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 distractionDF 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