Feasibility of single-stage combined anterior and posterior approach for fixation of highly unstable subaxial cervical spine trauma: A single surgeon case series

INTRODUCTION

Unstable trauma of the subaxial cervical spine is a frequent condition^[1] that can be efficiently treated using anterior cervical discectomy and fusion (ACDF).^[2] Nevertheless, ACDF may be insufficient^[3,4] to withstand real-life load-bearing neck motion,^[5] especially for highly unstable cervical traumas displaying associated burst fracture, facet fracture or facet dislocation, or ankylosing spondylitis, just to cite a few.^[5]

In such cases, delayed posterior fixation (PF) can be a valuable option in addition to ACDF.^[6,7] Indeed, PF has already proven useful for highly unstable neoplastic^[8] and axial spondyloarthritis trauma patients.^[9,10] Since the late 2000s, single-stage combined anterior and posterior cervical fixation (CF) has been scarcely reported for subaxial cervical spine trauma,^[3,4,11-14] allowing early mobilization without restriction. Nevertheless, after-hours PF in the trauma setting can seem technically demanding.^[15] Besides, for multiple reasons, even ACDF can be difficult to achieve in a timely manner within 24 h following trauma.^[16]

Given these elements, we present our real-life initial experience of emergency CF for highly unstable trauma of the subaxial cervical spine, without or with spinal cord injury (SCI).

CASE SERIES

The operating room (OR) logbook of Sainte-Anne Military Teaching Hospital (French level-1 trauma center) was retrospectively reviewed. Patients operated on by the senior author between November 2023 and July 2025 for trauma of the subaxial cervical spine using CF were included. Patients operated on sequentially were excluded.

Demographic data, clinical status on admission, operating data, and 6–9 months follow-up consult data were retrieved. Very-long-term follow-up was updated by phone interview.

This study was approved by the Ethical Board of the National French College of Neurological Surgeons on July 18^th, 2025 (n°IRB00011687, 2025/25).

There were five male patients (median 55 [54–77]), four of whom sustained high-kinetic trauma (2 bike accidents, Table 1 patients 1–2; 1 kite-surf accident, patient 3; 1 stair-fall, patient 4), and 1 ballistic spine injury [Table 1, patient 5]. On admission, three patients displayed neurological deficit [Table 1, patients 2, 4, 5], among whom 1 nerve root palsy, 1 incomplete SCI (American Spinal Injury Association [ASIA] C), and 1 complete SCI (C5-level ASIA A).

There were three cases of single-level trauma combined with posterior arch fracture [Table 1, patients 1–3], one case of spondylotic spine displaced fracture [Table 1, patient 4], and one case of ballistic C7 burst with exploded C7T1 posterior arch [Table 1, patient 5]. Four surgical procedures were carried out after hours, three during the dark night.

The three patients with single-level trauma and the ballistic injury patient underwent anterior cervical fixation first, and the spondylotic patient underwent PF first. Regarding the anterior surgical step (median operative time 77 [50–153] min), single-level ACDF was performed in 4 cases (patients 1–4, median 70 (50–85) min), whereas C7 corpectomy was done for ballistic injury (patient 5, 153 min). During anterior fixation, the posterior longitudinal ligament was systematically preserved for ligamentotaxis. Corpectomy was carried out using a 9 mm round-cutting high-speed burr.

Switching position from either prone to supine took a median of 55 (35–60) min. Posterior surgical step lasted a median 102 (85–160) min, was shorter for single-segment lateral mass fixation (patients 1–3, median 94 [85–102] min) compared to cervicothoracic fixation (patients 4–5, median 145 (130–160) min). Magerl-trajectory lateral mass screws were guided by profile fluoroscopy, and thoracic pedicle screws by anteroposterior fluoroscopy. Median blood loss was 300 (200–450) mL. Patient 3 underwent percutaneous T6-T10 fixation for type B spine trauma during the same procedure [Table 1 and Figure 1].

