Complete cervical spinal cord transection cephalad to noncontiguous sub-axial vertical distraction injury: a rare complex injury case report, surgical technique and literature review

Introduction

Cervical spinal cord injuries are a catastrophic injury that occurs in approximately 40 per one million individuals in the United States annually (1). Spinal cord transections leave patients with complete irreversible motor and sensory loss distal to their injury level. They often are associated with a fracture and/or dislocation at the level of the injury, many of the reported cases due to atlanto-occipital dislocation with high fatality rates (2,3). Due to advancement in prehospital medical care, patients with these injuries present to the hospital and may necessitate management and intervention. Additionally, vertical distraction injuries are a rare spinal injury phenomenon with only a few cases described in the literature. The authors of this study present a case where a patient survived his injury of an occiput-C1 spinal cord transection with a noncontiguous sub-axial vertical distraction injury. The authors of this report believe this case provides value to the literature as it further discusses the author’s management, treatment modality, patient outcomes, and a review of the literature regarding this injury pattern. To the best of the authors’ knowledge, there are no documented reports of a patient with a complete, high cervical spinal cord transection with an associated caudal, noncontiguous vertical distraction injury. We present this case in accordance with the CARE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-24-13/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee (Royal Papworth Hospital Research and Development) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 27-year-old male presented to the emergency department following a motor vehicle accident. According to Emergency Medical Services (EMS) reports, the patient was unrestrained and found ejected halfway through the back window of the vehicle. He suffered a traumatic arrest at the scene of the accident, was intubated, received immediate cardiopulmonary resuscitation (CPR) and achieved return of spontaneous circulation in the field before arriving at the hospital. The patient was noted to be in both spinal and neurogenic shock given his previous circulatory collapse in the field requiring CPR, persistent to be hemodynamically unstable with bradycardia and hypotension, areflexia and absent bulbocavernosus reflex. Glasgow coma scale was 3 with no movement of extremities spontaneously or to painful stimuli. The physical exam demonstrated no motor function in the upper and lower extremities bilaterally, areflexia throughout upper, lower extremities, and upgoing Babinski signs bilaterally. Initial trauma workup included a computed tomography (CT) cervical spine which demonstrated C6–7 vertical distraction injury with retrolisthesis of C6 on C7 (Figure 1). After this initial finding, a stat cervical magnetic resonance imaging (MRI) was obtained revealing an occiput-C1 cord transection with hemorrhage within the spinal cord at the site of transection with associated posterior ligamentous injury, vertical distraction injury at C6–7, with complete disruption of the anterior, posterior longitudinal ligaments, and posterior ligamentous complex (Figure 2). The patient also had additional spinal fractures including transverse process fractures at C7–T4.

Figure 1 Sagittal view of cervical spine CT showing C6–7 vertical distraction injury with retrolisthesis. CT, computed tomography.

Figure 2 Sagittal STIR MRI revealing complete transection of spinal cord at occiput-C1 with increased signal within posterior ligamentous complex, C6–7 vertical distraction injury including complete disruption of the anterior, posterior longitudinal ligaments, and posterior ligamentous complex. STIR, short tau inversion recovery; MRI, magnetic resonance imaging.

Neurosurgery evaluation deemed the patient to have intact cerebral brain function. Once the patient was hemodynamically stabilized, interdisciplinary discussion occurred with the patient’s family regarding patient outcome expectations and goals of care. This included surgical goals to stabilize the patient’s three column unstable spine with reduction, instrumentation, and fusion that will allow him to be sat up postoperatively while in bed and wheelchair with the understanding he will remain ventilator dependent and not regain functional improvements from surgery. Patient’s family understood and agreed to proceed with surgical stabilization. Of note, a greenfield filter was placed by vascular surgery prior to his spine procedure to hold anticoagulation postoperatively for 48 hours.

Patient was then taken to surgery and placed supine on Jackson operative table with three-point Mayfield head clamp, then turned prone using the turning mechanism of the Jackson table. Partial closed reduction was achieved by axially compressing the patient’s head through the Mayfield head clamp. Through a standard midline posterior approach, lateral mass screws were placed at C4–6 via Magerl technique and pedicle screws at T1–2. After screw placement, attention was directed for further, open reduction of C6–7 vertical distraction injury by tension band cerclage wire, performed by drilling a pilot hole in the C6 spinous process and passing a 20-mm cerclage wire through it and around the inferior aspect of the C7 spinous process. With wire tightening, the distraction gap was reduced. Titanium rods were then placed to secure our fixation to the screws that provided additional reduction and improvement in alignment. Cancellous bone graft was placed after decortication, followed by placement of a hemovac drain prior to wound closure. An aspen cervical collar was maintained postoperatively. Due to the injury of his spinal cord being above C4, he was deemed ventilator dependent, and a tracheostomy tube was surgically placed several days later. Six-month postoperative radiographs of the cervical spine identified proper alignment and reduction of the spine with intact hardware (Figure 3).

Figure 3 Six-month postoperative AP (A) and lateral (B) X-rays showing C4–T2 instrumentation, C6–7 posterior cerclage wire and tracheostomy. AP, anteroposterior.

At follow-up, the patient was able to mouth words but was otherwise quadriplegic. Of note, the patient’s mother noted him to have signs and symptoms of autonomic dysreflexia by 3 months after injury including headaches, hypertension, cold skin in lower extremities and facial flushing. Miami J was discontinued at 3 months postoperative. The patient’s family and facility were instructed to monitor for foley catheter obstruction, maintain high suspicion for urinary tract infections and refrain from any tight or restrictive clothing along the patient’s skin.

