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Monostotic fibrous dysplasia of the spine is a rare entity. Only 26 cases, of which 11 were located in the cervical spine, are to be found in the literature. We report a 56-year-old male patient with cervicobrachialgia of half year's duration. Radiographs showed a diffuse destruction of the vertebral body and the spinous process of C4. A biopsy of the spinous process confirmed histopathologically a fibrous dysplasia. Due to minor symptoms, no surgical treatment was performed or is planned unless in case of increasing pain, an acute instability or neurological symptoms.

The effect of fused segments in the cervical spine has been documented to cause chronic changes in adjacent levels. This article reports an association between the presence of fused cervical segments and the predisposition to acute, traumatic instability at adjacent levels. Patients with cervical fractures were reviewed during a 12-year period. Fifteen patients were identified who sustained cervical fractures in the presence of previously fused segments. The presence of fusion was reviewed for its effect of neurologic injury, delay in diagnosis, and patterns of fractures. The diagnostic studies used to document instability were reviewed. We found that preexisting cervical fusions often result in a delay of diagnosis because of altered anatomy and atypical fracture patterns. The fractures occurred within one or two levels from the fused segment. There are different fracture patterns associated with fusions in the upper cervical spine and those fusions in the lower cervical spine. The presence of fusions significantly affected treatment choices in this group of patients.

The goals of management of spine fractures from C3 to C7 are to provide stability for maximum pain-free function and to prevent further or future injury to the spinal cord and nerve roots. Surgical fusion may be necessary to provide immediate and long-term stability. Posterior instability should be treated by posterior fusion, and anterior instability should be treated with anterior stabilization.

This paper described 27 patients who had seemingly stable compression cervical vertebral fractures. All were treated in cervicothoracic orthoses. None was initially treated in a Halo device or with surgery. Twenty patients were stable and healed without progressive displacement, angulation, or pain. One patient demonstrated an angular deformity, which spontaneously stabilized within six months with anterior bony ankylosis in a kyphotic position. Six patients demonstrated persistent progressive post-injury instability related to posterior ligament rupture. As muscle spasm diminished, the patients could be given a more reliable flexion-extension radiographic examination, unmasking the hidden posterior instability. Five of the six who demonstrated this instability were disabled because of pain. Two of the six patients were treated with a two-segment fusion. The other four have had fusion recommended and are currently being followed clinically. This paper emphasizes the need for better initial criteria of potential instability and close follow-up of patients with simple compression fractures of the cervical spine.

Anterior intervertebral-body fusion has been advocated by various authors for management of several varieties of fracture and fracture-dislocation of the cervical spine. This report is a retrospective study of sixteen patients, all of whom had a fracture-dislocation of the cervical spine, who were treated with an anterior dowel interbody fusion. All had postoperative instability with recurrence of angular deformity, and all sixteen were shown to have disruption of the posterior ligaments. Three patients had a progressive neurological deficit postoperatively. Thirteen patients required two or more operative attempts at stabilization. Anterior fusion should not be performed as primary surgical treatment for fractures of the cervical spine when there is either evidence of disruption of the posterior ligaments or a strong presumption that such disruption exists.

The true incidence of spinal cord injury as a complication of elective anterior discectomy and interbody fusion is not known. It would appear that the risk of encountering this complication increases if the surgical procedure includes instrumentation within the spinal canal. In 5 of the cases reported herein the cause for spinal cord injury was identifiable; in the remaining 5, the mechanism of injury is either obscure or not reported. All 10 patients reported had their surgery performed using the drill and dowel technique. The role of the posterior osteophyte in spondylosis and the rationale for routinely entering the spinal canal in order to decompress the spinal cord and nerve roots are examined. Since the majority of refractory disk problems that require surgery can be satisfactorily managed by discectomy and interbody fusion alone, routine instrumentation within the spinal canal may be an avoidable hazard in the majority of instances. The pathogenesis and prognosis of the anterior cord syndrome is reviewed, a possible etiology is suggested, and the anatomy, the autonomy and the importance of the anterior spinal artery system are noted. Its vulnerability in the treatment of degenerative disk disease and a possible mechanism for its occult impairment is mentioned.

Surgical stabilization of the cervical spine for maintaining reduction and facilitating fusion following trauma may be accomplished by wiring the dorsal elements together. Twenty gauge (0.8 mm) 316L stainless steel surgical wire is the most convenient size to use. Meticulous atraumatic technique is necessary to reduce and fix the unstable spine in order to prevent damage to the spinal cord. Multiple wiring techniques of the upper and lower cervical spine are described and demonstrated, noting the advantages and disadvantages of each.

Of 256 patients with a major spinal cord injury as a result of fracture of the cervical spine, 38 per cent had a laminectomy. Three months after injury, 33 per cent of the patients with laminectomy required fusion for instability compared to 22 per cent of the nonlaminectomy group. There were no cases of late instability in pure flexion or extension fracture groups. Ninety per cent of the late instability cases were in the groups with hyperflexion and flexion compression fractures. Laminectomy should be avoided for these fractures, but early fusion may be necessary to prevent progressive deformity.

The diagnosis of complete or incomplete quadriplegia and designation of functional levels can be accurately determined during the first 24 hours after injury in virtually all cases of severe traumatic quadriplegia. The prognosis for recovery depends upon an understanding of regeneration of nerve roots following injury and the significance of return of involuntary reflex activity. A realistic prognosis and accurate evaluation of various forms of treatment depend upon accurate documentation of the pattern of sensory and motor deficits.

Surgical stabilization should be individualized for each patient. The procedure used should provide both immediate and prolonged stability at the site of instability. The choice of procedure depends on knowledge of the structures providing stability and of the mechanism of injury. Pure flexon injuries without comminution or disruption of ligaments are stable and do not require surgical treatment. Flexion-rotation dislocations, with either unilateral or bilateral facet dislocation, should be treated by posterior open reduction and fusion if they cannot be reduced by a closed method or if there is demonstratable motion on three-month flexion-extension roentgenograms. A comminuted burst ("teardrop") fracture produced by axial loading of the vertebral bodies should be stabilized by an anterior cortical strut graft for early mobilization and realignment of the spinal column to prevent progressive deformity.