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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 82-98

Traumatic cervical spine injury: Clinical scenarios

1 Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India
2 Department of Orthopaedics, K.J. Somaiya Medical College & Research Institute, Mumbai, Maharashtra, India
3 Department of Spine Surgery, Ganga Medical Centre & Hospital Pvt Ltd, Coimbatore, Tamil Nadu, India
4 Department of Spine Services, Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
5 Department of General and Gastrointestinal Surgery, University Hospital Cleveland Medical Centre, Cleveland, Ohio, USA
6 Department of Spine Surgery, Ontario, Canada

Date of Submission24-Nov-2021
Date of Decision25-Nov-2021
Date of Acceptance03-Dec-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
Jitesh Manghwani
Department of Spine Services, Indian Spinal Injuries Centre, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ISJ.ISJ_105_21

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This section of the symposium deals with different clinical situations related to the management of traumatic cervical spine cord injury (SCI) and its complications. These cases give an overview of the clinical dilemmas that test our decision-making abilities in dealing with patients with cervical SCI and its associated complications. The patients were managed in various centers across India with different infrastructures and facilities. They are managed by different experts in the field of spine surgery. This should help the reader in providing a wider perspective in the management of vertebral lesions of traumatic cervical SCI. This section also helps in understanding the newer advances in dealing with the dreaded complication of invasive long-term ventilation in a patient with cervical SCI. The spine clinic ends with comments by the authors on key takeaway points from each case scenario, and some literature supported recommendations for the management of traumatic cervical SCI.

Keywords: Diaphragmatic pacing, extension injuries, flexion injuries, spinal cord injury, sub axial cervical trauma

How to cite this article:
Nanda A, Srivastava SK, Shetty AP, Dave BR, Chhabra HS, Onders R, Manghwani J, Marathe NA, Karthik R, Muttha MN. Traumatic cervical spine injury: Clinical scenarios. Indian Spine J 2022;5:82-98

How to cite this URL:
Nanda A, Srivastava SK, Shetty AP, Dave BR, Chhabra HS, Onders R, Manghwani J, Marathe NA, Karthik R, Muttha MN. Traumatic cervical spine injury: Clinical scenarios. Indian Spine J [serial online] 2022 [cited 2022 May 25];5:82-98. Available from: https://www.isjonline.com/text.asp?2022/5/1/82/337135

  Introduction Top

The approach and management of traumatic cervical SCI have changed drastically over the past decades. During the same time frame, the controversies surrounding cervical SCI have grown twofold. The discrepancy is at every step of investigations, awake reduction, and management.[1] Unilateral and bilateral facetal dislocations are a continuum of same injury. Unilateral facetal injuries may present with either an intact neurology or nerve root injuries, in contrast to complete deficits with bilateral facetal dislocations. The soft tissues, ligaments, and facetal capsules are significantly more damaged in bilateral injuries.[2] Surgeons are divided on the reduction of these fractures. Studies have compared manipulation under anesthesia versus rapid reduction of fracture dislocations with incremental weights for giving the best chance of neurological recovery.[3] Literature also has tried to establish whether these patients should be subjected to MRI first to decide on further treatment or rapid reduction to attain spine alignment by closed reduction and posterior fixation. These have been the topics of controversy, with the common aim of deciding what will benefit the patients more.[4]

The approach to the vertebral lesion is a matter of debate too. Literature has evidence to favor anterior or posterior or combined anterior + posterior surgeries.[5],[6],[7],[8],[9] The preference for anterior surgery is the ease, familiarity, and good results.[5],[6],[9] The added advantage is direct access to the herniated disc causing the compression. If reduction is not achieved, supplement posterior surgery may be required too.[5],[10],[11],[12],[13] However, combined surgeries may increase surgical trauma and risks. Posterior-only surgeries can reduce and stabilize trauma.[7],[8]

CSI is associated with a gamut of complications. One of the most catastrophic ones is the respiratory failure needing long-term mechanical ventilation. The cost of this care exceeds $1 million in the first year and $185,000 per year if the patient is on a ventilator in the United States. The feasibility and practicality of long-term ventilation is a challenge.[14] When compared with an able-bodied 20-year-old, the life expectancy for a 20-year-old patient with SCI on long-term mechanical ventilation decreases markedly from 58.6 years to only 17.1 years.[15] The DPS functions as a powered muscle stimulator for treating disuse atrophy as well as a functional electrical stimulator to drive respiration. The spinal cord literature indicates that functional electrical stimulation and physical therapy have a positive trophic effect on the recovery of patients from SCI.[16]

