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

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

classification

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

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

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

unifacetal dislocation

bifacetal dislocation

MRI surgery DECISIONS reduction

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 disadvantages 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 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 25-160 lbs (75% < 50 lbs) 10 min to 3 hrs (average 75 mins)

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

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

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 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