1. B. J. Medical College,Pune)
Comparison of Hartshill Technique with Lateral Mass Screw Fixation technique in the treatment of subaxial cervical spine fractures
DR. MOHIT M. KUKREJA,
ASSISTANT PROFESSOR,
GRANT MEDICAl COLLEGE,
MUMBAI
Dr. A. S. Chandanwale
(currently Dean
B. J. Medical College,Pune)
Grant medical college & Sir J.J.Group of hospitals, MUMBAI
Dr. Shashikant Nawale
(Ex-Assistant Professor,GRANT MEDICAL COLLEGE,MUMBAI)

2. Introduction Most critical , Life-threatening
Cervical spine injury
Most critical , Life-threatening
due to affection of vital centers
Spinal trauma- 6% of total trauma patients and half present with neurodeficit .
( Burney RE, Maio RF, Maynard F, et al)
>50% of spinal trauma patients have cervical spine injury
(Tator CH,-Review of treatment trials in
human spinal cord injuty: Issues,
difficulties and recommendations
Neurosurgery 2006:59(5): )

3. Cervical Spine injury
Motor Vehicle accident most common cause for traumatic spinal cord injury -42%.
. Woodruff BA, Baron RC. A description of
nonfatal spinal cord injury using a
hospital-
based registry. Am J Prev Med
1994;10(1):10-14
Common at most mobile region of spine Cranio cervical,C4-C5 &
C5-C6 junction
Ligamentous injuries & Bony
injuries
Facet dislocations
Lamina fractures

4. Mechanistic Classification Sub-axial Cervical Spine Injuries
Compressive flexion
Classification by allen et al
Tear drop fracture
Anterior and posterior ligamentous injury

5. Mechanistic Classification Sub-axial Cervical Spine Injuries
Vertical compression
Superior and inferior
end plate #
Vertebral body comminution

6. Mechanistic Classification Sub-axial Cervical Spine Injuries
Distractive flexion
Subluxation Uni.dislocation
Facet
Bil. dislocation Floating vertebra

7. Mechanistic Classification Sub-axial Cervical Spine injuries
Compressive extension
Lamina #
Anterior body displacement

8. Mechanistic Classification Sub-axial Cervical Spine injuries
Distractive extension
Avulsion # anterior
vertebral body
Posterior vertebral
translation

9. Emergency evaluation and Care
Maintenance vitals- A,B,C
Proper history with systemic & neurological examination
Neurological status documented with American Spinal Injury Association Scale.(ASIAS)

10. American Spinal Injury Association Scale
GRADE#
MOTOR DEFICIT
SENSORY DEFICIT A
0/5
Complete B
Incomplete C
<3/5 D
>3/5 E
5/5
Normal
# : Caudal to the level of injury

11. Imaging Lateral X-ray >7mm at C2-C3 disc space
Cervical spine X-rays
AP, lateral and open mouth view –
injuries detected 83 to 99%
(MacDonald RL , Schwartz ML, Mirich D, et al. Diagnosis of cervical spine injury in motor
vehicle crash victims : how many X rays are enough? J trauma 1990;30: )
Lateral X-ray
Soft tissue shadow
>7mm at C2-C3 disc space
>21mm at C6-C7 disc space
high chance of cervical spine injury
( Matar LD et al-Prevertebral soft tissue measurements
In cervical spine injury .Aust Radiol 1997;41: ).

12. Radiological instability assessment
Segmental kyphosis suggestive of Posterior ligamentous injury
Cobb method Posterior vertical body
tangential method
>11 degrees
Sagital plane translation >3.5 mm suggestive of instability

13. CT- SCAN and MRI SCAN Initial screening tool
Detecting soft tissue injuries
Traumatic disc
herniation
Epidural hematoma
Spinal cord compression& edema
Ligamentous
disruptions.
Initial screening tool
More sensitive for fracture detection
Assessing the status at Occipital-cervical and Cervical thoracic junction.

14. Non operative Treatment Protocol(IMMOBILIZATION with ORTHOSIS and SKULL TRACTION)
What cases??
Stable compression fractures
If all anterior structures plus one posterior structure are intact, Or
If all posterior structures plus one anterior structure are intact (White AA, III, Panjabi MM. Clinical Biomechanics of the Spine. Philadelphia: J. B. Lippincott; 1978.)
Undisplaced fractures of
Lamina
Lateral mass
Spinous process.

15. Surgical Management Unstable fracture With neurodeficit
Without neurodeficit
With neurodeficit

16. Surgical techniques and approaches
Anterior approach:
All burst fractures
Decompression-discectomy, corpectomy
Reconstruction with titanium cage or strut graft with cervical plating
POSTERIOR APPROACH.
Reduction- dislocated facets and fixation and fusion of cervical spine.
TECHNIQUES-
Cervical facet wiring
Interspinous wiring
SUBLAMINAR WIRES with HARTSHILL
Transarticular screws
LATERAL MASS PLATES AND
SCREWS

17. Lateral Mass Screw
Hartshill Rectangle

18. Aims and Objectives To study and compare the functional outcome of
The Lateral Mass Screw Fixation and
The Hartshill Rectangle
in management of Sub-axial cervical spine fractures
To compare the complication rates between the two
techniques

19. QUESTIONS TO BE ANSWERED
Is the LATERAL MASS SCREW FIXATION TECHNIQUE now the “benchmark” for the treatment of such fractures???
Is the HARTSHILL RECTANGLE TECHNIQUE still a validated technique in certain situations or should it be considered an “obsolete” and a “condemned” modality???

