Discussion
The term spondyloptosis is made of spondylo and ptosis words and is used when the vertebrae slips and falls down totally in front of lower corpus from its original anatomical level [3]. It is more common in the lumbar spine than in the cervical spine and can be seen following birth trauma, congenital conditions of the cervical spine (like absent cervical pedicles or corticated defect in pars interarticularis), neoplastic diseases (like neurofibromatosis or aneurysmal bone cyst) and after vehicle or diving trauma [4]. Traumatic cervical spine spondyloptosis is a very rare entity and is considered the most severe form of cervical spine injuries [5]. A systematic review published in 2023 was reported only 66 cases [2]. The incidence of cervical spine spondyloptosis is probably underestimated basing on the fact that most of patients present this severe lesion haven poor outcomes limiting the good management and so the presentation of the cases. This lack of data reporting is more pronounced in developing countries [1]. The etiology of his spondyloptosis was a fall from a tree. Falls from trees related traumas are rarely reported in literature. But, they are public health problems in developing countries where their frequency is still important. These falls concern particularly children with mean age of 14 years [6].
Traumatic Cervical Spondyloptosis (TCS) is an unstable injury due to complete distruption of all ligamanter structures involving three columns [5]. The case described in this report was a posterior form of spondyloptosis and located at the C5–C6 level. Concerning location, approximately two-third of all fractures, and three-fourth of all dislocations involve the subaxial cervical spine [7]. Dislocations occur most commonly at C5—C6 and C6—C7 levels [8]. This segment of the spine is highly vulnerable to injury as it is greatly mobile and at the proximal end it carries the weight of the head. Moreover, it has to bear great amount of force in acceleration and deceleration injuries [8]. Posterior form of TCS, as in our case is very rare and it is seen in only 10% of cases. The anterior slippage of the superior vertebrae (anterolisthesis) is the dominated form in more than 83% of cases; whereas only one case (1.5%) of laterolisthesis was reported [2].
Clinical presentation varies in the literature. According to Khelifa andal ., one‑third of reviewed patients are received initially without any neurologic deficit and one‑third with incomplete motor deficit, whereas only 36% of patients are totally paralytic [2]. Our patient had an incomplete neurological deficit. It may explain by the pattern of lesion. In fact, there was a total rupture between anterior and posterior elements (bipedicular fracture) at the level of C6 and C7. That led to a spontaneous decompression of the spinal canal.
Concerning medical imaging, computed tomography (CT) is important to identify a spondyloptosis with the associated bone lesions and to plan management strategy. Exploring arterial posttraumatic lesions with either angiography or angio‑CT must be done to research vertebral artery lesions (pseudoaneurysm, dissection). Magnetic Resonance Imaging (MRI) is very useful in detecting associated soft tissues lesions, especially spinal cord compression, ligamentous rupture, and disk hernia, which led surgeons to prefer starting with anterior decompression before posterior reduction or stabilization [5]. Magnetic Resonance Imaging was not available in our hospital, but computed tomography haven permitted to establise the diagnosis of cervical spondyloptosis with ventral compression of spinal cord. Angio-CT sequences was not available also.
The ultimate goal of treatment in cervical spondyloptosis is to obtain anatomic alignment, neural decompression, and to prevent further instability with a solid fusion [9]. Like any other instable cervical spine lesions, it is an emergency. But our case is managed nine days after the trauma. This delay is due to the fact that costs of health care are borne by the family and they took time to gather surgical kit. Management of cervical spondyloptosis in case of incomplete injury or normal neurological status at presentation represents a challenging clinical scenario for the clinician.
There is no definite consensus when it comes to the management of TCS. Concerning preoperative closed cervical traction, some authors think that it could compromise neurologic function by compression of the spinal cord. This compression would be due to retropulsion of the disc into the spinal canal during traction [3,10]. However, other reports think that cervical traction can be safely implemented in spondyloptosis patients because spinal canal was decompress by fractures of the posterior elements [4,11]. In our case there was anterior compression of spinal cord by bone fragment. So closed cervical traction was not indicated due to risk of neurological deterioration.
Surgical management options described in the literature ranging from a simple anterior or posterior approach to 540-degree fusion [12]. An anterior and posterior fusion is the standard management due to greater realignment and stabilization being achieved in unstable injuries, with all ligamentous structures involving the three columns [4]. No significant differences were observed between the anterior‑only, posterior‑only, and 360° repair groups regarding immediate postoperative ASIA grade and ASIA grade at the end of the follow‑up period [13]. In our case, we have indicated ventral surgery in accordance with the location of the compression. Some authors have demonstrated that anterior-only fusion might suffice in selected patients with cervical spondyloptosis [14,15].
Our patient had an excellent short-term neurologic and functional recovery. This supports the view that anterior ventral surgery alone can be used with success in the management of cervical spondyloptosis in selective cases.