back to 1500 B.C. where cases of injuries to cervical spine have been described and their relation to paralysis was implicated. The Greek and Roman history (Hippocrates and Galen respectively) also describe the types of fracture dislocations. Galen studied the spinal cord function by sectioning it at various levels in animals. During the first to fifteenth century, management of the spine was largely conservative with occasional description of surgical procedures. It was only in the Renaissance period that Europe rose and started to understand the anatomy and physiology of spine and spinal cord. The ultimate reform in the understanding and management of these injuries started in the nineteenth century. It was during this period that anatomy of vertebral column, intervertebral discs, spinal cord, and pathophysiology of spinal cord injuries with resultant neurological deficit were studied in detail. Neurological examination signs and clinical features were realized and practiced for deciding the diagnosis and management. Introduction of asepsis and anesthesia was a critical stepping stone in development of modern-day cervical spine trauma surgery. Gradually the surgical management of spine disorders started especially with lumbar disc degeneration, as lumbar area was relatively safer, less complex, and larger in size.[4] The success achieved in this zone paved way for cervical spine surgeries.
| Technological Advancement and Cervical Trauma | |  |
Advent of radiographs improved the diagnosis, the understanding of the mechanism, and decision making in cervical spine trauma. Subsequent development of computed tomography (CT) scan allowed the three-dimensional assessment of bony anatomy and development of magnetic resonance imaging (MRI) allowed assessment of neural structures and soft tissues in relation to spinal column. Recent advancement of the novel diffusion tensor imaging sequence of MRI even allows to assess the neural tracts.[5] These modalities have definitely improved the diagnostic capabilities, predictability of prognosis, and planning of surgical management. Further, availability of intraoperative imaging in the form of C-arm and O-arm is providing top imaging guidance to the surgeons, especially in difficult area of atlantoaxial and occipito-cervical injuries.[4],[6],[7],[8] The conventional approaches to these areas required large and debilitating exposures. Guided interventions are minimally invasive, allow quicker rehabilitation, and are giving better clinical outcome, especially in occipito-cervical and C1-C2 region. Introduction of operating microscope and neurophysiological monitoring has allowed better and more confident handling of cord and neural tissues.[4]
Analysis of motion studies and biomechanics of cervical spine has improved understanding the role of each anatomical structure in cervical spine stability and mobility and the pathology which will result if they are damaged or diseased. Robotic navigation has improved the accuracy of lateral mass, laminar screws, and odontoid screws.[8] 3D printed models and patient-specific guides (although more useful for deformity correction) provide the surgeon an extra edge in surgical planning and management,[9] especially in pre-existing deformity or in re-surgery.
| Better Operation Theatre Technology and Advances in Anesthesia | | |
Development of laminar flow/positive pressure Operating Rooms, along with development of instruments like high-speed drills/burrs, electrocautery, navigation technology, ultrasonic bone cutting technologies have improved the patient outcome and reduced the postoperative complications.[4],[6] The novel, less toxic anesthetic agents provide a good perioperative support to the surgeon. Critical care, which is usually required immediately after cervical trauma/surgery, has reformed and understood the natural course after cervical spine and spinal cord injuries.[10] Therefore, the survival and function of patients who have faced these injuries have improved dramatically over the past 2–3 decades.