20. Methodology
Study Group: Patients admitted with cervical spine injury fulfilling the inclusion criteria
Sample Size: Number
Hartshill technique
Lateral mass screw fixation 20
Study Design: Prospective, randomized

21. Inclusion Criteria Age - 15-70 years Equal sex
Post-traumatic C3-C7 level cervical spine injury
Facet joint dislocation with lamina fracture
Vertebral body tear drop fracture
Compression fracture with kyphosis
Patients with partial and complete neurodeficit.

22. Exclusion Criteria
Pathological fractures - Neoplasms, Tuberculosis, Osteoporosis etc.
Anterior Approach is mandatory-Burst fractures with retro-pulsed fragments
Fractures of C1-C2 group
Patients with concomitant spinal abnormalities such as Ankylosing Spondylitis, Rheumatoid Arthritis, Diffuse Idiopathic Skeletal Hyperostosis.

23. Materials and Methods Two techniques Hartshill Rectangle And
Lateral Mass Screw-rod
System
in 20 cases each
Midline Extensile approach
Autogenic Bone Graft used for fusion

24. Materials and Methods Lateral Mass Screw Fixation
Titanium 3.5 mm Diameter Poly-axial Screws With Rod System used.
Magerl Technique of insertion used: screw was placed 2-3 mm medial and cephalad to the middle of the lateral mass
Screws were angulated to about 25 degree laterally and were placed parallel to the superior articular facets.
Entry point
Divergence
Cephalic Angulation

25. Materials and Methods Hartshill Rectangle
Stainless Steel Hartshill of appropriate size with Sublaminar Wires of 2 mm diameter
Contoured for cervical lordosis and fixed with sublaminar wires.

26. Post-op X rays
Lateral Mass Screw Fixation
Hartshill Rectangle

27. Follow-up Assessed Clinically, Radiologically and Functionally
At 6th, 8th and 12th week and then
At 3 months, 6 months and 12 months.
Mobilized depending on the fusion status .
We looked for -complications -
Wire Breakage
Wire dislodgement
Screw back-out/pull out
Loss Of Sagittal Alignment (Residual Kyphosis )
Persistent pain (Oswestry Scale For Neck Disability using Neck Disability Index Questionnaire)

28. Observations and Results
Demographic Data
Parameters
Lateral Mass Technique (N=20)
Hartshill Technique (N=20)
Age*
Mean
41.05
40.95 SD
11.2
14.1
Range
23 – 60
*: Student ‘t’ test
‘p’ > 0.05: NOT significant

29. Observations and Results
Sex Distribution
Study total of 40 patients
12 males &
8 females each group
‘p’ > 0.05: NOT significant

30. ASIA Scale for Neurological Assessment
Percentage of Cases
Lateral mass technique
Hartshill technique
‘p’ > 0.05: NOT significant

31. ASIA Scale for Neurological Assessment
70% – 80% of total cases were in ASIA Scale of C and D in each group
No deterioration post-operatively except one case of Hartshill technique from Category D preoperatively to Category A after surgery
The Scale was comparable after procedure at time of discharge

32. Profile of Mechanism of Injury
Percentage of Cases
‘p’ > 0.05: NOT significant

33. Profile of level of cervical Injury
Percentage of Cases
‘p’ > 0.05: NOT significant

34. Oswestry Disability (Pain) Score
Hartshill Technique
No. of Patients
20 %
10%
None of the patients in Lateral Mass group had Disability .

35. Average fusion duration Mean Fusion Time (Weeks)
‘p’ 0.000: Significant

36. Profile of Complications
Percentage of complications

37. Comparison of Complications
Lateral Mass Screw Fixation
Hartshill Rectangle Technique
Radiation Exposure with average of 92.5 flouro sec with SD of 6.95
Absence of
dural tears,
radiculopathy,
persistent pain
Dural tears in 3 (15%) patients
Deterioration of ASIA Scale in 1(5%) of the dural torn patients
Wire Breakage in 1 (5%) patient on 6 months post-op
Persistent pain in 6 (30%) patients

38. Discussion
Our Study has compared two posterior stabilization techniques;
Hartshill Rectangle Technique and
Lateral Mass Screw Fixation
Both groups comparable-
Age, Sex
Mechanism of injury
ASIA scale category.

