Perioperative management and neurological outcomes of traumatic spondyloptosis: A retrospective case series of 14 patients

Abstract

BACKGROUND

Traumatic spondyloptosis is a severe, high-energy spinal injury, and priority should be given to emergency resuscitation and vital-sign stabilization during the perioperative period.

AIM

To analyze the clinical characteristics, perioperative treatment strategies, surgical protocols, and long-term neurological rehabilitation outcomes of patients with traumatic spondyloptosis.

METHODS

A retrospective analysis was conducted on 14 adult patients diagnosed with traumatic spondyloptosis who were admitted to our orthopedic department from January 2018 to January 2025. Clinical data, including demographic characteristics, injury mechanisms, combined fracture sites, spinal injury segments, preoperative resuscitation measures, surgical approaches, postoperative rehabilitation protocols, and neurological function assessed by the American Spinal Injury Association (ASIA) impairment scale, were analyzed. All patients completed at least 12 months of regular follow-up to evaluate surgical efficacy, fracture healing and neurological recovery.

RESULTS

Among the 14 patients, 11 had polytrauma with extra-spinal fractures involving the scapula, ribs, maxilla, skull and other parts, and three presented with hemorrhagic shock on admission and received emergency resuscitation. Thirteen patients underwent posterior-only spinal surgery, and one patient underwent combined anterior-posterior surgery, with complete anatomical vertebral reduction achieved in all cases. Preoperatively, all patients had severe neurological deficits (ASIA A or B). At the final follow-up, eight patients achieved elevated ASIA grades, five showed obvious neurological recovery, three showed mild improvement, and six remained unchanged. Postoperative complications included joint contractures, pneumonia, pressure ulcer, urinary tract infection, and deep vein thrombosis.

CONCLUSION

Posterior surgical treatment combined with individualized postoperative rehabilitation is useful and can achieve complete spinal reduction, relieve spinal cord and nerve root compression, promote fracture healing and improve neurological recovery.

Key Words: Spondyloptosis; Fractures; Clinical management; American Spinal Injury Association; Rehabilitation

Core Tip: Traumatic spondyloptosis is a high-energy injury frequently associated with polytrauma and hemorrhagic shock, demanding prioritized emergency resuscitation. In this 14-patient retrospective series, posterior-only instrumentation (with one combined anterior–posterior case) achieved complete anatomical reduction in all cases. Although all patients presented with severe preoperative neurological deficits American Spinal Injury Association (ASIA) (ASIA A/B), 8 of 14 attained ASIA grade elevation at final follow-up. Individualized postoperative rehabilitation reduced complications and promoted neurological recovery, supporting posterior surgery plus tailored rehabilitation as a useful strategy.

INTRODUCTION

Spondyloptosis, defined as Meyerding grade V spondylolisthesis, refers to the complete anterior or posterior displacement of one vertebral body relative to the adjacent inferior vertebra, with a slip percentage exceeding 100% on standing lateral radiographs[1]. The pathogenesis of this severe spinal disorder is multifactorial, primarily involving structural instability of the spinal column[2]. It can arise from congenital dysplasia of the neural arch, isthmic defects that progress from spondylolysis, high-velocity trauma, degenerative changes in the facet joints and intervertebral discs in the elderly, or pathological conditions such as spinal tumors and metabolic diseases[3,4]. Regardless of the etiology, progressive vertebral displacement often leads to compression of the spinal cord or nerve roots, resulting in a series of clinical manifestations including severe low back pain, lower limb radiculopathy, motor and sensory deficits, and, in severe cases, cauda equina syndrome[5]. However, traumatic spondyloptosis is a rare condition and a limited number of cases have been reported[6,7]. TS predominantly affects the thoracolumbar and lumbosacral junctions, particularly the T12-L1 and L5-S1 segments, followed in rare instances by the cervical and midthoracic spine[8,9]. TS has no obvious age or sex predilection and is often associated with high-energy injuries such as traffic accidents or falls from height[5].