| Modern Instrumentation | | |
For stabilization of cervical spine over the years we relied only on Plaster of Paris casts and bed rest. Over the last two centuries postsurgery stabilization using collars, tractions (tongs/head halter), Minerva jackets, braces (SOMI) and halo were introduced. But these were external immobilization devices and needed prolonged use. Prolonged immobilization with their use can lead to poor functional outcomes, morbidity, and even mortality. Development of internal fixation of cervical spine started with posterior approaches using interspinous wiring by Hadra in 1891. It had poor results as it was done without bone grafting, which was added by Holdsworth and Hardy in 1953. Similar fusion techniques were used in the C1–C2 region. The anterior fixation options were developed later, as anterior approach to cervical spine was initially avoided with fear of damage to vital structures. The need for anterior approach was later realized when risks of damage to vertebral body and disc space by posterior approach were realized. The first anterior fusion was attempted using plates in 1950s and from then on with better lighting, operating microscope, and surgical technique advancements anterior cervical fixation is used very commonly in sub axial spine.[4]
With time, metallurgical advancement and bio-engineering advancements have led to the development of robust fixation and fusion devices (lateral mass screws, C1–C2 transarticular screws, anterior transoral screws, pars screws, anterior cervical locking plate, and cages), which can stabilize cervical spine at all levels through 360 degrees. These devices have allowed surgeons to perform reliable stabilization to allow early rehabilitation of patients. Moreover, development of bone substitutes and work over osteogenic Bone Morphogenic Protein (BMP) has improved the fusion rates after surgery.[1],[4],[6],[7]
| Rehabilitation | | |
Urinary retention followed by bilateral hydro-ureteronephrosis and renal failure had remained leading cause of death in para/quadriplegics. Development of bed sores, dependent pneumonia and deep venous thrombosis (DVT) were also contributory in the mortality of paralyzed patients. Early bladder rehabilitation (physical and pharmacological measures), aggressive preventive and therapeutic interventions for pressure sores, dependent pneumonia, and DVT have prolonged the life expectancy of paralyzed patients and have also reduced perioperative morbidity and mortality of patients. Early physical and occupational rehabilitation also helps patient to recover at a faster pace and achieve the near-normal function as compared to their pre-trauma status.[3],[6],[7]
We have evolved a lot from a gross conservative management of all cervical spine injures to a radical, scientific, and a protocol-based management. The decision relies on the neurological examination, imaging findings, patients’ characteristics (general condition, and comorbidities), and future implications of the injury. Also, understanding of implications of missing a cervical spine injury has made stabilization and clearing of cervical spine injury an important step in the primary survey of any trauma guideline. This has reduced the delay and/or neglect in diagnosis of cervical spine injuries, especially in polytrauma patients. Unfortunately, healing and regeneration of neural tissue have not been reliably demonstrated till date and this has been the stumbling block in management of cervical spine injuries.[1] The spinal cord, if damaged, does not recover and gives a permanent disability. Many agents (steroids, minocycline, riluzole, and even stem cells) have been tried in order to stimulate neurological recovery, but none of them have shown reliable results. Development or discovery of such an agent will be the game changer in the management of cervical spinal cord injury patients. Also, development of nanotechnology and bionics can dramatically improve the functional status of paralyzed patients.[4] Hopefully, we would be able to develop these in the future and improve the clinical outcomes in patients suffering from these otherwise devastating injuries.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Okereke I, Mmerem K, Balasubramanian D The management of cervical spine injuries: A literature review. Orthop Res Rev 2021;13:151-62.  |
| 2. | Beeharry MW, Moqeem K, Rohilla MU Management of cervical spine fractures: A literature review. Cureus 2021;13:e14418. |
| 3. | Silver JR History of the treatment of spinal injuries. Postgrad Med J 2005;81:108-14. |
| 4. | Dweik A, Van den Brande E, Kossmann T, Maas AI History of cervical spine surgery: From nihilism to advanced reconstructive surgery. Spinal Cord 2013;51:809-14. |
| 5. | Shanmuganathan K, Gullapalli RP, Zhuo J, Mirvis SE Diffusion tensor Mr imaging in cervical spine trauma. Ajnr Am J Neuroradiol 2008;29:655-9. |
| 6. | Schiller MD, Mobbs RJ The historical evolution of the management of spinal cord injury. J Clin Neurosci 2012;19:1348-53. |
| 7. | Denaro V, Di Martino A Cervical spine surgery: An historical perspective. Clin Orthop Relat Res 2011;469:639-48. |
| 8. | Campbell DH, McDonald D, Araghi K, Araghi T, Chutkan N, Araghi A The clinical impact of image guidance and robotics in spinal surgery: A review of safety, accuracy, efficiency, and complication reduction. Int J Spine Surg 2021;15:10-20. |
| 9. | Sheha ED, Gandhi SD, Colman MW 3d printing in spine surgery. Ann Transl Med 2019;7:S164. |
| 10. | Dooney N, Dagal A Anesthetic considerations in acute spinal cord trauma. Int J Crit Illn Inj Sci 2011;1:36-43. |
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