39. Intra-operative complications
Hartshill technique-3 patients (15%) had Dural Tears (sutured intra-operatively)
Hartshill technique-Out of 3 patients amongst the ruptured dura, one had a Worsened Neurodeficit with deterioration from Category D to A. (ASIAS)
Geremia GK et al.: Complications of
sublaminar wiring. Surg Neurol 23:629–635, 1985)

40. Intra-operative complications
LATERAL MASS TECHNIQUE-
NO INTRAOPERATIVE COMPLICATIONS in our study.
Wang et al-minimally invasive lateral mass screws in the treatment of cervical facet dislocation ; neurosurgery 52:
Sekhon et al-posterior cervical plate mass screw fixation ; analysis of 1026 consecutive screws in 143 patients-FRAC journal of Spinal Disorder & Techniques . AUG 2005-volume 18-issue 4-pp
Vertebral artery injury occur.-Nazaria n Louis et al- posterior internal fixation with screw plates in traumatic lesions of cervical spine . Spine 1991;17:S442-S446
Spinal nerve injury (0.6%)-Heller et al-0.6 % (complications of posterior cervical plating.spine.1995;20: )

41. Implant failure and Disability(HARTSHILL)
Hartshill technique: one patient (5%) presented with WIRE BREAKAGE at 6 months with no consequent complications after 3 years follow up and did not warrant removal.
(J Dove et al .Geremia gk et al. –Inadequate external immobilisation or
failure to use sufficient diameter wire)
Hartshill technique :30% had PERSISTENT PAIN ,
4–mild and
2 moderate disability
(Persistent pain ,broken implants and worsening kyphosis- P Ward, A R
Harvey, J Ramos, JE Carvell, D J Grundy Hartshill rectangle failure of
spinal stabilisation in acute spinal cord injury.; Eurojournal april 2000
,9(2)152-5)

42. Implant failure and Disability(LATERAL MASS)
Lateral mass technique-poly-axial screw size -14mm
no follow-up complications
(Screw pullout -Sekhon et al-Posterior cervical plate mass screw
fixation ; analysis of 1026 consecutive screws in 143 patients-FRAC
journal of Spinal Disorder & Techniques .AUG 2005-volume 18-issue 4
-pp )
Lateral mass technique No disability

43. Immobilization
Hartshill technique-immobilized by Philadelphia Brace for weeks.
Lateral mass fixation-
Stable implant provides –immediate rigid fixation
Immobilized- hard cervical collar for 6-8 weeks
(No necessity of complex orthoses post- operatively-Cooper PR: the axis
fixation of posterior instrumentation of the cervical
spine.neurosurgery;39: ,1996)

44. Fusion Hartshill technique-100 % fusion rate with average 20.20 weeks
(100 % Fusion rate-Lee et al-Roger’s posterior cervical fusion:a 3 months
radiological review. injury 1996;27: )
Lateral mass technique-100 % fusion rate with average rate 8.5 weeks.
(100 % fusion rate -Jeannerre et al-Posterior rod system of cervical
spine: a new implant allowing optimal screw insertion.Eur spine J 5:350 –
Nazarian and Louis-Posterior internal fixation with screw plates in
traumatic lesion of cervical spine.spine 1991;16:S64-S71)

45. Fusion X rays
20 weeks
9 weeks

46. Limitations of Lateral Mass Screw Technique
Technically demanding procedure
Need of expertization
High cost
Use of image-intensifier intra-operatively
Radiation Exposure was significantly higher with all screws inserted under C-arm guidance with an average exposure of 92.5 flouro sec.

47. Limitations of Hartshill technique
Less rotational stability-
Wire slippage
Loss of Reduction and fixation
Thus recurrence of Facetal dislocation
Could not be used in laminar disruptions due to requirement of sub-laminar wires fixation.
(Exception: Transpinous wires used to stabilize the Hartshill rectangle in deficiency of lamina-Cooper PR-The axis fixation system for posterior instrumentation of the cervical spine. neurosurgery 39: ,1996

48. The Lateral Mass Screw Technique
Conclusion
The Lateral Mass Screw Technique
Biomechanically much more stable implant
Broader spectrum of cervical spine fractures can be treated[vertebral body tear-drop fractures (compression-flexion type-3), in fractures of lamina, in Post-laminectomy cases].
Excellent results in terms of
Patient Tolerance
Post-operative Fusion
Early Mobilization
Excellent Functional Outcome

49. Conclusion Hartshill rectangle
Narrow spectrum of treating cervical fractures
Higher incidence of intra-operative and post-operative complications which are manageable and are not exclusively a fallacy of the implant but a surgeon-based technical pitfall.
HOWEVER
Ideal implant for peripheral hospitals in a country like India with vast population.
Surgery can be done on an emergency basis
Cost is not a constraint for patients

50. TAKE HOME MESSAGE
“THE LATERAL MASS SCREW TECHNIQUE is a biomechanically much more stable implant application with excellent results in for the operative management of sub-axial cervical spine fractures .”
HOWEVER,
“the age-old HARTSHILL RECTANGLE cannot be designated as a condemned modality as it conspicuously and prominently stands out in certain practical situations faced by an operating surgeon in day-to-day practice.”