This edition of spine clinics brings you a series of cervical spine trauma cases that are managed differently by the experts in the field. This helps in a better understanding of their ideology behind the management since the literature lacks in consensus on defining the gold standard. The key points of all the cases are summarized in [Table 1]. The cases are explained in detail by the authors for our readers. Using this as a guide for understanding the ideas and experience of the experts, surgeons can define the individualized strategy working best in his/her hand in the best interest of the patient.
Table 1: Clinical case scenarios traumatic cervical spine injury—An overview of cases 1–4

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  Clinical Scenario I Top

Bifacetal dislocation of the subaxial cervical spine

Clinical Scenario

The patient was a healthy 60-year-old male who presented after an RTA (road traffic accident), complaining of neck pain and right arm numbness. After appropriate trauma triage and hemodynamic stabilization, the detailed neurological assessment was performed and the patient was ASIA C grade.


Plain radiographs, CT scan, and MRI of the cervical spine demonstrated bilateral facet dislocation at the C6-7 level with an epidural hematoma at that level [Figure 1.1], [Figure 1.2], and [Figure 1.3]. The MRI also showed a hyperintense signal on the T2-weighted image between C5 and C7, suggestive of cord edema [Figure 1.4]. As per the Spinal Trauma Study Group that proposed a new classification system, the Sub-axial Injury Classification System (SLIC), and injury severity score, a SLIC score of 7 was calculated (4 points for morphology, 2 points for DLC, and 1 point for root injury).
Figure 1.1: AP and lateral X-rays of the cervical spine demonstrating C6-7 bifacetal dislocation. Typically >50% is visualized in bifacetal dislocations

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Figure 1.2: The CT scan demonstrates bilateral facet dislocations

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Figure 1.3: The CT scan demonstrates bilateral facet dislocations

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Figure 1.4: Traumatic C6–C7 disc

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Treatment options

Facet injuries are typically the result of flexion-distraction injury and may contain an element of rotation. These injuries can be purely ligamentous or have substantial bony involvement of facet/ lateral mass and run the spectrum from fracture and subluxation to a locked dislocation. Dislocations should be treated initially with attempted closed reduction under right conditions. During clinical stabilization, following standard trauma protocols, patients should be maintained in the supine position with a rigid cervical collar and lateral immobilization. Reduction can simplify surgical treatment as well as provide prompt decompression of neural tissues in neurologically impaired patients. Up to 70% of cervical fractures can be realigned with traction. Usually, weight necessary is ~5 pounds (2.5 kg) per level of injury and can be performed in neutral, flexion, or extension position, according to injury characteristic. Close clinicoradiological observations are mandatory in patients undergoing cervical traction until performing definitive surgical stabilization. Weight can be increased rapidly as allowed by a reliable, new neurologic examination and new radiographs. The main objective of traction is to obtain and maintain closed reduction on lateral cervical radiographs. During reduction, surgeons should be aware of the risk of over distraction as well as the potential for neurologic worsening. Regarding Gardner-Wells tong application, the patient is placed in a neutral supine position. After local asepsis, local and periosteal infiltration with anesthetic is performed. Pins are placed below the greatest diameter of the skull. Surgeons must avoid entering the temporal muscle and artery; as such, the common site is generally 1 cm above the pinna and 1 cm posterior to the external auditory meatus. Pins can be placed asymmetrically (slightly anterior or posterior) to influence flexion or extension according to injury morphology/dislocation. As an example, cervical flexion (tongs placed slightly posterior) can help achieve reduction of locked facet joints. In the unilateral locked facet joint, some flexion and rotation away from the luxation side can help achieve reduction. In addition to pin placement, the surgeon can also obtain reduction by flexing and/or rotating the cervical spine to further “unlock” dislocated facet joints by recreating the traumatic deformity. Once facet reduction is obtained, cervical extension and lower weight in-line traction (15 to 20 pounds) can be utilized to maintain the reduction. Patients in whom a reliable neurologic exam cannot be obtained should not undergo closed reduction. This includes obtunded/ inebriated/ sedated/ intubated patients, and patients who cannot comply with neurologic examination. Traction is also contraindicated in patients with rostral injuries, especially distractive ones, such as atlantoaxial or occipito-cervical dislocations. An MRI before closed reduction is recommended to identify traumatic cervical disc herniation. However, routine prereduction MRI can delay spinal decompression and increase hospital costs. As such, it is commonly obtained before reduction only in select patients, most notably surgical patients who are unable to undergo a safe, closed reduction.

