title: Anterior cervical discectomy and fusion with a locked plate and wedged graft effectively stabilizes flexion-distraction stage-3 injury in the lower cervical spine: a biomechanical study.
abstract: METHODS
  An in vitro three-dimensional (3D) flexibility test of human C3-C7 cervical spine specimens.
  
  
  OBJECTIVE
  To test the hypothesis that anterior cervical fusion with a wedged graft and a locked plate can effectively stabilize the cervical spine after complete anterior and posterior segmental ligamentous release.
  
  
  BACKGROUND
  Distraction-flexion Stage 3 injuries of the lower cervical spine (bilateral facet dislocations) are usually reduced under awake cranial traction. When the magnetic resonance imaging reveals a traumatic disc prolapse, anterior cervical discectomy and fusion (ACDF) is usually recommended. Most authors advise combining ACDF with posterior instrumentation to address the insufficiency of the posterior elements. However, there is clinical evidence that ACDF with a locked plate alone suffices for the treatment of these injuries, especially in young patients. Still, there are no biomechanical studies on the effect of a locked plate on the complete anterior and posterior ligamentous-deficient young cervical spine under physiologic preload.
  
  
  METHODS
  Eight fresh frozen human lower cervical spines (C3-C7) from young donors (age, 44.5 years; range, 21-63 years) were used. A 3D flexibility test was conducted using a moment of 0.8 Nm without preload. Flexion-extension was additionally tested using a moment of 1.5 Nm under 0 and 150 N follower preload. Spines were tested first intact, then after complete C5-C6 discectomy with posterior longitudinal ligament resection and ACDF with a wedged bone graft and a rigid locked plate, and finally after complete release of the supraspinous, interspinous, and intertransverse ligaments; the facet capsules; and ligamentum flavum. RESULTS.: When tested under 0.8 Nm moment without preload, complete posterior and anterior ligamentous release did not significantly increase the ROM of the ACDF construct in flexion-extension (P > 0.025), lateral bending (P > 0.025), and axial rotation (P > 0.025). When tested under 1.5 Nm moment with or without a compressive preload, the complete posterior and anterior ligamentous release did not significantly affect the ROM of the ACDF construct (P > 0.01). The application of preload significantly reduced the motion at the C5-C6 ACDF construct with ligamentous disruption in comparison with the motion in the absence of a preload (P < 0.01).
  
  
  CONCLUSIONS
  Anterior cervical fusion with a wedged graft and a rigid constrained (locked) plate can effectively stabilize the nonosteoporotic cervical spine after complete posterior element injury when excessive ROM is prevented (for example, by the use of postoperative external immobilization). Even when the construct is subjected to higher moments, adequate stability can be achieved when physiologic preload is present. Osteoporosis and lack of sufficient preload due to poor neuromuscular control may affect long-term screw stability, and additional external immobilization may be needed until fusion matures.
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA.
authors.forename: Odysseas
authors.initials: O
authors.lastname: Paxinos
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Ghanayem
authors.forename: Michael R
authors.initials: MR
authors.lastname: Zindrick
authors.forename: Leonard I
authors.initials: LI
authors.lastname: Voronov
authors.forename: Robert M
authors.initials: RM
authors.lastname: Havey
authors.forename: Gerard
authors.initials: G
authors.lastname: Carandang
authors.forename: Alexander
authors.initials: A
authors.lastname: Hadjipavlou
authors.forename: Avinash G
authors.initials: AG
authors.lastname: Patwardhan
mesh_terms: D000328:Adult; D001696:Biomechanical Phenomena; D015519:Bone Density; D001860:Bone Plates; D016025:Bone Transplantation / Q000379:methods*; D002574:Cervical Vertebrae / Q000601:surgery*; D017586:Diskectomy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016059:Range of Motion, Articular; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods*; D013124:Spinal Injuries / Q000601:surgery*