Traumatic injuries at the cervicothoracic junction (CTJ) are a relatively rare event and considered as a significant cause of paraparesis or paraplegia posttraumatic. As young people are most commonly injured, it is considered as a significant economic burden to the family and society. In CTJ injuries, surgical techniques and associated complications have been extensively described in the literature during the past decade, whereas the choice of anterior versus posterior or double-stage fixation has been given little attention [
A seventy-year-old male was transferred to our hospital after sustaining trauma falling down into a watercourse. The initial Glasgow Coma Scale score was 15. Upon examination, he was hemodynamically stable and breathing spontaneously; we found paresthesia corresponding with dermatomes C7 and C8 bilaterally. The rest of the neurological physical examination was normal, and the patient was categorized grade E based on the American Spinal Injury Association classification.
Cervical spine radiography and two-dimensional reconstructed computed tomography (CT) scans (Figure
Preoperative CT scan of the patient shows vertebral body fracture of T1 and biarticular dislocation of the cervicothoracic junction.
Under general anesthesia, an image intensifier was used, and 16 kilograms of halo traction was applied with full muscle relaxation; the dislocation was irreducible. Iliac crest autogenous bone grafting was harvested. A left long presternocleidomastoid to the midline approach was then made for exposing the T2 vertebral body. Traumatic disc material at C7-T1 was removed by anterior cervical discectomy. Then, as the patient had biarticular dislocation, we placed the Caspar distractor on the medial line. The dislocation was reduced partially by increasing gently the distraction. When the facets were point to point on the oblique fluoroscopic view, we pushed gently on the upper vertebra, and the reduction was achieved on the oblique fluoroscopic. Anterior fusion from C6 to T2 was performed by iliac crest bone graft and anterior plate. This technique of reduction is successful in 34% of uniarticular dislocations and 27% of biarticular dislocations [
Secondly, for increasing the stability of CTJ, the patient was turned to the ventral position. Fixation was done without facetectomy associated with instrumentation from C6 to T2. Screws were placed in the lateral mass of C6 and pedicular screws from C7 to T2. Cervical spine radiography (Figure
The patient underwent a C6-T2 fixation, followed by posterior C6-T2 arthrodesis.
Postoperative CT scan shows complete reduction of cervicothoracic dislocation.
MRI postoperative does not show any abnormality of the spine canal.
At one-year follow-up, cervical spine radiography (Figure
X-ray at one-year follow-up shows a well bony fusion.
CTJ is a region in the vertebral column where biomechanically, it represents a region where there is an inflection from mobile cervical lordosis to rigid thoracic kyphosis. Radiographically, it is not easy to visualize especially in traumatic cases. Traumatic injuries to the CTJ usually include fracture-dislocation or isolated fracture [
Nichols et al. [
Dislocations of the CTJ are frequently missed especially in simple cervical trauma cases visiting the emergency department. Evans [
Following trauma at CTJ, neurological problems are commonly seen. This may be due to the anatomical features of the upper thoracic spine through the small canal size, even though vascular insufficiency through the low blood supply of the lower cervical spine makes it more susceptible to ischemic injury.
A large and growing body of literature has investigated the successful results for anterior instrumentation for pathological fractures of the CTJ; the reported results of anterior instrumentation for traumatic fractures and dislocations are limited [
Anterior approaches can be practically classified into a low anterolateral cervical approach, a transmanubrial-transsternal approach, and a thoracotomy [
Posterior approach to the CTJ has been performed largely because of the technical difficulty of the anterior approach. Practically posterior instrumentation of the CTJ should always be fused, because of the instability of the CTJ. In the cervical spine, lateral mass screws are often performed in the posterior fixations. The thickness of the lateral mass is decreased from C5 to C7 from 11 to 8.7 mm [
Collectively, in our case, we started with the anterior approach to reduce the dislocation from the front as it is less invasive comparing with posterior facetectomy and we have direct exposure of the body and disc. Then, we have instrumented the cervical spine posteriorly to decrease the risk of instability and mechanical complications as the patient had a three-column injury of CTJ. Our case report with the grand round presentation of the literature outlines the importance of anterior versus posterior or double-stage fixation at the CTJ. Our case presented with a three-column injury and has shown the importance of previous literature for understanding the stability at this unique region [
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The authors declare that they have no conflicts of interest.
The authors contributed equally to this work.
We would also like to show our gratitude to the 5th International Conference on Spine and Spinal Disorders and the 15th International Conference and Exhibition on Alzheimers Disease, Dementia & Ageing which were held in Rome from April 22 to 23, 2019, for giving us a chance to present this case report.