Presented by: Dr Paul Licina — Spine Surgeon Event: Bone School Presentation - 2014

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 45o left & right ?
N Y
1. lateral C spine film
2. peg view
no radiology
required
neurological deficit ?
N
plain films normal
and adequate?
N Y
CT whole C spine clinical concern ?Y N C spine
cleared
1. consultation
2. ? flex/ext views
Rx
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. 0
1
2
3
4
5
6
7
upper cervical spine
lower cervical spine
•‘atypical’ vertebrae
•distinct injury patterns
•separate classifications
•‘typical’ vertebrae
•complex injury patterns
•classified together

7. compression distraction lat. flexion
flexion
extension
flexion
vertical
extension
A CB

9. DF DECF VC CE LF
compression distraction lat flexion
DF
distraction
AO
B
FACET
DISLOCATION

10. unifacetal dislocation

11. bifacetal dislocation

12. MRI
surgery
reduction
DECISIONS

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 25-50 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%)

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
– 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)

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

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

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
– 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