Introduction and Aims: Vertebral artery patency is not routinely documented in cervical fractures and dislocations. The incidence of vertebral artery injuries following cervical trauma is unknown, as they are rarely symptomatic. Vertebrobasilar insufficiency may be catastrophic and such vascular occlusion should be identified and treated early.

Method: One hundred and eighteen patients who sustained fractures and dislocations of the cervical spine between January 1996 and February 2001 were evaluated and subjected to MRI (magnetic resonance imaging) and MRA (magnetic resonance angiography). The average age was 34 years and there were 30 females. Seventy patients had unifacet dislocations, 10 burst fractures and 38 bifacetal dislocations. Forty-five patients had neurological deficit. Seven patients died within the first six weeks of injury. Reduction and surgical fusion were performed on 115 patients. None of the patients had signs/symptoms of vertebrobasilar ischaemia. MRA was repeated in six patients three years post-injury.

Results: Vertebral artery injury was diagnosed in 20 patients (23.6 %) – one patient had bilateral injury. Diagnosis was based on the loss of normal flow void on MRI and confirmed on MRA. Twelve patients with vascular compromise had unifacetal dislocations, two had burst fractures and six bifacetal dislocations. Thrombosis was present in 13 patients, three patients had intimal tears and five dissections (one patient with bilateral injury). The patient with bilateral injury also had significant neurological deficit (frankel C), confusion that resolved in 24 hours and evidence of cerebellar infarct. She had no symptoms of vertebrobasilar insufficiency and recovered full neurological function. Repeat MRA in six patients showed no evidence of recanalisation.

Conclusion: VAI was more common in unifacet dislocations, emphasising the effect of a rotation force predisposing to vascular injury. We recommend early diagnosis of vertebrobasilar insufficiency. Future anterior cervical surgery in patients with VAI should be undertaken with caution.

This paper reviews 32 patients (seven boys and 25 girls, mean age 14.5 years) with adolescent idiopathic scoliosis treated by anterior spinal release, fusion and instrumentation from 1989 to 2001. In 22 patients the thoracic curve was involved, in six the thoracolumbar and in four the lumbar curve. The mean preoperative kyphosis (thoracic curves) was 22.3° and the mean Cobb Angle was 56°. Routine exposure through the convexity was performed (sixth rib for thoracic curve and 10th rib for other curves).

After discectomy (four to nine levels), morselised rib was used as bone graft and instrumentation was applied with correction of deformity and saggital profile. Costo-plasty was performed in 10 patients. The mean operation time was three hours; mean blood loss was 180 ml. Intraoperative problems were partial pull-out of screws from the first proximal vertebra in three patients. In one asthmatic patient, who was on steroids, instrumentation was abandoned because of pull-out of several screws.

The mean hospital stay was 10 days. Two patients developed superficial wound sepsis and one sustained a burn to the right shoulder (cause unknown). Rod breakage occurred in two patients. Angulation at the level below the lowest instrumented vertebra occurred in five patients and was attributed to inappropriate fusion levels. Pseudarthrosis developed in two patients. At final follow-up, the mean Cobb angle was 26° and the mean thoracic kyphosis 30°.

The advantages of anterior surgery for idiopathic scoliosis include fewer fusion levels, correction by shortening the spinal column and less blood loss. Difficulty may be encountered in selection of fusion levels and instrumentation of the proximal vertebrae. In cases of very rigid curves, posterior spinal release may improve results.

Fractures and fracture dislocations involving the lower lumbar spine and lumbosacral junction are uncommon. These high velocity injuries are often associated with neurological deficit, incontinence and dural tears. The accepted treatment has been posterior stabilisation with fusion, but loss of reduction has often been reported.

We reviewed our experience over the past four years in the management of eight male patients, two of whom sustained injuries in motor vehicle accidents and two in falls from a height. Two patients had L5/S1 traumatic spondylo-listhesis with no neurological deficit. Of the six patients with fracture dislocations of L3/4, four had translation in the sagittal and coronal planes and incomplete neurological deficit. Associated injuries in four patients included an ankle fracture, multiple rib fractures, dislocation of knee and hip, and a fracture dislocation of the midfoot.

Following satisfactory reduction, seven patients were treated by posterior spinal fusion (PSF) with instrumentation. One patient had anterior decompression, strut-grafting and posterior instrumentation. Three patients had dural tears.

In three patients treated by single segment PSF, reduction was not maintained. The maintenance of alignment was attributed to stable facet joints in one patient, two-segment instrumentation in three, and anterior strut grafting in one. One patient developed postoperative wound sepsis, which settled after repeated debridement and antibiotic treatment. Symptoms of nerve root compression improved in two of the four patients with neurological deficit.

Posterior reduction and instrumentation alone did not maintain reduction in these severe injuries. Anterior column support and multisegmental instrumentation may be required where there is marked vertebral body compression and neurological deficit.