In the event of failed or unattempted closed reduction, an open reduction can be performed by either anterior or posterior approaches. Overall surgical treatment of cervical fracture dislocations is variable. In the anterior approach, after discectomy is performed, distraction is applied with either the use of Caspar pins or a lamina spreader. Once distraction has “unlocked” the facets, a posterior directed force can be applied to reduce the dislocation. After both discectomy and reduction are obtained, interbody fusion should be performed, reserving corpectomy for larger more complex disc herniations or compressive lesions that are inaccessible through discectomy. In more complex fracture dislocations, a combined anterior and posterior approach is required for adequate discectomy, reduction, anterior column reconstruction with grafting, and reconstitution of the posterior tension band with stabilization and fusion. In this case, we reduced the dislocation by preoperative traction and then surgically fixed and fused with autologous bone graft and anterior cervical plating.


The decision was made for operative intervention as per the SLIC score. Closed reduction was performed with the use of Gardner-Wells tongs and sequential addition of weight up to 12 kg [Figure 1.5]. Once reduction was confirmed radiographically, an anterior approach was utilized for discectomy, foraminal decompression, fusion with autologous bone graft, and anterior cervical plating. The postoperative course was uneventful, and the patient was discharged from the hospital after suture removal [Figure 1.6].
Figure 1.5: (A) Shows traction assembly central traction bar with a metal traction pin that can be placed in upper or lower holes as per need of flexion or extension. (B) Initial traction in flexion to unlock the dislocated facet. (C) 3 kg traction. (D) 6 kg traction. (E) 10 kg traction. (F) Reduction at 12 kg. (G) Positioned in extension. (H) Reduction achieved and maintained in extension

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Figure 1.6: Postoperative X-ray and follow-up CT scan demonstrates good alignment of the implant and solid bony union

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Currently at the two-year follow-up mark, his neurology has improved to ASIA D with some residual weakness in the right upper limb.

  Clinical Scenario 2 Top

Stage 4 compressive flexion injury

A 45-year-old male presented to our emergency department with weakness of the bilateral upper and lower limb after an RTA (two-wheeler versus four-wheeler), a day earlier. After injury, he was initially taken to a nearby private hospital where he was catheterized, investigated and first aid was given. The patient had no history of loss of consciousness, vomiting, or ENT bleed. On arrival to our hospital, his vitals were stable and GCS was 15.

On examination, the patient had tenderness over the posterior aspect of the neck, with difficulty in the neck range of movements. The patient had power of MRC grade 3 in bilateral C5 to C7 myotome and grade 2 in bilateral C8, T1 myotome. His lower limb power was MRC grade 3 from L2-S1 myotome. He had decreased sensation in the bilateral upper and lower limb below C5 level. His deep tendon reflex was decreased in the bilateral upper and lower limb. On per rectal examination, perianal sensation and anal tone were reduced with decreased voluntary anal contraction.


Cervical spine radiographs showed C4 vertebral body fracture in both anteroposterior and lateral view with an increase in prevertebral soft tissue shadow from C4 to C6 level in lateral view. Moreover, there was C3-C4 interspinous widening in the lateral view, suggesting PLC injury [Figure 2.1]. The CT scan showed flexion tear drop fracture of the C4 vertebral body with mild retropulsion of the posterior two-third body into the canal in sagittal sections [Figure 2.2]. In axial sections, there was retropulsion of the right two-third of the vertebral body with the fracture involving the junction of right lateral mass and lamina [Figure 2.3]. In MRI, there was hyperintense signal change in the cord at C4 level in the T2-weighed image, suggesting cord contusion. There was hyperintense signal change at the C3-C4 interspinous region, suggesting PLC injury [Figure 2.4].
Figure 2.1: Preoperative cervical spine radiographs (AP and lateral view) showing C4 burst fracture with C3-C4 interspinous widening

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Figure 2.2: Preoperative CT scan sagittal sections showing flexion tear drop fracture of C4 vertebra with retropulsion of posterior third C4 body

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Figure 2.3: Preoperative CT scan coronal and axial cuts shows retropulsion of vertebral body with lamina fracture

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Figure 2.4: Preoperative MRI scan showing cord contusion at C4 level and hyperintensity signal change at C3–C4 interspinous region suggesting PLC injury

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Management options

Diagnosis of cervical SCI with C4 burst fracture (stage 4 compressive flexion injury, according to Allen Ferguson classification) with ASIA D neurology was made. As depicted in [Figure 2.5], these injuries are unstable injuries and care has to be taken not to miss the posterior ligamentous complex injury. The treatment options were:
Figure 2.5: Diagrammatic representation of stage 4 compressive flexion injury

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  1. C4 corpectomy with Harms cage reconstruction and anterior cervical plating

  2. C4 corpectomy with Harms cage reconstruction and anterior cervical plating plus posterior instrumented stabilization


In our patient, we did C4 corpectomy with Harms cage reconstruction and anterior cervical plating [Figure 2.6]. The intraoperative and postoperative period was uneventful.
Figure 2.6: Postoperative X-ray shows C4 anterior reconstruction with Harms cage and anterior cervical plating from C3 to C5 level

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At one-year follow-up, the patient’s neurology improved to ASIA E with implants in good position [Figure 2.7].
Figure 2.7: One year follow-up X-ray shows healed fracture with cage and implants in situ

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  Clinical Scenario 3 Top

Stage 4 compressive extension injury

Clinical scenario

A 32-year-old male presented to our emergency department with weakness of the bilateral upper and lower limb after self-skid and a fall from a two-wheeler two days ago. The patient was referred to our institute after receiving first aid at a local hospital.