The management of spondyloptosis is highly challenging, with no universal clinical guidelines currently available[3,7,10]. Conservative treatment, including physical therapy, nonsteroidal anti-inflammatory drugs, epidural steroid injections, and bracing, is only suitable for asymptomatic patients or those with mild symptoms, as it cannot reverse vertebral displacement or relieve severe neural compression effectively[11]. Surgical intervention is the cornerstone of treatment for traumatic spondyloptosis, aiming to achieve neural decompression, vertebral realignment, and spinal stabilization through techniques such as posterior-only reduction and fusion, a combined anterior–posterior approach, or corpectomy[12]. However, these surgical procedures are technically demanding and associated with high risks of intraoperative neural injury, excessive blood loss, and postoperative complications such as pseudarthrosis and adjacent segment disease[13]. Additionally, the rarity of spondyloptosis has led to a lack of high-quality evidence from large patient cohorts, resulting in inconsistencies in surgical strategy selection and uncertainty regarding long-term clinical outcomes[6,14]. Therefore, accumulating data from well-characterized patient cohorts is crucial for optimizing treatment protocols and improving prognosis for this severe spinal disorder.

To date, most studies of traumatic spondyloptosis have been case reports and relevant case series have rarely been published. Discrepancies have emerged among trauma centers, and treatment efficacy varies because of inconsistent management of this severe injury. Herein, we report a case series of 14 patients who sustained traumatic spondyloptosis, with the aim of improving the clinical management of this condition.

MATERIALS AND METHODS

Patient selection

We retrospectively reviewed data from a maintained registry of spondyloptosis at our center over 6 years (from January 2018 to January 2025). This study was conducted in accordance with the Declaration of Helsinki. All patients enrolled in this retrospective study were selected from the Department of Orthopaedic Surgery. The study was approved by the Institutional Review Board of the 960^th Hospital of the PLA Joint Logistics Support Force (Ethics Approval No. 2026039). Patient de identification measures for all published radiographic images is performed and the institutional review board’s waiver of informed consent covers publication of fully de identified clinical imaging data.

Total 14 patients were included as described in Figure 1. Strict diagnostic and clinical eligibility criteria were applied, with all of the following criteria required for inclusion: (1) A confirmed diagnosis of spondyloptosis (Meyerding grade V spondylolisthesis); (2) Age ≥ 18 years; (3) A clear etiological diagnosis of traumatic spondyloptosis documented through etiological classification; (4) Complete baseline clinical and radiographic data showing the double-vertebra sign (Figure 2A); and (5) A minimum of 1 year of clinical follow-up data after surgical intervention. Patients were excluded if they met any of the following criteria: (1) Concomitant spinal disorders that could alter the natural history and treatment outcomes of spondyloptosis, including acute or non-union traumatic spinal fractures at the same or adjacent segments, primary or metastatic spinal tumors, pyogenic or tuberculous spinal infections, idiopathic or degenerative scoliosis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, and fixed kyphotic deformity at the lumbosacral junction; (2) A history of lumbar spine decompression, fusion, or instrumentation surgery at the spondyloptosis segment or adjacent levels before the initial diagnosis of spondyloptosis; (3) Incomplete or uninterpretable data; (4) Pathological spondyloptosis secondary to systemic disease; (5) Severe comorbidities affecting prognosis and follow-up; (6) Neuromuscular or congenital neurological disorders; and (7) Duplicate patient records, incorrect diagnostic coding, or loss to follow-up immediately after initial diagnosis without any treatment data.

Figure 1  The participant flow chart of this study.

Figure 2 Overview of spondyloptosis in this series. A: The double-vertebra sign on imaging indicates spondyloptosis; B: Definite vertebra location and distribution among patients in this cohort.

