Posterior plates in the management of cervical instability: long-term results in 44 patients

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✓ Although posterior plates are increasingly used to manage cervical spinal instability, long-term follow-up evaluation of patients with a critical analysis of efficacy and complications has not been reported. The authors have retrospectively analyzed the outcome in 44 consecutive patients (37 males and seven females, age range 16 to 80 years) treated with posterior cervical plates. The indications for instrumentation were instability due to trauma in 42 cases, tumor in one, and infection in one. In four patients the follow-up period was limited to 3, 5, 11, and 16 months. Two patients died of chronic medical problems 4 and 9 months after treatment. The remaining 38 patients were followed from 2 to 6 years (mean 46 months). One motion segment was stabilized in 23 patients using two-hole plates; two motion segments were stabilized in the other 21 patients using three-hole plates. In the majority of patients (37 cases), supplemental bone grafting was not used. Patients were immobilized postoperatively in a Philadelphia collar. Solid arthrodesis was achieved in 39 (93%) of 42 patients. Three patients required revision of the cervical plating: in one patient with a C-5 burst fracture, two-hole plates were applied at C5–6 and progressive kyphosis mandated anterior fusion; the second patient required posterior wiring due to screw pull-out resulting from a technical error in screw insertion; the third patient, who refused to wear an orthosis postoperatively, also developed screw pull-out. In two patients who went on to spinal fusion, there was an increase in sagittal kyphosis (6° and 8°) without clinical sequelae. Screw loosening was noted in five patients, involving eight (3.8%) of the 210 lateral mass screws; this complication resulted in instrumentation failure or increased kyphosis in three cases. There were two superficial infections.

This analysis indicates that posterior cervical plating is highly effective; at long-term follow-up review the cervical spine was successfully stabilized in 93% of cases. Plate failure was related to faulty screw placement, failure to include sufficient motion segments, and noncompliance with postoperative orthoses. Halo vest immobilization was unnecessary and supplemental bone grafting was generally not required for recent trauma.

Article Information

Address for Dr. Fehlings: Division of Neurosurgery, The Toronto Hospital, Toronto Western Division, University of Toronto, Toronto, Ontario, Canada.

Address reprint requests to: Paul R. Cooper, M.D., Department of Neurosurgery, NYU Medical Center, 550 First Avenue, New York, New York 10016.

© AANS, except where prohibited by US copyright law.

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Figures

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    Technique of lateral mass screw insertion. A point 1 mm medial to the exact center of the lateral mass is drilled to a depth of 11 mm as shown. Self-tapping screws (16 mm in length, 3.5 mm in major diameter) are positioned and connected to the plates.

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    Case 1. X-ray appearance in a 38-year-old man who sustained bilateral jumped facets at C4–5 in association with a left C-4 facet fracture. He was treated with C3–5 lateral mass plates without concomitant bone grafting. Left: Film obtained on admission. Center: At 9 months, there is evidence of spontaneous facet joint arthrodesis. A spontaneous fusion is forming between the lamina/facet complex of C2–3 (straight arrow). Moreover, early fusion is evident between the bodies of C-4 and C-5 (curved arrow). Right: At 66 months, the disc spaces from C3–5 have been obliterated and a solid posterior fusion from C2–5 is evident. This is the only case in this series where the fusion extended beyond the segments of the spine instrumented.

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    Case 24. Studies in a 22-year-old woman who sustained a burst fracture of C-6 in association with C6–7 facet subluxation and fractures of the spinous processes and laminae of C-5 and C-6. a: Admission x-ray film showing burst fracture and facet instability (arrow). b: Computerized tomography scan, axial view, illustrating C-6 body and bilaminar fractures. c and d: X-ray films obtained at 48 months illustrating stability in flexion (c) and extension (d). There is evidence of facet joint arthrodesis from C5–7 and disc space fusion at C6–7. This patient did not receive a supplemental bone graft.

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    This patient (Case 31) with traumatic ligamentous instability at C5–6 was treated with lateral mass plates. Left: The early postoperative x-ray film 1 week after treatment shows good alignment; however, the inferior screws at C-6 appear to be in the C6–7 facet joint (arrow). The patient was noncompliant with orthotic immobilization. Right: X-ray film at 4 weeks. There is loss of reduction with failure of the screw-plate construct.

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    Case 2. Left: Admission x-ray film showing traumatic C4–5 subluxation with marked sagittal plane angulation. Right: Follow-up x-ray film showing restoration of anatomical lordosis obtained with posterior plating.

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    This 22-year-old man (Case 21) sustained ligamentous injuries at C4–5 and C5–6. Left: The early postoperative x-ray film illustrates good position of the instrumentation from C-4 to C-6, with satisfactory alignment. Right: The follow-up film obtained at 46 months reveals 6° loss of sagittal plane correction with a loose screw at C-6 (arrow). Flexion-extension films revealed good stability despite these radiological findings.

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    This patient (Case 18) underwent C5–7 instrumentation for two-level instability. The left lateral mass of C-6 was fractured and thus was not included in the instrumentation. Left: X-ray film obtained at 46 months showing a solid fusion and good sagittal plane alignment. Right: Film showing that the right C-7 screw has partially backed out (arrow).

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