On examination, the patient had tenderness over the posterior aspect of the lower neck, with difficulty in the neck range of movements. The patient had power of MRC grade 5 in bilateral C5-C6, grade 4 in bilateral C7 myotome, and MRC grade 0 in C8, T1, and L2-S1 myotome. The patient had ASIA B neurology below C8 level with absent anal tone and voluntary anal contraction.


Cervical spine radiograph (anteroposterior view) showed malalignment of the spinous process between C7 and T1 vertebra, whereas the lateral view was inadequate as the cervicothoracic junction was not visualized [Figure 3.1]. The CT scan sagittal sections showed more than 50% translation of C7 over T1 vertebra with a fracture involving the articular process. In axial sections, there was a C7 lamina fracture with the bilateral articular process and a pedicle fracture with relative widening of the spinal canal, suggesting stage 4 compressive extension injury according to Allen Ferguson classification [Figure 3.2] and [Figure 3.3]. In MRI, there was hyperintense signal change in the cord from C5 to T1 level in the T2-weighed image, suggesting cord contusion. There was hyperintense signal change from C5 to T3 interspinous region suggesting PLC injury [Figure 3.4].
Figure 3.1: Preoperative cervical spine X-ray AP shows malalignment of C7 and T1 spinous process and inadequate exposure in lateral view

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Figure 3.2: Preoperative CT scan sagittal sections shows >50% translation of C7 over T1 vertebra with fracture through bilateral articular process and separation of C7 posterior elements. Midsagittal image shows a widening of the spinal canal at C7 level

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Figure 3.3: Preoperative CT scan axial cuts shows impaction type fracture involving posterior elements of C7 vertebra with fracture via bilateral pedicle and articular process

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Figure 3.4: Preoperative MRI scan shows cord contusion from C5 to T1 level and hyperintensity signal change in C5–T3 interspinous region, suggesting PLC injury

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Management options

A diagnosis of cervical SCI with C7-T1 translational injury (stage 4 compressive extension injury, according to Allen Ferguson classification) with ASIA B neurology was made. The most common cause of C7-T1 translational injuries would be due to either a compressive extension mechanism or a distractive flexion mechanism. Compressive extension injuries because of pedicle fracture cause auto decompression of the spinal cord. The treatment options were:

  1. C7 corpectomy with Harms cage reconstruction and anterior cervical plating

  2. C7 corpectomy with Harms cage reconstruction and anterior cervical plating plus posterior instrumented stabilization

  3. C7-T1 ACDF with anterior cervical plating plus posterior instrumented stabilization


In our patient, we did C7-T1 ACDF with anterior cervical plating plus C5-T3 posterior instrumented stabilization [Figure 3.5]. The intraoperative and postoperative period was uneventful.
Figure 3.5: Postoperative X-ray shows C7-T1 ACDF with anterior cervical plating and C5–T3 posterior instrumented stabilization

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At one-year follow-up, the patient’s neurology improved to ASIA D with implants in good position [Figure 3.6].
Figure 3.6: 1-year follow-up X-ray shows a healed fracture with cage and implants in situ

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  Clinical Scenario IV Top

Cervical distraction-extension injuries (CDEIs)

Clinical scenario

A 47-year-old male was being followed up from June 2004 for Nurick grade 2 cervical myelopathy. His symptoms included heaviness of bilateral upper limbs and weakness in the left lower limb. His mJOA (modified Japanese Orthopedic Association) score was 15. His symptoms gradually improved with medication, a cervical collar, and exercises. Hence, a conservative line of treatment was continued. This was evident on MRI as a reduced canal size at C6-7 level and as a fused segment on CT. Unfortunately, on 24 May 2015, he met with an RTA on the bike from work to home in the form of a head-on collision with a stationary vehicle. He presented to the emergency department with neck pain and quadriparesis. His neurology was grade C as per the American spinal injury association (ASIA) impairment scale. Neurological deterioration was more in the upper limbs as compared with the lower limbs, resembling a picture of a central cord syndrome. Sensory and bowel bladder functions were intact.