Surgery

Before surgery, all patients received mannitol and high-dose methylprednisolone pulse therapy. A posterior surgical approach was used in all 13 patients, and only one patient underwent combined anterior–posterior surgical treatment. Standard surgical procedures included laminar decompression and partial facetectomy to resect hypertrophic ligaments and osteophytes, achieving thorough neural canal decompression. Selective transpedicular corpectomy with bone grafting was performed in patients with severe vertebral destruction. Stepwise segmental distraction, rotational correction, and tension adjustment via pedicle screw-rod systems were applied for precise vertebral reduction. All patients obtained complete anatomical reduction without residual vertebral malalignment or slippage. Rigid transpedicular fixation and autologous bone graft fusion was performed to establish spinal stability, and all wounds were closed in layers with short-term postoperative drainage. The combined anterior–posterior approach was used only for the single cervical patient requiring anterior column reconstruction (anterior discectomy and bone grafting), whereas all other patients, including the remaining cervical cases, were treated via a posterior-only approach. Classical pedicle screw fixation and rod connection were performed. Several patients also underwent transpedicular corpectomy with cage placement. In all patients, the operative wound was closed in layers. Complete reduction of the listhesis as no alignment or slippage of the upper and lower vertebral bodies was achieved in all patients surgically treated for spondyloptosis. A standardized staged rehabilitation protocol was strictly implemented with regular adherence supervision. Regular imaging and neurological follow-ups ensured sustained surgical efficacy and standardized rehabilitation adherence.

Postoperative course

All patients received standardized postoperative care in the spine surgery ward, with routine daily monitoring of vital signs, surgical wound drainage, lower-extremity neurological function (including motor function, sensation, and reflexes), and bowel and bladder function. Prophylactic intravenous antibiotics were administered for 24 hours to prevent surgical-site infection, and subcutaneous low-molecular-weight heparin was routinely prescribed for deep vein thrombosis prophylaxis until patients resumed ambulation. Surgical drains were removed 48 hours to 72 hours postoperatively when daily output was less than 50 mL, and wound healing was assessed regularly for signs of infection, dehiscence, or bleeding. Passive lower-extremity exercises were encouraged during bed rest to prevent thromboembolism and muscle atrophy. Patients were discharged after meeting standardized criteria and were provided with detailed written rehabilitation protocols. Post-discharge rehabilitation included progressive lumbar extensor muscle training beginning 2 weeks after discharge. Regular follow-up was conducted by telephone. All postoperative complications were documented and managed promptly during hospitalization and follow-up. All patients were followed up at least for one year (with duration from 12 months to 48 months).

Data collection

Based on the medical records, we collected demographic data, including sex, body weight, height, and underlying diseases for all patients. Moreover, the mechanism of injury, blood pressure at admission especially for shock (difficulty in maintaining blood pressure caused by excessive blood loss), interval before surgery, and polytrauma such as concomitant fractures were also recorded. For the surgery and follow-up periods, the surgical approach, number of fixed segments, operative time, intraoperative blood loss, American Spinal Injury Association (ASIA) grade[15], and length of postoperative hospital stay were recorded. All data were analyzed accordingly. At the final follow-up, neurological functions were systematically evaluated, mild change means a small but measurable gain in ISNCSCI motor or sensory scores that does not reach the threshold for an upward shift in AIS grade, indicating subtle, non-categorical neurological recovery and improvement means an upward conversion of the AIS grade and/or a clinically meaningful increase in motor/sensory scores, reflecting significant neurological recovery. Categorical and continuous variables were described descriptively. No inferential hypothesis testing was performed owing to the small sample size of this retrospective case series.

RESULTS

In this study, 14 patients diagnosed with spondyloptosis were retrospectively enrolled (Table 1). Regarding the affected vertebrae (Figure 2B), four patients had cervical spine involvement (C6 in one and C7 in three), six patients had thoracic spine involvement (T3, T5, T7, and T12 in one patient each and T11 in two patients), and four had lumbar spine involvement (L1 and L2 in one patient each and L3 in two patients). Representative cases of cervical, thoracic, and lumbar spondyloptosis in this cohort are presented in Figures 3, 4 and 5. There were 3 women and 11 men, with a mean age of 50.36 ± 12.26 years (range, 36-77 years) and a mean body mass index of 23.81 ± 1.95 kg/m² (range, 20.70-26.60). Only two patients had hypertension. Approximately half of the cases of spondyloptosis were due to motor vehicle accidents, five resulted from falls from height, and only two resulted from crush injuries. Three patients were diagnosed with shock and low blood pressure; therefore, appropriate interventions were implemented to stabilize their vital signs before surgical decompression. The interval before surgery exceeded 10 hours in ten patients.

