Surgical Treatment of Traumatic Lesions of the Upper Cervical Spine

Yu.A. Shulev, V.V. Stepanenko, A.I. Verkhovsky, V.N. Bikmullin, V.V. Rudenko, V.V. Rychkov, A.V. Vorobyev,
K.S. Gordienko, M.I. Koreshkina, V.B. Remenets, D.A. Rzaev, E.E. Khaustova

(Saint Petersburg Research and Practice Neurosurgical Center, Municipal Multifield Hospital N2, Medical Academy of Postgraduate Education, Dzhanelidze Institute of Emergency Care, Saint Petersburg)

The Study Goal: To work out optimum tactics of surgical treatment in trauma of the atlantoaxial complex, which would be based on profound diagnosis of bone changes, injuries of the articular-ligamentous apparatus, allow to understand injury biomechanics and choose decompression, reposition, stabilization and fixation, using a neuroorthopedic approach.

Material and Methods: The results of treatment of 36 patients with different injuries of the upper cervical spine were analyzed. A choice of the optimum diagnostic algorithm and the most preferable method of treatment were based on principles of interdisciplinary team approach. A diagnostic complex included different methods of neurovisualization (X-ray, CT, MRI), estimation of neuromuscular conductivity (acoustic sensory EVP, EMG), dynamic urinary tests. Neurologic examination was carried out with application of the following scales: ASIA/IMSOP, Ranowat, VAS, Karnofsky's scale.

Results: Anatomic and biomechanical complexity of the atlantoaxial articulation determined individual peculiarities of traumatic changes in each case. It made a routine approach to choosing a type of intervention impossible. There were 14 patients with indications for surgical treatment. They were operated with application of various devices, used for fixation of the upper cervical spine and craniocervical junction and manufactured by Medtronic-Sofamor Danek, Codman, Stryker.

If there was fracture-dislocation with anterior compression of the spinal cord by a fragment of C2 tooth in an area of the craniocervical junction, the first stage of operation consisted in transoral decompression and anterior open reduction of dislocation. The last step was posterior fixation. Reposition and stabilization was performed in absent anterior invagination of the stem, using a posterior access. A simultaneous intervention was made in case of associated subaxial injury of the cervical spine.

Active surgical tactics resulted in correction of orthopedic disorders, guaranteed stabilization and complete or considerable regression of neurologic disorders in all patients. It permitted them to live actively or to become completely adapted to social conditions at an early stage after intervention.

Conclusion: Complex diagnosis and active surgical tactics in treatment of patient with unstable complicated trauma of the upper cervical spine, use of apparatus for internal fixation allow to achieve the highest clinical, neuroorthopedic and rehabilitative effect.