Imaging showed CDEI at C4-5 level and a fracture of the C1 arch [Figure 4.1]a and b. The patient had radiological features of diffuse idiopathic skeletal hyperostosis (DISH) and ossified posterior longitudinal ligament (OPLL). The CT scan [Figure 4.1]c showed posterior element injury, C1 arch fracture, OPLL at C2-3–4 level, and confirmed presence of CDEI at C4-5 level. The MRI images [Figure 4.2] showed (1) disc injury, (2) fluid in retropharyngeal space, (3) posterior soft tissue edema, and (4) signal changes in the cord on the T2-weighted scan that suggested instability and severity of the injury.
Figure 4.1: (A and B) Preoperative X-ray showing extension distraction injury at C4–C5 level with features suggestive of DISH. (C) CT scan confirmed the presence of CDEI at C4–C5 and posterior element injury with OPLL seen at C2–C3–C4 level. (D and E): Associated injury included fracture of the anterior arch of C1

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Figure 4.2: T2, STIR, and T1 images of MRI 1. Intensity changes in the disc space at C4–C5 associated with signal change in the cord. 2. Fluid retropharyngeal space. 3. Posterior edema soft issue

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Treatment options

CDEIs account for 8% to 22% of sub-axial cervical spine injuries. Pathologic conditions reducing flexibility of the cervical spine, such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), predispose to CDEI in the setting of blunt trauma to the forehead.

Neurologic and vascular complications may occur in cases with significant displacement or angulation. CDEI require a high index of suspicion, as the spine may show minimal or no displacement because of a spontaneous postural reduction of injury. Elderly patients with a history of a significant traumatic mechanism and spondylosis should be examined for this type of trauma. In such cases, MRI is a valuable tool; high T2-weighted signals or STIR images within disc space are consistent with traumatic disruption.

The CDEI was classified by Allen and Ferguson into two stages. In a stage 1 CDEI, the disruption involves the ALL and disc (with or without an adjacent vertebral fracture) and one may observe widening of the anterior disc space. In a stage 2 CDEI, the disruption additionally involves the posterior ligamentous structures and leads to retrolisthesis of the superior vertebral body. These more severe injuries are severely unstable, with a higher risk of neurological deficit. Samartzis et al. studied a cadaver model with serial disruption of the ligamentous structures and expanded the CDEI classification into four categories (DES-1, DES-2A, DES-2B, and DES-3), based on degree of posterior translation and angulation noted on the lateral radiograph.

Treatment strategies for Stage 1 CDEI

If injury occurs through vertebral body with minimal displacement, this can be treated successfully by conservative management and immobilization alone. If the injury involves disruption of anterior soft tissue structures, then surgical treatment with an anterior fusion with the plate acting as a tension band is recommended. If planning for conservative management in a halo orthosis or rigid cervical orthosis, one should obtain frequent follow-up radiographs to ensure maintenance of cervical alignment.

Treatment strategies for stage 2 CDEI

Bicolumnar failure, often with displacement of the upper vertebral body posteriorly into the canal, is seen. Because of the extensive nature of the injury, these are often optimally treated with combined anterior/posterior fusion with instrumentation. In our case, it was a stage 2 CDEI managed with anterior fixation and an additional postoperative external hard cervical collar. Subaxial cervical spine injury classification (AO Spine) classifies this injury as C4-5, type C modifier F2, N3, and M3, suggesting the severity of injury.


Surgery was planned for the C4-5 level, and C1 fracture was to be managed conservatively.

Surgical management

In the supine position, with skull traction, fiberoptic intubation was performed. Anterior Smith-Robinson approach was used from the left side. Caspar pins were inserted in the bodies of C4 and C5 vertebrae. Distraction force was applied over the pins, and C4-5 discectomy was completed. ACDF with iliac crest autograft was done. Anchoring and grip of screws was satisfactory. The distraction was released, and reduction was confirmed on the C-arm. The incision was closed in layers over a negative suction drain [Figure 4.3].
Figure 4.3: Immediate postoperative X-ray after ACDF at C4–C5 level with a hemovac drain in situ

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The patient was mobilized on day one postsurgery. Hard cervical collar was continued for three months after the surgery.


At the last follow-up on 15 October 2020 [Figure 4.4], neurological status was grade D as per the ASIA impairment scale (AIS) with some residual weakness in the left upper limb.
Figure 4.4: On follow-up, on October 15, 2020—ADL satisfactory

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  Clinical Scenario V Top

Diaphragmatic pacing system (DPS)

Clinical scenario

DPS was done for the very first time in our country. It included a review of the laparoscopic diaphragm, motor point mapping, electrode implantation, and subsequent diaphragm conditioning and ventilator weaning. All patients gave informed consent for both the evaluation and the implantation of DPS.

