Finite element analysis of the biomechanical effects of anterior and posterior cervical fusion surgery for bilateral cervical dislocation
Abstract
Lower cervical spine injuries often manifest as lower cervical vertebral fractures and dislocations, as well as lower cervical facet joint dislocations. Especially in cases of bilateral facet joint dislocations, it is important to rapidly and effectively relieve spinal cord and nerve root compression to prevent secondary spinal cord injury, while also providing reliable and long-lasting stability to the injured segment after surgery. Combined anterior and posterior approaches have the advantages of both pure anterior or posterior approaches, but the actual situation is complex and variable, making systematic theoretical analysis crucial. This study, with bilateral facet joint dislocation of the C6 segment and cervical spinal cord injury as the research background, established a three-dimensional model of the cervical spine C3-C7 after implementing four types of anterior-posterior combined surgeries. The four surgical approaches consist of four combinations: anterior parallel or inclined screw placement combined with posterior Margel or Anderson method screw insertion. Through finite element method, a systematic comparative analysis of the theoretical effects of the four combined surgeries in treating bilateral facet joint dislocation of the cervical spine was conducted. The conclusion was that the variations in the four combined fixation methods have a certain impact on the biomechanical characteristics of the intervertebral disc nucleus. There is a clear mutual influence relationship among anterior and posterior fixation instruments. Based on the model used in this study, it is recommended to use a torque greater than 2.1 nm to tighten the locking nut of the posterior rod to ensure reliable internal fixation.
References
1. Iencean SM. Double noncontiguous cervical spinal injuries. Acta neurochirurgica. 2002; 144(7): 695-701. doi: 10.1007/s00701-002-0940-7
2. Seçer M, Alagöz F, Uçkun O, et al. Multilevel Noncontiguous Spinal Fractures: Surgical Approach towards Clinical Characteristics. Asian Spine Journal. 2015; 9(6): 889. doi: 10.4184/asj.2015.9.6.889
3. Passias PG, Poorman GW, Segreto FA, et al. Traumatic Fractures of the Cervical Spine: Analysis of Changes in Incidence, Cause, Concurrent Injuries, and Complications Among 488,262 Patients from 2005 to 2013. World Neurosurgery. 2018; 110: e427-e437. doi: 10.1016/j.wneu.2017.11.011
4. Zileli M, Osorio-Fonseca E, Konovalov N, et al. Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations. Neurospine. 2020; 17(4): 710-722. doi: 10.14245/ns.2040282.141
5. Ngo LM, Aizawa T, Hoshikawa T, et al. Fracture and contralateral dislocation of the twin facet joints of the lower cervical spine. European Spine Journal. 2011; 21(2): 282-288. doi: 10.1007/s00586-011-1956-6
6. Yang H, Wang H, Zhang B, et al. Cervical spine fracture-dislocation in patients with ankylosing spondylitis and severe thoracic kyphosis: Application of halo vest before and during surgical management. Clinical Neurology and Neurosurgery. 2021; 207: 106744. doi: 10.1016/j.clineuro.2021.106744
7. Mu X, Li Z, Ou Y, et al. Early and short-segment anterior spinal fusion for cervical spinal cord injury without fracture and dislocation can achieve more significant neurological recovery: a retrospective study based on the current medical system in southern China. Journal of Orthopaedic Surgery and Research. 2019; 14(1). doi: 10.1186/s13018-019-1487-0
8. Liao JC, Fan KF. Posterior short-segment fixation in thoracolumbar unstable burst fractures – Transpedicular grafting or six-screw construct? Clinical Neurology and Neurosurgery. 2017; 153: 56-63. doi: 10.1016/j.clineuro.2016.12.011
9. Miao DC, Qi C, Wang F, et al. Management of Severe Lower Cervical Facet Dislocation without Vertebral Body Fracture Using Skull Traction and an Anterior Approach. Medical Science Monitor. 2018; 24: 1295-1302. doi: 10.12659/msm.908515
10. Wang J, Li J, Cai L. Effects of Treatment of Cervical Spinal Cord Injury without Fracture and Dislocation in A Medium-to Long-Term Follow-Up Study. World Neurosurgery. 2018; 113: e515-e520. doi: 10.1016/j.wneu.2018.02.071
11. Lee S, Kim C, Ha JK, et al. Comparison of Early Surgical Treatment with Conservative Treatment of Incomplete Cervical Spinal Cord Injury Without Major Fracture or Dislocation in Patients with Pre-existing Cervical Spinal Stenosis. Clinical Spine Surgery: A Spine Publication. 2020; 34(3): E141-E146. doi: 10.1097/bsd.0000000000001065
12. Aebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. European Spine Journal. 2009; 19(S1): 33-39. doi: 10.1007/s00586-009-1120-8
13. Liu K, Zhang Z. Comparison of a novel anterior-only approach and the conventional posterior–anterior approach for cervical facet dislocation: a retrospective study. European Spine Journal. 2019; 28(10): 2380-2389. doi: 10.1007/s00586-019-06073-3
14. Yu ZS, Yue JJ, Wei F, et al. Treatment of cervical dislocation with locked facets. Chinese Medical Journal. 2007; 120(3): 216-218. doi: 10.1097/00029330-200702010-00008
15. Garvey TA, Eismont FJ, Roberti LJ. Anterior Decompression, Structural Bone Grafting, and Caspar Plate Stabilization for Unstable Cervical Spine Fractures and/or Dislocations. Spine. 1992; 17(Supplement): S431-S435. doi: 10.1097/00007632-199210001-00015
16. Liu K, Zhang Z. A Novel Anterior-Only Surgical Approach for Reduction and Fixation of Cervical Facet Dislocation. World Neurosurgery. 2019; 128: e362-e369. doi: 10.1016/j.wneu.2019.04.153
17. Chen M, Wang Z, Fan Y, et al. Nursing Care of a Patient with Cervical Spinal Cord Injury Without Fracture and Dislocation: A Case Report. American Journal of Nursing Science. 2020; 9(5): 352. doi: 10.11648/j.ajns.20200905.16
18. Schleicher P, Kobbe P, Kandziora F, et al. Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine Journal. 2018; 8(2_suppl): 25S-33S. doi: 10.1177/2192568217745062
19. Alam N, Haque MR, Kamaluddin M, et al. Cervical spinal injury: experience with 82 cases. International Congress Series. 2002; 1247(1): 591-596.
