INTRODUCTION
Spinal cord injury is a serious medical condition that usually leads to
death and permanent disability. It is caused by the disruption of axon nerves
inside the spinal cord, affecting both motoric and sensory function below the
level of the impacted vertebra. Most spinal cord injuries happen due to
significant trauma and primary irreversible injury in people under 30 years old
(Tindle & Tadi, 2022). In America, around 17.500 new cases are reported annually. The total
case in Asia remains unclear. In a 2019 study in Saudi Arabia, spinal cord
injury incidence reaches 38 per 1 million (Alexander et al., 2019). One of the most common injuries found is dislocation fracture.
Subluxation is commonly seen in lower segments, from C4 to C7, and only 24% of
cases happened above C4.
Dislocation injury at the level of C2-C3 is infrequent (Kiessling et al., 2019). However, regardless of the type, total recovery to condition
pre-injury is hard to achieve. One of the symptoms is complete or incomplete
tetraplegia or paraplegia. Considering the severe consequences of this kind of
injury, it is crucial to perform a thorough evaluation, especially in
polytrauma and cervical spine trauma that potentially cause stroke in posterior
circulation or cervical trauma accompanied by fracture and dislocation. Bad
progression of symptoms can still happen despite being asymptomatic. Patient's
condition evaluation becomes hard since there's no agreed algorithm used in
deciding therapy approach.
Generally, subaxial injury classification
encompasses neurological clinical outcome scoring, trauma morphology, discoligamentous integrity and neurology status. If the
patient scored less or equal to three, the patient could be managed
conservatively. However, a surgical procedure must be done if the score is more
significant than five (Mehdar et al., 2019).
Cervical spine fracture can be handled with external fixation using
orthosis or halo fixation, decompression procedure and internal fixation,
depending on fracture type, instability and spinal cord compression degree. The
primary purpose of the operation is to decompress the nerves' structure and to
stabilize the injured vertebra segment. This approach allows the patient to do
early mobilization, support recovery while healing other injuries, provides
rehabilitation, and facilitates daily activities adaptation faster (Abdelgawaad et al., 2021). Outcomes from spinal cord injuries vary, but injury around the
cervical segment is usually more severe with higher mortality risk than other
segments due to its risk of damaging the phrenic nerve and respiratory centre.
Moreover, secondary injury can cause systemic shock, spinal shock and
hyperthermia that contribute to the clinical course and hinder recovery (Mattiassich et al., 2017).
This case study reports a case of a 17 years old male patient with a dislocation fracture at the level of C2-C3 that came in with a complaint of tetraplegia in the emergency room 7 hours before being admitted to the hospital after the neck was hit to the corner of the table. �
Using the case study method.
RESULTS AND DISCUSSION
Case Presentation
A 17 years old
male came in due to his inability to move all extremities (tetraplegia) for 7
hours before hospital admission. The patient was referred from the regional
hospital with a history of cervical spine injury and motoric dysfunction right
after the incident. At first, the patient played with his friends, then he got
pushed, and his neck was hit on the corner of the table. Shortly afterward, the
patient couldn�t get back on his feet. The patient was diagnosed with dislocation
fracture C2/C3 with spinal cord compression, causing the tetraplegic symptoms.
Figure 1. X-Ray finding showing C2-C3������ Figure 2. 3D CT-Scan showing C2-C3 dislocation
fracture����������������������������������������������� � dislocation fracture
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Figure 3. MRI Findings [A] Sagittal View [B] Axial
View showing spinal cord compression
B A
This patient was managed through a decompression
procedure and cervical spine fusion at the level of C1-4 with posterior
stabilization using a pedicle screw. A day after the operation, the patient
successfully moved both legs and arms with motoric strength of 2/2/2/2.
Moreover, the patient also did physiotherapy. Two weeks after the procedure,
the patient improved motoric function, evaluated by the increased motoric power
from all 2s to 4/4/4/4. Three weeks later, the patient started to write again.
During the three-month follow-up period, the patient could do daily activities
independently. A longer follow-up period is needed for further
evaluation.
Figure 4. Radiology Findings [A] Anteroposterior
and [B] Lateral after Decompression Procedure and Posterior Stabilization using
Pedicle Screw
A B
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Figure 5. Functional Outcome during 3 Months
Follow-Up
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Discussion
Cervical spine
injury usually happens on the upper segment, connection junction between C1-C2
or C5-C6. This study reported a traumatic event on a 17-year-old patient with a
dislocation fracture at the level of C2-C3. The patient's age group is not
considered typical and is no longer included in groups vulnerable to this
injury type. Generally, the pediatric population is more prone to this injury
due to high ligament laxity. There are only a few similar case studies, as the
condition usually leads to sudden death. One case found in children was linked
to dislocation during birth. Another case in a 57-year-old patient was
connected to a laminectomy procedure he underwent, causing mild neurologic
symptoms. It's hard to compare this case study to previous issues because of
the different age groups and absence of vascular injury (Kalafat et
al., 2016).
The patient came
in with motoric dysfunction in all extremities with an American Spine Injury
Association (ASIA) score of B, indicating no sensory dysfunction under the
lesion level (Otsuka et
al., 2021). A previous study mentioned that around 50%
of patients with B scores would experience changes in motoric strength,
especially in lower extremities and sensory perception. Functional outcomes
heavily depend on location and injury severity degree. Generally, injuries on
C1-C3 with A-C scores tend to depend on others to perform daily activities and
need ventilation to preserve respiratory function (Guest et
al., 2022). However, it didn't happen in our patient
due to a different mechanism, trauma course, and adequate management. The best
clinical outcome was observed in patients who underwent decompression under 24
hours, although there's no consensus agreeing on the best time for operation in
spinal cord injury (Alizadeh et
al., 2019).
