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.