[Injuries to the lower cervical spine].

PURPOSE OF THE STUDY: The authors present a retrospective evaluation of a group of patients with injury to the lower cervical spine. The aim of the study is to show current trends in the diagnosis and treatment of this trauma.

MATERIAL: Between 1995 and 2003, 363 patients with trauma to the lower cervical spine were treated in our clinic. They included 63 women and 300 men, who fell into age categories as follows:14-19 years, 52 patients; 20-29, 108 patients; 30-39, 76 patients; 40-49, 57 patients; 50-59, 40 patients; 60-69, 22 patients; over 70, 8 patients. Neurological findings were classified as Frankel A in 109 patients, Frankel B in 24 patients, Frankel C in 19 patients, Frankel D in 12 patients and Frankel E in 199 patients. The trauma was due to a car or motorcycle accident in 183 patients, a fall from a height in 67 patients, a dive in water in 57 patients, a fall of the pedestrian in 47 patients and other causes in 9 patients. According to the level of the vertebra injured, fractures of the fifth cervical vertebra and the C6/7 segment were most frequent; fractures of the C7/T1 segment were least frequent. The AO classification showed type A injury in 22 %, type B in 23 % and type C in 55 % of the patients.

METHODS: Conservative treatment was carried out in 100 patients, of whom 56 had a halo vest and 44 received a Philadelphia collar. Surgery was performed in 463 patients, most of whom, i. e., 246 patients, were treated from the anterior approach. Monocortical stabilization was used in 228 patients, bicortical fixation in 18 patients. Fifteen patients were treated from the posterior approach and two patients underwent a combined two-stage treatment.

RESULTS: In the group of 263 patients treated surgically, there were several complications. Injury to the recurrent laryngeal nerve were recorded in nine patients, an abscess in the operative wound following the anterior approach developed in one patient and a hematoma of the anterior operation wound requiring revision surgery occurred in two patients. Complications involving implants were the following: fracture of the anterior plate in one patient, failure of anterior plate fusion in two patients, failure of posterior plate fusion in one patient and loosening of two anterior, bicortically inserted screws in one patient. Pseudoarthrosis was recorded in one patient with a fracture of the cervical spine locking plate. In the remaining patients (99.8 %) bony union was achieved by 6 months. Of the 363 patients, 164 had a medullary lesion; of these 17 died. Sixteen were classified as having Frankel A lesions and one having a Frankel B lesion. The cause of death was unrelated to the operation. Six patients with neurological deficit were transferred abroad. A patient diagnosed by the neurologist as Frankel A remained included in this group, although an improvement in his neurological status suggested an incomplete medullary lesion. Of the 141 patients with neurological deficit who were followed up for more than one year, 60 showed an improvement in neurological findings.

DISCUSSION: The treatment of fractures of the lower cervical spine aims a decompression of the affected nerve structures and at restoration of the correct position and stability of the cervical spine. It is predominantly performed from the anterior approach; the posterior approach is used less frequently, only when indicated.

CONCLUSIONS: The diagnosis of injuries to the lower cervical spine is based on the medical history, X-ray images in three basic projections and a CT scan. The necessity of a pre-operative MRI examination has recently been discussed. The use of the anterior approach in treatment of the injured lower spine is safe and effective. It allows us to carry out decompression as well as insertion of a graft and plate under direct visual control. It is associated with a minimum of complications and a high probability of bony fusion. Only immediate decompression will facilitate the regeneration of an injured spinal cord. Key words: cervical spine, spinal injury, anterior fixation.