Case 1

A 53-year-old male served as a case of C3 traumatic tetraplegia with AIS A neurology. The patient had a history of gunshot injury four years ago that was managed conservatively. Currently, the patient was on a domestic ventilator [Figure 5.1].
Figure 5.1: MRI showing cord edema up to brainstem of case 5a

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Case 2

An operation was performed on a 45-year-old male c/o C4-C5 fracture dislocation with AIS A neurology since 16 months. The patient was on tracheostomy, presented with increased secretions and poor cough reflex. As the ability to cough was impaired, the risk of respiratory tract infections increased. Although regular suctioning of secretions helps avoid these complications, this can be intrusive and disruptive for the patient [Figure 5.2].
Figure 5.2: Radiograph showing previous surgery implant and tracheostomy tube in situ of case 5b

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Case 3

A 60-year-old male with C7-T1 fracture dislocation three months ago was operated with C2 to T3 stabilization. The patient had AIS A neurology. The patient was on pressure support mode with rate 14 of the ventilator [Figure 5.3].
Figure 5.3: MRI showing C7–T1 injury in ankylosed spine of case 5c

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Operative procedure

Laparoscopic abdominal access is approached in a supraumbilical location, and two 5-mm trocars are placed bilaterally in the lateral subcostal location. First, the ability to stimulate the diaphragm is tested by evaluating the motor points within the muscle that correspond to phrenic nerve insertion into the diaphragm. As the phrenic nerve passes through the thoracic cavity and reaches the diaphragm from a cranial orientation, it divides into three or four branches, which then supply the motor control for each (left or right) diaphragm. These phrenic nerve branches are not visible from the abdomen. As a result, the motor points of the diaphragm must be ‘‘mapped.’’ It is important to note that the anesthesia team should not use any neuromuscular blocking agents or paralytics for induction or during the case, as this would prohibit electrical stimulation of the muscle. With the use of a laparoscopic dissector, each diaphragm is quickly stimulated to check for contraction [Figure 5.4]A. Via connection to a clinical station, an electrical current through the dissector is applied in a train fashion over one second. A stimulable diaphragm is easily visualized [Figure 5.4]B. If no contraction is seen, the abdominal wall musculature (transversus abdominus) is stimulated in the lateral subcostal position. This evaluates both the innervation of the motor neurons in the thoracic cord and if the system is working appropriately. If there is contraction of the abdominal wall, but not the diaphragm, there is complete loss of the phrenic motor neurons either directly from the injury, subsequent vascular compromise of the spinal cord, or complete injury of the phrenic nerve rootlets. In any of these cases, the diaphragm is denervated and cannot be directly stimulated; DPS wires are not implanted and it is, indeed, difficult to wean these patients. If there is diaphragm movement, then the diaphragm is formally “mapped” to optimize placement of the electrodes. The falciform ligament is divided to allow better exposure of the diaphragm, and an epigastric 12-mm port for both the implantation device and exit of the wires from the abdominal cavity is made. Mapping involves both qualitative assessment of diaphragm contraction via direct visualization, maximizing diaphragm contraction, and preferentially capturing posterior diaphragm, and quantitative assessment of changes in abdominal pressure. Once the sites are identified, two electrodes are placed in each diaphragm [Figure 5.4]C, brought out through the epigastric port, and tunneled to an exit site on the chest or abdomen. A separate ground or anode electrode is placed in subcutaneous tissue. Before extubation, all electrodes are maximally stimulated, and the tidal volume of respiration from DP is assessed without ventilator support.
Figure 5.4: Laparoscopic evaluation and operative mapping. (A) Mapping of the diaphragm to identify the optimal site for implantation of electrodes. The laparoscopic dissector is touching the presumed motor point of the diaphragm. (B) The diaphragm is now contracted, showing that there are intact cervical phrenic motor neurons and an intact phrenic nerve. (C) The electrode implant instrument with the electrode housed in the needle, which will then be placed superficially into the diaphragm muscle. Slight countertraction when backing the needle out of the diaphragm allows deployment of the electrode. (D) The electrodes are placed in the connector block, which is then connected to the external pulse generator, which has been programmed to maximize the patient’s stimulated tidal volume

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When stable after surgery, the patient’s external pulse generator is programmed to maximize the patient’s tidal volume for each electrode via the frequency, pulse width, amplitude, and rate of respiration [Figure 5.4]D. Trials of ventilator weaning with concurrent DP can begin immediately. The amount of time it takes to wean from the ventilator depends on the patient’s comorbidities and the duration of mechanical ventilation. The length of each weaning trial is extended as the diaphragm is conditioned and may depend on the patient’s expectations and the comfort and experience in weaning for the rehabilitation facility.