20. Brodke DS, Zdeblick TA. Modified Smith-Robinson Procedure for Anterior Cervical Discectomy and Fusion. Spine. 1992; 17(Supplement): S427-S430. doi: 10.1097/00007632-199210001-00014
21. Rao RD, Wang M, McGrady LM, et al. Does Anterior Plating of the Cervical Spine Predispose to Adjacent Segment Changes? Spine. 2005; 30(24): 2788-2792. doi: 10.1097/01.brs.0000190453.46472.08
22. Theodotou CB, Ghobrial GM, Middleton AL, et al. Anterior Reduction and Fusion of Cervical Facet Dislocations. Neurosurgery. 2018; 84(2): 388-395. doi: 10.1093/neuros/nyy032
23. Johnson MG, Fisher CG, Boyd M, et al. The Radiographic Failure of Single Segment Anterior Cervical Plate Fixation in Traumatic Cervical Flexion Distraction Injuries. Spine. 2004; 29(24): 2815-2820. doi: 10.1097/01.brs.0000151088.80797.bd
24. Song KJ, Lee KB. Anterior versus combined anterior and posterior fixation/fusion in the treatment of distraction-flexion injury in the lower cervical spine. Journal of Clinical Neuroscience. 2008; 15(1): 36-42. doi: 10.1016/j.jocn.2007.05.010
25. Lee JY, Nassr A, Eck JC, et al. Controversies in the treatment of cervical spine dislocations. The Spine Journal. 2009; 9(5): 418-423. doi: 10.1016/j.spinee.2009.01.005
26. Cybulski GR, Douglas RA, Meyer PR, et al. Complications in Three-Column Cervical Spine Injuries Requiring Anterior–Posterior Stabilization. Spine. 1992; 17(3): 253-256. doi: 10.1097/00007632-199203000-00001
27. Henriques T, Olerud C, Bergman A, et al. Distractive Flexion Injuries of the Subaxial Cervical Spine Treated With Anterior Plate Alone. Journal of Spinal Disorders & Techniques. 2004; 17(1): 1-7. doi: 10.1097/00024720-200402000-00002
28. Ren C, Qin R, Wang P, et al. Comparison of anterior and posterior approaches for treatment of traumatic cervical dislocation combined with spinal cord injury: Minimum 10-year follow-up. Scientific Reports. 2020; 10(1). doi: 10.1038/s41598-020-67265-2
29. Zhou Q, Zhang J, Liu H, et al. Comparison of Anterior and Posterior Approaches for Acute Traumatic Central Spinal Cord Syndrome with Multilevel Cervical Canal Stenosis without Cervical Fracture or Dislocation. Mouzopoulos G, ed. International Journal of Clinical Practice. 2022; 2022: 1-11. doi: 10.1155/2022/5132134
30. He A, Xie D, Cai X, et al. One-stage surgical treatment of cervical spine fracture-dislocation in patients with ankylosing spondylitis via the combined anterior–posterior approach. Medicine. 2017; 96(27): e7432. doi: 10.1097/md.0000000000007432
31. Molinari L, Falcinelli C, Gizzi A, et al. Biomechanical modeling of metal screw loadings on the human vertebra. Acta Mechanica Sinica. 2021; 37(2): 307-320. doi: 10.1007/s10409-021-01063-5
32. Karim SMdR, Rahman AKMS, Sobhan SA, et al. Outcome of Long Segment Transpedicular Screw Fixation in Unstable Thoracolumbar Spine Injury with Incomplete Neurological Deficit. Journal of Biosciences and Medicines. 2020; 08(03): 166-187. doi: 10.4236/jbm.2020.83015
33. Wang X, Feng M, Hu Y. Establishment and Finite Element Analysis of a Three‐dimensional Dynamic Model of Upper Cervical Spine Instability. Orthopaedic Surgery. 2019; 11(3): 500-509. doi: 10.1111/os.12474
34. Yoganandan N, Kumaresan S, Voo L, et al. Finite Element Model of the Human Lower Cervical Spine: Parametric Analysis of the C4-C6 Unit. Journal of Biomechanical Engineering. 1997; 119(1): 87-92. doi: 10.1115/1.2796070
35. Do Koh Y, Lim TH, Won You J, et al. A Biomechanical Comparison of Modern Anterior and Posterior Plate Fixation of the Cervical Spine. Spine. 2001; 26(1): 15-21. doi: 10.1097/00007632-200101010-00005
36. Ebraheim NA, Klausner T, Xu R, et al. Safe Lateral-Mass Screw Lengths in the Roy-Camille and Magerl Techniques. Spine. 1998; 23(16): 1739-1742. doi: 10.1097/00007632-199808150-00006
37. Magerl F. Stable posterior fusion of the atlas and axis by trans articular screw fixation. Cervical Spine. 1987; 1: 322-327.
