3 history examination imaging mechanism neurological symptoms neck neurologyother injuriesx-rayCTMRI
4 Rx are any present? GCS < 14 neurological deficit (or history of neurological symptoms at any time)other major injury that may mask neck painneck pain or midline neck tendernessNunconscious or multitrauma requiring ICU ?able to actively rotate neck 45o left & right ?YYNNYlateral C spine filmCT whole C spine with CT head / other regionlateral C spine filmpeg viewno radiology requiredone attempt with traction on armsmust show C7-T1no APno swimmersno obliquenormalabnormalneurological deficit ?YNRxabnormalMRI and/or CT in consultationplain films normal and adequate?abnormalNYYNC spine clearedCT whole C spineclinical concern ?normalconsultation? flex/ext viewsconsultation? flex/ext views
14 The herniated disc & MRI incidence of herniated discvaries from 0% to 50%significance of herniated discreduction may lead to further displacement of disc into canalclinical evidencecase reports of catastrophic neurologic deterioration with herniated disc founddeterioration occurred after reductionreduction (open or closed) under GA
15 The herniated disc & MRI questionswhich patients should have MRI ?when should it be performed ?what should be done for a herniated disc ?answerseveryone should have an MRI before reductiona herniated disc should be removed before reduction
16 Contentions neurological deterioration during closed reduction rare ? significance of disc protrusioncanal size increased with reduction? is delay to obtain MRI before reduction justified? need for MRI at all if routine anterior discectomy and fusion
17 My solution plain x-ray and CT scan if neurologically intact, no need for MRIif neurologically complete, obtain MRIonly if established defect (days old)if early, treat as incomplete belowif neurologically incomplete, initiate rapid reductiondelay for MRI not justifiedreduction will increase space for cordproceed to theatre for definitive treatment
18 Gradual traction, rapid reduction, manipulation or open reduction?
19 Gradual traction traditional technique skull tongs applied conscious patient5-10 lb added every 30 min – 2 hrsneuro exam and x-raymaximum weight lbscontinued until reduction achieved or success unlikely (72 hrs)
20 Gradual traction advantages disadvantages patient awake so neurological deterioration able to be assesseddisadvantagescan take many hours or daysnot always successful (55%)
21 Rapid reduction ICU setting with II or x-ray machine doctor and radiographer stay for duration of manoevrestart with 10 lbs and add 10 lbs every 10 mins (until film developed)immediate neuro exam and x-rayafter 50 lbs, countertractionreverse Trendelenberglower limb countertraction
22 Rapid reduction stop time and weight required once reduction achieved with neurological deteriorationwith distraction > 1 cmif reduction unlikely (sufficient distraction without reduction)time and weight requiredlbs (75% < 50 lbs)10 min to 3 hrs (average 75 mins)
23 Rapid reduction advantages disadvantages rapid reduction achieved safe (no neurological deficits)effective (88%)disadvantagestheoretical risk of overdistraction and neurological deficittraction and pin site problemstime consuming
24 Manipulation under GA advantages disadvantages allows immediate reduction and subsequent surgical stabilisationgood evidence of efficacy (91%)shown to be safedisadvantagesrequires GA with unstable neckpotential for unrecognised neurological deterioration
25 My solution start rapid reduction organise theatre discontinue rapid reduction if unsuccessful within 1 hourgo to theatre for definitive treatmentgentle manipulation (traction and flexion) under GAopen reduction if unsuccessful
27 Surgery anterior approach posterior approach discectomy, graft and fusionbetter toleratedcan directly remove discproven to be clinically effectiveposterior approachlateral mass fusionoperation directed at pathologymore biomechanically soundallows direct facet reduction
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