Case 5a

The left diaphragm was completely stimulable intraoperatively; the right diaphragm was partially stimulable. Two electrodes were placed on each diaphragm. Stimulation was started on the immediate postoperative day. Gradually, the duration of stimulation was increased. Three months postoperatively, the patient was maintained for 2 h without a ventilator [Figure 5.5] and [Table 2].
Figure 5.5: (A) Dividing falciform ligament. (B) Stimulable diaphragm

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Table 2: Clinical case scenarios traumatic cervical spine injury—An overview of cases 5a, 5b, and 5c

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Case 5b

The patient was decanulated within a week. His left diaphragm descended down. At 18 months’ follow-up, his cough, speech, and olfactory sensation had improved. Apart from being able to achieve effective negative pressure inspiration, the most noticeable effect was seen in the patient’s voice and ability to smell. He sounded more natural [Figure 5.6] and [Table 2].
Figure 5.6: (A) Preoperative plain X-ray and (B) Postoperative plain X-ray. They show difference in the left dome of the diaphragm; the left dome came lower

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Case 5c

The patient’s diaphragm was not stimulable even on maximum intensity. This may have resulted from either phrenic nerve damage or infarction of the involved phrenic motor neurons; he was not implanted. To countercheck, his abdominal musculature was stimulable. The patient had an ankylosed spine [Table 2].

  Discussion Top

These case scenarios depict the management of typical and atypical cases of cervical spine fractures. They clearly bring out the message of differential management of these cases as per the fracture type and associated conditions. A survey analysis of the STSG again shows extreme variations in the choice of approach for unilateral or bilateral facet fracture dislocations.[17]

The first case scenario brings out the use of the significance of awake reduction in a case of C6C7 fracture dislocation. After reduction, the case is managed by standalone anterior surgery. In such cases reduced by traction, discectomy after distraction with interbody fusion generally suffices. Corpectomy is reserved for large complex disc herniations or lesions that are inaccessible via discectomy. The type of approach depends on: (1) Stability of the fracture/dislocation, (2) Associated anterior disc herniation, and (3) Reducibility of dislocation from the anterior approach in isolation. Hence, in general, there is no consensus or gold standard on the surgical approach of unilateral or bilateral fracture dislocations.[5],[18],[19],[20],[21],[22],[23],[24],[25] Complications in flexion distraction injuries managed by anterior surgeries in isolation are reported in cases with associated fracture of both facets and endplates. This complication is secondary to biomechanical failure and nonunion.[26] Hence, it is advised that posterior surgery be supplemented in such cases with end plate fractures.[27] However, an alternative is the usage of longer screws in plates for better purchase and immobilization after surgery in the form of a rigid collar or orthosis.[28]

Case 2 shows a C4 burst fracture (stage 4 compressive flexion injury, according to Allen Ferguson classification) with ASIA D neurology managed by C4 corpectomy with Harms cage reconstruction and anterior cervical plating. The other option would have been supplementing with a posterior stabilization. However, it is proven that better direct decompression can be achieved from the anterior approach. With stable fixation, the need of posterior surgery may not be warranted.[29]

Complex fracture dislocations warrant a combined anterior and posterior surgery. These cases would have a compromised posterior ligamentous complex. Reconstitution of the posterior tension band by stabilization is highly recommended in such injuries.[29]

Case 3 shows a three-column C7-T1 translational injury (stage 4 compressive extension injury, according to Allen Ferguson classification) with ASIA B neurology. The most common cause of C7-T1 translational injuries would be due to either a compressive extension mechanism or a distractive flexion mechanism. Compressive extension injuries because of pedicle fracture cause auto decompression of the spinal cord. Such three-column injuries, especially in junctional areas, are best dealt with globally (anterior+posterior surgeries). Literature has enough evidence that the complex biomechanics in the cervicothoracic junctional area of the spine warrant global reconstruction.[30]

Even though there is recommendation of long segment fixations in ankylosed spine, there is a lack of biomechanical studies establishing significance in the cervical spine.[31] Case 4 is a case of C4-5 CDEI and fracture of the C1 arch with AIS-C neurology. The patient had radiological features of DISH and ossified posterior longitudinal ligament (OPLL). The patient was managed by anterior cervical discectomy with an iliac crest autograft with a hard cervical collar. Due to the experience of surgeons, these patients do well with anterior surgery in isolation as well.