Discussion

Acute cervical spinal trauma can present several challenges in management regarding surgical timing, approach, instrumentation methods, need for decompression and predicting outcomes. Several classification systems for both upper and sub-axial cervical spine injuries are well described to help guide patient care and treatment. Vaccaro et al. retrospectively reviewed 24 consecutive patients with cervical distraction extension injuries, 16 of 24 underwent surgical stabilization (4). All patients undergoing surgical stabilization were noted to have a stable fusion at their latest follow-up. There were three patients who suffered neurologic deterioration due to over-distraction of the anterior column interspace at the time of graft placement and recommended caution during anterior graft placement to avoid such complications from over-distraction of the spine. They reported mortality rate in 42% of this injury. They recommended anterior reconstruction of the cervical spine with an anterior cervical graft and plate acting as a tension band for stabilization of acute distraction extension type 1, injuries involving primarily the anterior longitudinal ligament and intervertebral disc. Type 2 injuries, depending on the degree of displacement and the adequacy of closed reduction, may need to be approached initially posteriorly to obtain adequate alignment, followed by an anterior reconstructive procedure (4). In this case report, surgical management included combined closed/open reduction, C4–T2 posterior cervical spinal instrumentation and fusion. The authors selected not to perform anterior column fixation due to the tracheostomy required due to ventilator dependency associated with high cervical spine occiput-C1 injury level.

The associated vertical distraction nature of the patient in this report offers a unique addition to the literature as it is rarely reported. Sharma and Sieg report a case of a patient who had a C5–6 vertical distraction injury, Wu et al. also report a C4–5 vertical distraction case (5,6). Both patients expired after multiple resuscitation attempts and intensive care. There is a report of a patient surviving such vertical distraction injury at C5–6 with associated vertebral artery transection where the patient underwent vascular intervention followed by C5–6 laminectomy with posterior fixation from C4–T1 (7). Sivakanthan et al. report a spinal cord transection with a vertical distraction injury at C5–6 level in a 3-year-old patient (8). They placed the patient in a halo vest to reduce the fracture with cervical compression and stabilize the spine prior to the operating room before undergoing C4–7 posterior instrumented fusion. Additionally, there have been a few reported cases of high cervical spinal cord complete transections, but none of which had an associated vertical distraction injury at a noncontiguous level. Two reports discuss patients who suffered a type 2 odontoid fracture with associated C2 level spinal cord transection, both of which expired or were removed from life support (9,10). An additional two cases of traumatic atlanto-occipital dislocation with complete medulla/spinal cord transections have been reported with poor patient outcomes (2,11).

The noncontiguous nature of this patient’s injury also adds value to the literature. Double level spinal cord injury without radiographic abnormalities is reported in the literature in both adult and pediatric populations but no known cases have an associated vertical distraction injury (12,13). Taylor et al. discuss the phenomena of floating cervical spine which they define as a cranio-cervical dissociation (CCD) with an associated unstable, noncontiguous, sub-axial spine fracture or dislocation. CCD was characterized by either atlantooccipital dissociation, atlantoaxial dissociation or a combination of both (14). Through their retrospective review, they identified 13 such patients with 9 of them having sub-axial cervical spine injuries at C6–7. The presumed mechanism of injury consisted of a combination of extension and distraction in six, pure distraction in three, or a combination of flexion and distraction in the last four patients. Seven of the patients had associated vascular injuries. In the 11 patients they operated on (two died before surgical management), short segment posterior instrumentation and fusion was selected for the secondary noncontiguous injury in combination to the occiput-C2 in 10 of the cases. In their report they discussed some of the cases were performed in a staged fashion based on stability of the patient, and in five of their cases they addressed the distraction injury of the sub-axial spine prior to the CCD due to operating surgeon’s interpretation of it being more unstable than the CCD. Sixty-nine percent (9/13) of their operative patients survived. The patient presented in this case report likely had a high energy mechanism of injury similar to patients seen with floating cervical spine injuries. He did not have any obvious dislocations or fractures at the occipital cervical junction or atlanto-axial junction, however, the spinal cord transection and associated posterior ligamentous injuries seen leads us to believe he had a similar injury pattern. However, what makes our case unique is that the paper by Taylor et al. did not comment on any of their patient’s having spinal cord transections.

Overall, this case report discusses an atypical complete cervical spinal cord transection to occiput-C1 alongside a noncontiguous, caudal C6–7 vertical distraction injury. Due to the rare and devastating injuries of the patient, the goal of cervical spinal fusion surgery was primarily to improve stability of the sub-axial cervical spine. Given the patient’s high cervical transection, the authors discussed the surgical goal of obtaining spine stability to allow for him to sit upright without spinal failure into kyphosis. Subsequently, a posterior instrumentation and fusion only at the sub-axial distraction injury was performed given its significant instability, the authors elected against anterior column support due to tracheostomy for ventilation. The high cervical spine injury was managed nonoperatively with a Miami J given purely ligamentous injury, complete C1 with no expected functional improvement and purposeful cervical motion. No decompressive laminectomy was performed due to the patient having a high cervical spinal cord transection.

Conclusions

The presented case highlights the complexity and challenges associated with severe cervical spinal cord injuries. The combination of an occiput-C1 cord transection and a caudal, noncontiguous C6–7 vertical distraction injury posed significant management hurdles that has not previously been reported in the literature. In his scenario, the patient/family’s goals and patients’ prognosis guided the surgical treatment, however we outlined the unique vertical distraction mechanism and how to address noncontiguous injuries in hopes to assist future surgeons and patients on how to manage these injuries while minimizing complications.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-24-13/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-24-13/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-24-13/coif). H.E. serves as an unpaid editorial board member of AME Surgical Journal from October 2023 to September 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee (Royal Papworth Hospital Research and Development) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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