Like other
patients with cervical spine injury fractures, it is best to stabilize the neck
area using a stiff collar in a neutral position to prevent mobilization and
ensure the spinal column stays in line to avoid unnecessary movement. Anamnesis
regarding type, mechanism and clinical course is beneficial in diagnosing and
identifying primary injury and therapy approach. CT Scan examination also helps
evaluation, specifically in the unconscious patient. ATLS algorithm and
neurological examination are performed to score patients using ASIA
classification, which helps create a more detailed management approach. X-Ray
radiology was done in this case; however, whenever possible, CT-Scan is
preferable because it gives out a better structural visualization, especially
in transitional areas like craniocervical and
cervicothoracic (Beeharry et
al., 2021). The patient, in this case, report,
underwent three radiology examinations; X-Ray, CT-Scan and MRI. MRI remains the
gold standard for spinal cord injury because its finding helps predict
neurological outcomes (Rutges et
al., 2017). MRI also should be performed if
conventional radiology and/or CT-Scan resulted in the suggestive discovery of
ligament injury and/or dislocation, similar to this case (Kumar &
Hayashi, 2016). MRI offers several advantages, such as
higher picture resolution, multiplanar imaging and various sequences needed in
this condition evaluation. Worse neurological outcomes were seen with oedema and
hematoma on the spinal cord (Alkadeem et
al., 2021). The patient's MRI showed compression on
the anterior horn, so the patient was scheduled for a decompression procedure.
A more precise
outcome prediction can be made 72 hours after the primary injury. Another
important aspect of predicting prognosis is identifying whether the damage was
complete or incomplete. Spinal cord injury patients will have shown functional
ability improvement in the first three months before hitting a plateau in month
9. However, a complete recovery can take up to 12-18 months. Patients' recovery
with incomplete tetraplegia is better, but sometimes it only happens in the
lower level from the injured area. Similar to what's done in this patient,
motoric function improvement can be evaluated from motoric strength moments
after trauma and is linked with better neurological outcomes (Alizadeh et
al., 2019). Other factors associated with patient's
betterment are age, comorbidity and social environment (Investigation,
2021).The reported patient is relatively young
and healthy with no other comorbidity, which might explain the observed
well-functional outcome.
A dislocation
fracture in this patient caused spinal cord compression until the anterior
horn, eventually causing motoric dysfunction. This goes with the primary injury
mechanism concept that commonly happens in spine dislocation fractures. This
kind of injury can affect ascending and descending impulse transport, and
disrupt blood flow and cell membrane, leading to spinal shock, systemic
hypotension, vasospasm, ischemia, ionic imbalance and neurotransmitter
accumulation or exotoxicity (Alizadeh et
al., 2019). Anterior spinal cord compression at the
level of C2-C3 in the patient hindered neurotransmitter impulse transport and
caused total paralysis in all extremities without any sensory dysfunction. Like
the theory, a lesion on the anterior horn will disturb the motoric system from
the neck to the feet (Louis &
Richards, 2018). A retropulsion of a fracture fragment can
be displaced towards the spinal canal, causing more injury. The condition can
be worse with discoligamentous and vascular injuries
around it.
The purpose of
temporary external stabilization is to maintain the traumatized neck area
stability and is a part of operation preparation. This maneuver goes along with
the first cervical spine dislocation fracture principle: decompressing the
spinal cord and ensuring permanent stability using pedicle screws via a
posterior approach. The pedicle screw can hinder spinal growth in kids. Still,
it can be done considering its effect on decreasing fixation and fusion degree,
superior biomechanics structure, support fusion rate and reducing the need for
external fixation. However, the risk of complications can't be eliminated. The
posterior approach is preferred over the anterior to minimize infection and
other complication risks associated with a tracheostomy (Zeng et al.,
2022). Till now, there has yet to be a consensus
recommending either approach as long as the primary objectives of decompression
are achieved. Other factors influencing the therapy approaches include changes
in bone structure, nerve compression and symptoms (Jung et al.,
2020). The management of the reported patient
went along with other C2-C3 cases that experienced multiple column instability,
considering a heavier burden on the anterior side (Alexander et
al., 2019). The affected spinal cord decompression
operation will fix the motoric impulse transport peripherally so the motoric
function can be regained.
Physiotherapy is
also needed to optimize the patient's motoric function to how it was
pre-injury. The Sci-Fi study stated five essential aspects to help recover the
patient's functional ability: basic mobility, self-care, fine motor, wheelchair
mobility and ambulation (Wu et al.,
2022). Physiotherapy should be started as soon as
possible to build strength and flexibility to support a safe and effective
healing process (Gabada et
al., 2021). Moreover, early physiotherapy can prevent
muscle contracture or permanent shortening of the muscle cell and improve the
overall quality of life by supporting cellular signal transport and growth
factor expression. In a study on animal subjects, early mobilization increased
growth factors such as insulin-like growth factor 1 level and axon regeneration
(Badhiwala et
al., 2018). There has yet a study that explored the
effectiveness of y in cervical trauma cases. Still, it has been proven
effective in the reported patient cause after three months of operation and
constant physiotherapy, the patient managed to perform daily activities
independently
CONCLUSION
A dislocation fracture caused spinal cord
compression in this patient. A retropulsion fragment fracture can be displaced
into the spinal canal and potentially cause more spinal cord injury.
Displacement towards the anterior horn will cause motoric dysfunction.
Dislocation fracture on C2/3 hinders neurotransmitter impulse transport,
causing total paralysis on all four extremities without sensory dysfunction. A
temporary external stabilization around the neck area was needed in this
patient. Along with the therapy principle, the approach in this patient is
decompression of the affected spinal cord and internal fixation using a pedicle
screw for fracture stabilization.
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