39 yr male…h/o trauma 6 mths back…gradual onset quadriparesis…bowel/bladder involved..ASIA C…evidence of cervical myelopathy..kindly give inputs regarding options and PEARLS of treatment…
- Vedant Vaksha Neglected Fracture sublux C3-4 & C6-7 – C6-7 seems to be the culprit for myelopathy. The involved segements must have fused by know (Midline Sag CT Scan cuts). If C3-4 is not stenotic then Lami C5-6 or may be a level more & PSF in situ C3-T1/T2 seems a good option.
- Sandeep Sonone Its unifacetal subluxation at c3-c4 and maybe unifacetal at c6-7 ..
I would open up post …do sup facet resection on subluxated side at both levels . Attempting reduction from post is out of question .
Second stage anteriorly do a C34 dissectomy and fusion and C67 dissectomy and fusion and plating .
This is young patient ..unifacetal pathology …6 months old …no point in fusing half or more of cervical spine at 40 .
- Niranjan Kavadi Abhishek Ray Can you post axial cuts at both levels? I feel C6-7 is bilateral so would resect bilateral facets at C6-7 and add a C6 laminectomy. Flip and then C6-7 and C3-4 ACDF. Would be interesting to see how much reduction is possible by taking down facets after 6 months.
- Abhishek Ray The facets r not only dislocated but at both levels there r fracture-dislocations…with this in mind, is it biomechanically safe to do just C3-4 and C6-7 ACDF after facet excision posteriorly or does the situation warrant some sort of posterior fixn also…if so, how about doing just a C3-4 and C6-7 posterior fusion together with the same level ACDF…I agree that the xray is going to b really funny!!!…thots?
- Niranjan Kavadi I meant axial cuts for assessing canal diameter and cord compression at both levels. C6-7 is obvious here but not sure how significant C3-4 is. If C3-4 is not compressive can we just aim at fusing c3-4 without any bony resection? Bimechanically not ideal but results with fusion for missed unreduced unifacetal dislocations have been shown similar once they fuse.
- Senthil T. Nathan the dislocation/usubluxation is 6 months old, most often they are fused . The idea of only doing acdf in both levels- it may be difficult to reduce it except if you doa corpectomy, also tye disc does not appear to be an offending agent in the front. I would just do a posterior laminectomy of c4 , lat mass/ped screws at c3-4,post laminectomy c7,post fusion of c6/t2
- Abhishek Ray On a lighter note, please feel free to comment atleast in my patients…the merits of discussion far outweighs the demerits of a remotely possible scenario!!!BTW, thot that the moderators did have a discussion about this sometime back and the solution was to make it into a closed group…not fool-proof but may b a little more secure
- Sandeep Sonone Like Niranjan Kavadi thought of fusing c3/4 without reducing but contact area fr fusion wud be less ..marginally though
Dont feel the bodies will fuse in 6 months time ..safer option would be to do a bck front . Reduction wont be achieved by facet excusion but by anterior disc realease and restoration of disc height ..