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Figure 1:

Patient 1 (A-D). (A) Computed tomography (CT) scan shows a fracture of the anteroinferior C5 osteophyte, air within the C5C6 disc, and a fracture of the posterior arch from C4 to C6. (B) T2 short-tau inversion recovery (STIR)-weighted magnetic resonance imaging (MRI) shows brightness of C5C6 disc with prevertebral hematoma, and complete disruption of C4C5 and C5C6 posterior ligaments. (C) Post-operative three-dimensional (3D) CT scan. (D) 6-month follow-up X-ray shows C5C6 interbody fusion. Patient 2, (E) 8-month follow-up X-ray shows C6C7 interbody fusion. Patient 3 (F-I). (F) CT scan shows C6C7 traumatic endplates angulation associated with C6 posterior arch fracture, and (G) C6 facets fracture. (H) T2 STIR-weighted MRI shows brightness of C6C7 disc with prevertebral hematoma, and complete disruption of C5C6 posterior ligaments. (I) Postoperative 3D CT scan shows circumferential C6C7 fusion and the upper part of T6T10 fixation. Patient 4 (J-M). (J) CT scan shows traumatic angulation of C4C5 endplates, and traumatic angulation at C6C7 level as well with listhesis. (K) C6C7 facet dislocation. (L) T2 STIR-weighted MRI shows brightness of C4C5 and C6C7 disc with prevertebral hematoma, and complete disruption of C6C7 posterior ligaments. (M) Postoperative 3D CT scan shows circumferential fusion with C6C7 ACDF and C4T1 posterior fixation. Patient 5 (N-R). (N and O) CT scan shows comminuted burst of C7 vertebral body and the right facets of C7T1. (P) T2 STIR-weighted MRI shows brightness of the whole C7 vertebral body, and spinal cord edema extending from C4 to T2. (Q and R) Post-operative 3D CT scan shows C7 vertebrectomy with bone graft and C6T1 plate and screws, associated with C5T2 fixation and focal laminectomy.

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No patient wore a cervical collar, and the post-operative course was uneventful. Three patients were discharged home after a median of 7 (4–14) days, whereas two patients went to rehabilitation after a median of 21 (0) days. After a median follow-up of 12 (6–18) months, all patients achieved bone fusion witnessed by both lateral radiographs and a median pain score of 1/10 (0–3) according to the visual analog scale. Median Neck Disability Index was 6/100 (0–52), and down to 3/100 (0–10) excluding patient 5. Three patients returned to work after a median of 6 (3–6) months, and four patients resumed usual physical activity after a median of 6 (3–6) months [Figure 2]. Among the three patients with pre-operative deficit, two recovered completely, and the patient with ballistic injury patient recovered down to partial C8 function.

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Figure 2:

Patient 3, climbing 3 months post-operative.

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DISCUSSION

Even though ACDF has become the gold standard for emergency surgical treatment of unstable subaxial cervical spine trauma according to guidelines,^[16] thanks to its reasonable learning curve^[17] and low rate of complications,^[18] and the adjunct of PF may be necessary to reduce the odds for hardware failure in a few selected cases.^{[3,11-13,19,20]}

CF may be an interesting surgical treatment option for highly selected cases. (1) For patients with single-level highly unstable but isolated suffering from isolated but highly unstable cervical trauma, CF allows for early hospital discharge. (2) For severe trauma patients, CF allows for easier and safer mobilization by the medical team in the intensive care unit.^[21] (3) Last, for patients with severe SCI responsible for disabling motor deficit, CF allows to remove cervical collar, which may reduce dysphagia and thus the incidence of intensive care unit-acquired pneumonia in the acute setting, and helps enduring tracheostomy in the middle-term [Figure 3]. Besides, early mobilization of patients suffering from incomplete SCI may improve neurological function.^[21]

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Figure 3:

Patient 5. (A) Anterior cervical surgical scar near the tracheostomy. (B) Patient positioning and care seem easier in the intensive care unit thanks to the definitive stability of the cervical spine and the absence of a cervical collar. With kind patient permission.

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Nevertheless, some critically ill patients with hemorrhagic or neurogenic shock cannot withstand a long-lasting spine procedure, and CF must therefore always be discussed with the attending anesthetist.

Last, completion of CF in the emergency setting may optimize the occupancy time of the OR, which may be the only way to perform both anterior and PF of cervical spine in facilities with limited access to the operating theatre.^[22]

CONCLUSION

This case series demonstrates the feasibility, safety, and advantages of CF in selected cases of highly unstable trauma of the subaxial cervical spine. Such demanding emergency circumferential spine surgery must be conducted in hemodynamically stable patients and after discussion with the anesthetist. Nevertheless, we hope that this patient series will encourage spine surgeons to perform CF whenever deemed necessary.