Presentation is loading. Please wait.

Presentation is loading. Please wait.

Cervical spine trauma Initial management of facet dislocation

Similar presentations

Presentation on theme: "Cervical spine trauma Initial management of facet dislocation"— Presentation transcript:

1 Cervical spine trauma Initial management of facet dislocation
Paul Licina Brisbane

2 evaluation

3 history examination imaging mechanism neurological symptoms neck
neurology other injuries x-ray CT MRI

4 Rx are any present? GCS < 14
neurological deficit (or history of neurological symptoms at any time) other major injury that may mask neck pain neck pain or midline neck tenderness N unconscious or multitrauma requiring ICU ? able to actively rotate neck 45o left & right ? Y Y N N Y lateral C spine film CT whole C spine with CT head / other region lateral C spine film peg view no radiology required one attempt with traction on arms must show C7-T1 no AP no swimmers no oblique normal abnormal neurological deficit ? Y N Rx abnormal MRI and/or CT in consultation plain films normal and adequate? abnormal N Y Y N C spine cleared CT whole C spine clinical concern ? normal consultation ? flex/ext views consultation ? flex/ext views

5 classification

6 Cervical fractures ‘atypical’ vertebrae distinct injury patterns
separate classifications ‘typical’ vertebrae complex injury patterns classified together 1 2 3 4 5 6 7 upper cervical spine lower cervical spine

7 A B C Allen & Ferguson AO system compression distraction lat. flexion
vertical extension flexion extension AO system A compression B distraction C rotation


9 B Allen & Ferguson FACET DISLOCATION AO compression distraction
DF DE CF VC CE LF compression distraction lat flexion DF distraction FACET DISLOCATION

10 unifacetal dislocation

11 bifacetal dislocation

12 MRI surgery DECISIONS reduction

13 The herniated disc & MRI

14 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

15 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

16 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

17 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

18 Gradual traction, rapid reduction, manipulation or open reduction?

19 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 lbs continued until reduction achieved or success unlikely (72 hrs)

20 Gradual traction advantages disadvantages
patient awake so neurological deterioration able to be assessed disadvantages can take many hours or days not always successful (55%)

21 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

22 Rapid reduction stop time and weight required once reduction achieved
with neurological deterioration with distraction > 1 cm if reduction unlikely (sufficient distraction without reduction) time and weight required lbs (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%) disadvantages theoretical risk of overdistraction and neurological deficit traction and pin site problems time consuming

24 Manipulation under GA advantages disadvantages
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

25 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

26 Surgery

27 Surgery anterior approach posterior 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



Download ppt "Cervical spine trauma Initial management of facet dislocation"

Similar presentations

Ads by Google