Background

Fractures and dislocations of the spine are among the most challenging in trauma clinical practice. The choice of surgical approaches for the management of subaxial spine facet dislocations is a source of controversy among surgeons. This is primarily due to safety reasons, which include the interpretation of the images regarding the existence of disc herniation and the neurological status of the patient. Therefore, all surgical approaches need to ensure that any reduction and fixation in the attempt to acquire anatomical realignment and bony fusion consider maximizing neurological recovery, long-term relief of pain, functional recuperation, and early return to activities of daily living.

Objective

To compare the effects (benefits and harms) of the different surgical approaches used for treating adults with acute cervical spine facet dislocation.

Intervention/Methods

The review included randomized controlled trials and quasi-randomized controlled trials. All the participants were adults with acute (<3 weeks) and radiologically confirmed distraction-flexion dislocation or fracture-dislocation of the lower cervical spine with or without neurological deficit. The main comparison was between the anterior and the posterior approach for surgical fixation. There are two main stages to surgery: reduction and fixation. Reduction is the restoration of an injured or dislocated bone or joint to its normal anatomical position and can be achieved either with surgery or through closed reduction, which is performed with traction or manipulation. Fixation is the medical procedure used to stabilize one or more joints, or a fractured bone, usually by surgically inserting devices such as wires, screws, plates, and rods.

The primary outcome of the review was final postsurgical neurological status (recovery or deterioration). The secondary outcomes included pain, functional aspects and quality of life, radiological outcomes, and complications.

Results

Two studies with 94 participants were identified. One trial included patients with spinal cord injuries, and the other included patients without spinal cord injuries. Both trials compared anterior versus posterior surgical approaches. Both trials were at high risk of bias, including selection bias (one trial), performance bias (both trials), and attrition bias (one trial). Reflecting also the imprecision of the results, the evidence was deemed to be of very low quality for all outcomes, which means that the level of uncertainty about the estimates is high.

Neither trial found differences between the two approaches in neurological recovery or status at 1 year of follow-up in 33 participants. Only one trial reported on the functional aspects and quality of life of the participants. This trial found no differences between the approaches at 1 year in patient-reported quality of life using the 36-item Short Form Survey Physical (mean difference [MD] = -0.08, 95% CI [-7.26, 7.10]) and Mental Component scores (MD = 2.88, 95% CI [-3.32, 9.08]).

When addressing the long-term pain scores of these patients, neither trial found any evidence of significant differences in long-term pain. With regard to the radiological outcomes, one trial found better sagittal and more "normal" alignment after the anterior approach whereas the other trial reported no significant differences in cervical alignment. There was insufficient evidence to indicate between-group differences in medical adverse events, rates of instrumentation failure, and infection. One trial found that the several participants had voice and swallowing disorders after anterior approach surgery (11/20) versus none (0/22) in the posterior approach group (risk ratio [RR] = 25.19, 95% CI [1.58, 401.58]); all had recovered by 3 months.

Conclusions

Very low-quality evidence from two trials indicated little difference in long-term neurological status, pain, or patient-reported quality of life between anterior and posterior surgical approaches to the management of individuals with subaxial cervical spine facet dislocations. Sagittal alignment may be better achieved with the anterior approach. There was insufficient evidence available to indicate between-group differences in medical adverse events, rates of instrumentation failure, and infection. The disorders of the voice and swallowing that occurred exclusively in the anterior approach group all resolved by 3 months. The reviewers were uncertain about this evidence and could not say whether one approach is better than the other. There was no evidence available for other approaches. Further higher quality multicenter randomized trials are warranted.

Implications for Practice

The evidence contained within this review is of poor quality and limited. The evidence further substantiates the lack of differences in long-term neurological status, pain, or patient-reported quality of life between the two surgical approaches. Therefore, it is vital that practice and procedures are patient led, with decisions regarding the surgical approaches based on the surgeon's experience.

Reference