Figure 3 Representative case of cervical spondyloptosis. A 63-year-old man sustained an injury after falling from a height. A and B: Preoperative radiographs and computed tomography (CT) showed C7 spondyloptosis (orange arrow); C: Magnetic resonance imaging demonstrated spinal cord compression. The patient subsequently underwent combined anterior–posterior fixation and discectomy with bone grafting (orange arrow); D and E: Postoperative radiographs and CT images demonstrated vertebral reduction and favorable internal fixation (orange arrow).

Figure 4 Representative case of thoracic spondyloptosis. A 55-year-old man was injured in a motor vehicle accident. A and B: Preoperative radiographs and computed tomography (CT) images showed T11 spondyloptosis (orange arrow); C: Magnetic resonance imaging showed spinal cord compression and soft-tissue swelling. The patient subsequently underwent posterior pedicle screw fixation (orange arrow); D and E: Postoperative radiographs and CT images demonstrated vertebral reduction and favorable internal fixation (orange arrow).

Figure 5 Representative case in lumbar spondyloptosis. A 50-year-old man was injured in a motor vehicle accident. A: Preoperative radiographs (orange arrow); B: Computed tomography (CT) image showed L3 spondyloptosis with double-vertebra sign. The patient subsequently underwent posterior pedicle screw fixation (orange arrow); C and D: Postoperative radiographs and CT images demonstrated vertebral reduction and favorable internal fixation (orange arrow).

Table 1 General characteristics of the 14 patients with spondyloptosis.

No.	Sex	Age (year)	BMI (kg/m2)	Basic diseases	Mechanism of injury	Shock	Blood pressure (mmHg)	Affected vertebra	Interval before surgery (hours)
1	Female	36	20.7	None	MVA	No	90/56	C6	52
2	Male	38	23.8	None	CA	No	128/75	L1	10
3	Male	63	23.9	Hypertension	FFH	No	147/88	C7	30
4	Male	36	26.6	None	MVA	No	109/68	T5	15
5	Male	39	26.4	None	CA	Yes	82/46	C7	13
6	Male	61	25.4	None	MVA	Yes	70/46	T3	80
7	Female	37	20.7	None	MVA	No	106/77	T12	16
8	Male	48	23.9	None	FFH	No	125/85	L3	10
9	Male	77	24.2	Hypertension	MVA	No	154/85	L2	16
10	Male	56	21.7	None	FFH	No	112/76	T7	24
11	Female	53	22.6	None	FFH	No	119/72	T11	10
12	Male	55	24.6	None	MVA	No	134/87	T11	21
13	Male	56	26.1	None	FFH	No	100/61	C7	12
14	Male	50	22.7	None	MVA	Yes	59/32	L3	14

BMI: Body mass index; MVA: Motor vehicle accident; CA: Crushing accident; FFH: Fall from height.

Regarding concomitant fractures, 11 patients were classified as having polytrauma, including fractures of the scapula, ribs, maxilla, or skull (Table 2). Each patient underwent a specific posterior surgical approach, and only one patient underwent a combined anterior–posterior approach. The number of fixed segments ranged from 2 to 6. The mean operative time was 194.60 ± 37.08 minutes (range, 110-260 minutes), and the mean intraoperative blood loss was 632.10 ± 203.40 mL (range, 150-800 mL). The mean postoperative hospital stay was 30.50 ± 17.82 days (range, 11-78).

Table 2 Surgical interventions in the 14 patients with spondyloptosis.