38. Ren G, Wang G, Xiao B, et al. The use of cervical lateral mass plate and screw for the treatment of fracture and dislocation of the lower cervical spine. Journal of Practical Orthopaedics. 2007; 13(5): 259-261.
39. Anderson pa, Henley MB, Grady MS, et al. Posterior Cervical Arthrodesis with AO Reconstruction Plates and Bone Graft. Spine. 1991; 16: S72-S79.
40. Zhang QH, Teo EC, Ng HW. Development and Validation of a C0–C7 FE Complex for Biomechanical Study. Journal of Biomechanical Engineering. 2005; 127(5): 729-735. doi: 10.1115/1.1992527
41. Yoganandan N, Kumaresan S, Pintar FA. Biomechanics of the cervical spine Part 2. Cervical spine soft tissue responses and biomechanical modeling. Clinical biomechanics (Bristol, Avon). 2001; 16(1): 1-27.
42. Hong-Wan N, Ee-Chon T, Qing-Hang Z. Biomechanical Effects of C2–C7 Intersegmental Stability due to Laminectomy with Unilateral and Bilateral Facetectomy. Spine. 2004; 29(16): 1737-1745. doi: 10.1097/01.brs.0000134574.36487.eb
43. Moroney SP, Schultz AB, Miller JA, Andersson GB. Load-displacement properties of lower cervical spine motion segments. Journal of biomechanics, 21(9), 769-779.
44. Panjabi M, Brand R, White A. Mechanical properties of the human thoracic spine as shown by three-dimensional load-displacement curves. The Journal of Bone & Joint Surgery. 1976; 58(5): 642-652. doi: 10.2106/00004623-197658050-00011
45. Zeng HS, Jin J, Chen ZJ, Chen XY. Analysis of the effect and safety of anterior and posterior combined surgery for the treatment of cervical spine fractures in ankylosing spondylitis. Heilongjiang Medicine. 2023; (03): 534-538.
46. Yang B, Lu T, Li H. Single-Session Combined Anterior-Posterior Approach for Treatment of Ankylosing Spondylitis with Obvious Displaced Lower Cervical Spine Fractures and Dislocations. BioMed Research International. 2017; 2017: 1-7. doi: 10.1155/2017/9205834
47. Kumar R, Kumar A. Biomechanical analysis of a single-level customized cage screw fixation for anterior cervical discectomy and fusion in the cervical spine: an in-silico study. Biomedical Physics & Engineering Express. 2023; 9(4): 045018. doi: 10.1088/2057-1976/acd784
48. Duan Y, Zhang H, Min SX, et al. Posterior cervical fixation following laminectomy: a stress analysis of three techniques. European Spine Journal. 2011; 20(9): 1552-1559. doi: 10.1007/s00586-011-1711-z
49. Kim GU, Ahn MW, Lee GW. Combined Anterior-Posterior Fusion Versus Posterior Alone Fusion for Cervical Myelopathy in Athetoid-Cerebral Palsy. Global Spine Journal. 2021; 12(8): 1715-1722. doi: 10.1177/2192568220987535
50. Coe JD, Vaccaro AR, Dailey AT, et al. Lateral Mass Screw Fixation in the Cervical Spine. The Journal of Bone & Joint Surgery. 2013; 95(23): 2136-2143. doi: 10.2106/jbjs.l.01522
51. Shimizu T, Koda M, Abe T, et al. Paravertebral foramen screw fixation for posterior cervical spine surgery: clinical case series. Journal of Neurosurgery: Spine. 2022; 36(3): 479-486. doi: 10.3171/2021.6.spine21411
Copyright (c) 2024 Dan Li, Ke Wang, Chao Dong, Bo Zhou, Lin Gu, Haoran Yang
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright on all articles published in this journal is retained by the author(s), while the author(s) grant the publisher as the original publisher to publish the article.
Articles published in this journal are licensed under a Creative Commons Attribution 4.0 International, which means they can be shared, adapted and distributed provided that the original published version is cited.
Submit a Paper