Missing cervical spine injuries are known.[32] In 30% of patients with discoligamentous injuries, initial imaging shows no evidence of injury, which is evident on subsequent imaging.[33] Patients with PLC injures in isolation on MRI may not need surgical management. Cervical instability cannot be decided on the basis of MRI findings alone. It is important to access the integrity of the discoligamentous complex in such cases. Dynamic radiographs, hence, are an important aid to diagnose such injuries. Dynamic flexion and extension radiographs may be obtained in such patients with significant neck tenderness with evidence of ankylosed spine. These images may be obtained in cases with ahigh index of suspicion with normal findings on other radiography.[34] Safety of dynamic radiographs has been established in the literature.[35],[36] However, the examination should be performed carefully to avoid neurologic deterioration.

In general, in the patients with ankylosed spine secondary to ankylosing spondylitis (AS) long posterior fixations three level above and three levels below the fractured segment is recommended, primarily because of long lever arms created in the fused column above and below the fracture site.[37] This is not the case with DISH. Posterior approach surgeries are often more common in patients with AS than DISH. One of the reasons may be the need for decompression of the spinal cord in patients with AS.[38] Literature has the paucity to establish the exact reasons of the same. Posterior surgery may be preferred in patients with AS since patients with AS have more compromised bone quality as compared with patients with DISH, as evident by BMD DEXA scores.[39] Other reported reasons are secondary deterioration of neurological status, unstable fracture pattern, and the presence of an epidural hematoma.

Respiratory failure and ventilatory dependence are dreaded complications of SCI. Case 5a, 5b, 5c is the experience of the author of using diaphragmatic pacing in India. This is the first time that the technique has been used in India. The cases on follow-up have shown a decrease of ventilatory dependence. Cases have shown improvement in cough, speech, and olfactory sensation. Along with an improvement in patients’ voice and smell, they are able to achieve effective negative pressure inspiration.

The ideology of reduction of fracture dislocations in the cervical spine is controversial with doubts and paucity of level I evidence in confirming whether closed or open reduction should be preferred.[40] Following the Spinal Trauma Study Group’s proposed classification system, the Subaxial Injury Classification System (SLIC), and injury severity score to decide on surgery is the choice of the surgeon.

Even though the approach to the vertebral lesion has been controversial, the consensus is to base the decisions on the neurology of the patient, associated disc injury, and whether it is a unilateral or bilateral dislocation.[17],[18],[41] One of the other contributing factors is the ease, training, and comfort of the surgeon. With the associated disc herniation, it is common for surgeons to prefer an anterior surgery. However, surgeons also report disc removal from a posterior approach, as that is preferred by them.[41],[42] Hence, the scientists across the world are yet to establish a gold standard.

The authors recommend anterior surgery in cases where the pathology can be easily approached anteriorly. If the injury is a three-column injury with the PLC involved, it is recommended that posterior fixation be supplemented. In cases with disc herniation with an irreducible fracture, a three-staged surgery may have to be done in the same sitting if the general condition of patient allows. After a discectomy in step I, the fracture is reduced and fixed posteriorly and in stage III anteriorly the column is supported in the form of bone graft / cage. In certain cases, the patient may be counseled of the need for a posterior stabilization on a later date if the anterior surgery in isolation suggests the need of support. Keeping such patients in follow-up is mandatory.

A significant amount of resources of the total care of patients with SCI is utilized on ventilator dependence. Respiratory failure and complications are one of the most dreadful of the complications. Diaphragmatic pacing has shown evidence of replacing mechanical ventilation in chronically ventilatory dependent tetraplegics. However, the limitation is that early use has not been reported.[43] Along with this the availability and expertise is limited. Physiologically, as a patient rests his or her diaphragm on a mechanical ventilator, the diaphragm muscle atrophies quite rapidly. Autopsy studies have shown a 50% to 60% decrease in both slow- and fast-twitch muscle fibers in the diaphragm, with as little as 18 h to 69 h of mechanical ventilation and decreased diaphragm muscle thickness measured by daily ultrasound within 48 h of mechanical ventilation.[44] When compared with other health care related illnesses, traumatic cervical SCI is relatively rare. As a result, innovative treatments and studies often lack the sample sizes to demonstrate dramatic statistical differences. However, similar to traumatic brain injury, the consequences of SCI are profound. Both are chronic and emotionally, physically, and financially taxing on patients and their families. All interventions that can improve patient outcome and prevent ventilator dependence should be aggressively explored.[45]

The ultimate goal is stabilization of the spine, decompression of the cord, recovery from deficit (if any), and fracture union. Patients’ expectations and characteristics should be carefully considered preoperatively. Surgeons may also have to consider their own experiences and familiarity with each technique. Acceptance and learning of new technology to aid in the management of complications of SCI is the need of the time. Diaphragmatic pacing shows hope in weaning off ventilatory support.

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Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29]

  [Table 1], [Table 2]


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