No.	Multiple trauma	Combined fractures	Surgical approach	Segment fixation	Operation time (minutes)	Blood loss (mL)	Hospitalized days	Complications
1	No	None	AT + PT	C5-T1	110	150	35	Joint contracture
2	Yes	None	PT	T12-L3	260	400	41	None
3	Yes	Scapular; rib	PT	C5-T2	230	800	27	Pneumonia
4	Yes	Maxilla	PT	T3-7	200	800	33	None
5	Yes	Skull	PT	C5-T2	210	800	16	Pressure ulcer
6	Yes	Rib	PT	T1-6	170	500	22	Urinary tract infection
7	No	None	PT	T10-L3	185	600	24	None
8	No	None	PT	L1-5	170	800	11	None
9	Yes	Scapular; rib	PT	L1-3	190	800	78	None
10	Yes	Skull; rib	PT	T5-T9	175	500	17	Deep vein thrombosis
11	Yes	Maxilla; rib	PT	T9-L2	190	800	20	None
12	Yes	None	PT	T9-T12	185	500	14	Pressure ulcer
13	Yes	Rib	PT	C4-T1	200	600	39	Joint contracture
14	Yes	Rib	PT	L1-5	250	800	50	Urinary tract infection

AT: Anterior; PT: Posterior.

Regarding neurological function evaluation (Table 3), all patients were graded as ASIA A or B before surgery (n = 10 and 4, respectively). However, the ASIA grades of eight patients improved after surgery. At the final follow-up, each patient’s overall recovery was assessed: Five patients showed clear improvement, three showed mild improvement, and six remained unchanged (Figure 6).

Figure 6 Presentation of preoperative, postoperative, and follow-up American Spinal Injury Association scale. ASIA: American Spinal Injury Association.

Table 3 Neurological function assessments in this cohort.

No.	Pre-op ASIA	Post-op ASIA	Follow-up ASIA	Outcomes
1	A	B	B	Mild change
2	B	C	C	Improvement
3	B	B	B	Unchanged
4	A	A	A	Unchanged
5	A	A	B	Mild change
6	A	A	A	Unchanged
7	A	A	A	Unchanged
8	A	C	D	Improvement
9	B	C	D	Improvement
10	A	A	B	Mild change
11	B	C	D	Improvement
12	A	A	A	Unchanged
13	A	B	B	Improvement
14	A	A	A	Unchanged

ASIA: American Spinal Injury Association.

DISCUSSION

This retrospective single-center study evaluated 14 adult patients with traumatic spondyloptosis. Unlike most of the existing literature on this condition, which consists of isolated case reports or small case series with limited generalizable data, this cohort provides a more robust body of clinical evidence for the management of traumatic spondyloptosis. The primary goal of this study was to fill critical evidence gaps in clinical practice, given the absence of universal treatment guidelines and the inconsistency of surgical protocols for this severe, life-altering spinal disorder.

The clinical and injury characteristics observed in this cohort highlight the distinctive severity and demographic patterns of traumatic spondyloptosis compared with the degenerative and congenital subtypes of the condition. The study cohort included 11 men and 3 women, with a mean age of 50.36 years. The cohort showed no strict age or sex predilection, consistent with prior reports linking traumatic spondyloptosis to high-energy impact injuries. Motor vehicle accidents were the leading cause of injury, followed by falls from height and crush injuries, and 11 of 14 patients presented with polytrauma involving extraspinal fractures, reflecting the high-force nature of the trauma that causes complete vertebral displacement. Notably, injury segments were distributed across the cervical, thoracic, and lumbar spine in this cohort, which differs from previous reports that identify the thoracolumbar and lumbosacral junctions as the most commonly affected sites. This variation suggests that traumatic spondyloptosis can occur at any spinal segment under sufficient mechanical force, and clinicians must maintain a high index of suspicion for complete vertebral slip regardless of spinal level. However, previous reports indicate that the cervicothoracic, thoracolumbar, and lumbosacral junctions are most commonly affected[16-19]. Additionally, three patients presented with hemorrhagic shock on admission, emphasizing the need for urgent hemodynamic stabilization before surgical intervention to prevent secondary neurological deterioration.

