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

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Presentation on theme: "Cervical spine trauma Initial management of facet dislocation Paul Licina Brisbane."— 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 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 45 o left & right ? NY 1.lateral C spine film 2.peg view no radiology required neurological deficit ? N plain films normal and adequate? NY CT whole C spineclinical concern ? Y N C spine cleared normal 1.consultation 2.? flex/ext views Rx abnormal 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

5 classification

6 upper cervical spine lower cervical spine atypical vertebrae distinct injury patterns separate classifications typical vertebrae complex injury patterns classified together

7 compressiondistraction lat. flexion flexion extension flexion vertical extension A A C C B B

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9 DF DE CF VC CE LFcompressiondistraction lat flexion DFdistraction AO B B FACET DISLOCATION

10 unifacetal dislocation

11 bifacetal dislocation

12 MRI surgery reduction DECISIONS

13 The herniated disc & MRI

14 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 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 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 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 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) 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 –patient awake so neurological deterioration able to be assessed disadvantages –can take many hours or days –not always successful (55%) advantages –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 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 –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) stop –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 –rapid reduction achieved –safe (no neurological deficits) –effective (88%) disadvantages –theoretical risk of overdistraction and neurological deficit –traction and pin site problems –time consuming 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

24 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 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

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 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 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 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

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