Cervical spine trauma

Initial management of

facet dislocation

Paul Licina Brisbane

evaluation

history

examination

imaging

•mechanism

•neurological symptoms

•neck

•neurology

•other injuries •x-ray

•CT

•MRI

are any present?

1. GCS < 14

2. neurological deficit (or history of neurological

symptoms at any time)

3. other major injury that may mask neck pain

4. neck pain or midline neck tenderness

N

able to actively rotate

neck 45o left & right ? N Y

1. lateral C spine film

2. peg view

no radiology

required

neurological deficit ?

N

plain films normal

and adequate?

N Y

CT whole C spine clinical concern ? Y N C spine

cleared

1. consultation

2. ? flex/ext views

Rx

1. one attempt with

traction on arms

2. must show C7-T1

3. no AP

4. no swimmers

5. no oblique

Y

1. lateral C spine film

2. CT whole C spine with

CT head / other region

1. consultation

2. ? flex/ext views

normal

abnormal

unconscious or multitrauma

requiring ICU ? Y

Y

MRI and/or CT

in consultation

abnormal

N

classification

0

1

2 3

4

5

6

7

upper cervical spine

lower cervical spine

•‘atypical’ vertebrae •distinct injury patterns •separate classifications

•‘typical’ vertebrae •complex injury patterns •classified together

compression distraction lat. flexion

flexion

extension

flexion

vertical

extension

A C B

DF DE CF VC CE LF

compression distraction lat flexion

DF

distraction

AO

B FACET

DISLOCATION

unifacetal dislocation

bifacetal dislocation

MRI surgery

reduction

DECISIONS

The herniated disc & MRI

The herniated disc & MRI

• incidence of herniated disc

– varies from 0% to 50%

• significance of herniated disc

– reduction may lead to further

displacement of disc into canal

• clinical evidence

– case reports of catastrophic neurologic

deterioration with herniated disc found

– deterioration occurred after reduction

– reduction (open or closed) under GA

The herniated disc & MRI

• questions

– which patients should have MRI ?

– when should it be performed ?

– what should be done for a herniated disc ?

• answers

– everyone should have an MRI before reduction

– a herniated disc should be removed before reduction

Contentions

• neurological deterioration during

closed reduction rare

– ? significance of disc protrusion

– canal size increased with reduction

• ? is delay to obtain MRI before

reduction justified

• ? need for MRI at all if routine

anterior discectomy and fusion

My solution

• plain x-ray and CT scan

• if neurologically intact, no need for MRI

• if neurologically complete, obtain MRI

– only if established defect (days old)

– if early, treat as incomplete below

• if neurologically incomplete, initiate rapid reduction

– delay for MRI not justified

– reduction will increase space for cord

• proceed to theatre for definitive treatment

Gradual traction, rapid reduction,

manipulation or open reduction?

Gradual traction

• traditional technique

• skull tongs applied

• conscious patient

• 5-10 lb added every 30 min – 2 hrs

• neuro exam and x-ray

• maximum weight 25-50 lbs

• continued until reduction achieved or

success unlikely (72 hrs)

Gradual traction

• advantages

– patient awake so neurological

deterioration able to be assessed

• disadvantages

– can take many hours or days

– not always successful (55%)

Rapid reduction

• ICU setting with II or x-ray machine

• doctor and radiographer stay for

duration of manoevre

• start with 10 lbs and add 10 lbs every

10 mins (until film developed)

• immediate neuro exam and x-ray

• after 50 lbs, countertraction

– reverse Trendelenberg

– lower limb countertraction

Rapid reduction

• stop

– once reduction achieved

– with neurological deterioration

– with distraction > 1 cm

– if reduction unlikely (sufficient

distraction without reduction)

• time and weight required

– 25-160 lbs (75% < 50 lbs)

– 10 min to 3 hrs (average 75 mins)

Rapid reduction

• advantages

– rapid reduction achieved

– safe (no neurological deficits)

– effective (88%)

• disadvantages

– theoretical risk of overdistraction and

neurological deficit

– traction and pin site problems

– time consuming

Manipulation under GA

• advantages

– allows immediate reduction and

subsequent surgical stabilisation

– good evidence of efficacy (91%)

– shown to be safe

• disadvantages

– requires GA with unstable neck

– potential for unrecognised neurological

deterioration

My solution

• start rapid reduction

• organise theatre

• discontinue rapid reduction if

unsuccessful within 1 hour

• go to theatre for definitive treatment

• gentle manipulation (traction and

flexion) under GA

• open reduction if unsuccessful

Surgery

Surgery

• anterior approach

– discectomy, graft and fusion

– better tolerated

– can directly remove disc

– proven to be clinically effective

• posterior approach

– lateral mass fusion

– operation directed at pathology

– more biomechanically sound

– allows direct facet reduction