Surgical strategy selection and perioperative management emerged as critical pillars of successful treatment for traumatic spondyloptosis, with posterior-only surgery demonstrating reliable efficacy in this cohort[20]. Thirteen patients underwent a posterior surgical approach, while only one required combined anterior–posterior surgery, a pattern that challenges the notion that complex spondyloptosis always requires dual approaches for adequate reduction and stabilization. All patients achieved complete anatomical reduction of the vertebral slip using pedicle screw fixation, rod contouring, and selective transpedicular corpectomy with cage implantation, confirming that posterior-only techniques can achieve sufficient decompression, realignment, and spinal stability without the added morbidity of an anterior approach. Preoperative administration of mannitol and high-dose methylprednisolone pulse therapy was uniformly applied to mitigate spinal cord edema and secondary neural injury, a key adjunctive measure that aligns with acute spinal cord injury management protocols[21,22]. The mean operative time and blood loss reflect the technical complexity of these procedures, but standardized perioperative prophylaxis for deep vein thrombosis and surgical-site infection minimized early postoperative complications.

Neurological recovery outcomes in this study offer valuable insights into prognostic factors for traumatic spondyloptosis, with improvements in ASIA grades supporting the benefit of timely surgical intervention. All patients presented with severe preoperative neurological deficits, classified as ASIA A or B, indicating complete or severely incomplete spinal cord injury at the time of admission. Postoperatively, eight patients showed measurable improvements in ASIA grades, with a significant difference among the preoperative, early postoperative, and follow-up assessments, demonstrating that surgical reduction and stabilization can halt neurological decline and promote partial recovery in selected patients. Patients with milder preoperative deficits (ASIA B) were more likely to achieve functional improvement, while those with complete spinal cord injury (ASIA A) showed minimal or no recovery, highlighting baseline neurological status as the strongest predictor of long-term functional outcome. Prolonged time to surgery due to initial resuscitation for polytrauma did not negate postoperative benefits, although earlier intervention after hemodynamic stabilization may optimize recovery potential, a finding that warrants further investigation.

This study provides meaningful clinical data on a rare spinal condition, but it has limitations that must be acknowledged when interpreting the results. Its primary strengths are its strict patient selection, complete follow-up data, and exclusive focus on traumatic spondyloptosis, which avoids the heterogeneity of mixed etiological subtypes seen in other small studies. However, the retrospective single-center design and small sample size of 14 patients limit the generalizability of the findings, and the 1-year follow-up period is insufficient to assess long-term complications. Compared with the 30patient cohort by Ladewig Bernaldez et al[23], the present 14case series showed several differences. The mean age was higher (50.36 years vs 35 years), and motorvehicle crashes constituted the leading injury mechanism rather than falls from height. Also, injuries were distributed across cervical, thoracic and lumbar segments, whereas thoracic lesions predominated in the 30case study. All our patients presented with preoperative ASIAA/B deficits, while the larger cohort included ASIAC/D cases. Inhospital mortality was not reported here, unlike the 13% mortality in the 30patient series. Additionally, the lack of a control group comparing surgical and conservative approaches in this study prevents a direct analysis of treatment superiority, although conservative care is not clinically feasible for most patients with traumatic spondyloptosis and neurological deficits. Future research should prioritize multicenter prospective cohort studies with larger sample sizes and extended follow-up to validate surgical protocols, define the optimal timing of intervention, and identify modifiable prognostic factors. Ultimately, this cohort reinforces that surgical intervention is the standard of care for traumatic spondyloptosis and that individualized, protocol-driven care can improve functional outcomes and reduce complication rates in this high-risk patient population.

CONCLUSION

This study confirms that posterior surgical intervention is a useful strategy, achieving complete vertebral reduction in all cases and yielding significant improvements in ASIA neurological grades. Most patients sustained high-energy injuries with concurrent polytrauma, requiring urgent perioperative resuscitation before surgery. While the baseline neurological deficit strongly predicts long-term recovery, timely surgical stabilization and standardized postoperative care improve clinical outcomes for this severe, rare spinal disorder. This study addresses critical evidence gaps, and future large-scale multicenter research is needed to refine treatment guidelines and improve long-term prognosis.