Stability following fracture-dislocations of the cervical spine

Abstract

IN 1970, Crue published his 20 years' experience with a conservative approach in 87 patients, pointing out that surgical fusion had not been proved to be a pro cedure of choice.In our own experience of over 25 years, we have dealt with almost twice the number of cases. In every case treated conservatively, spontaneous fusion followed as a rule, without interfering with the rehabilitation programme. Although the conservative approach was deliberately chosen as a means of treatment, there were a number of cases in which surgical fusion would have been technically and mechanically unsound.A large number of cases that came to our hands after laminectomy followed by anterior or posterior fusion or both, never showed any improvement as a direct result of the operation. One of the arguments that has been claimed for early surgical fusion is, that it facilitates the immediate rehabilitation of the patient. Early rehabilitation of the patient can be started immediately without any surgery. If skull traction is applied, apart from being mobilised every two hours, the patient is also encouraged to rotate his head, both as an exercise and to determine for himself the most comfortable position.We have found that skeletal traction by means of a de Anquin or Urrutia stirrup has not only been very well tolerated by the patient, but also facilitates the periodical turning and does not interfere with the continuous nursing care. The patient will soon start active flexo-extension exercises. In doing so, by the time the traction is discontinued-four to six weeks-he will be able to hold his head in any desired position.In recent cases, the dislocation is easily reduced. Traction has been kept for periods varying from 20 to 45 days. Once traction is discontinued, an adjustable leather collar or a minerva plaster jacket, depending on the case, is worn for several weeks. When active exercises are encouraged, the reduced position is maintained and X-ray examination will soon show spontaneous fusion due to ossification of the anterior longitudinal ligament.We do not agree with the minerva plaster jackets which immobilise the fore head, as they only lead to the necessity of liberating the chin to perform masticatory movements, the immediate consequence being the loss of the all important hold under the mandibular area. With the type of plaster that we advocate, the patient can freely open his mouth by raising his head. After a few days or weeks, they can even lift the chin from the plaster. The possibility of lifting the head will not 203 204 PARAPLEGIA impair immobilisation, but on the contrary this active movement will strengthen the muscles and enhance bone formation achieving auto-stabilisation.The treatment of fractures of the odontoid process has given rise to many a controversy. Those who maintain that the dens unites under adequate immobilisa tion, find opposition among the admonishers of surgical fusion.When there are clinical signs of a fracture of the dens, it is of the utmost importance to get X-ray films of excellent quality ...