This document discusses the initial management and treatment of cervical spine facet dislocations. It provides guidelines for evaluation including imaging based on neurological status. Reduction techniques discussed include gradual traction, rapid reduction, and manipulation under general anesthesia. The role of MRI is debated, with most recommending MRI for incomplete neurological injuries before reduction. Anterior discectomy and fusion or posterior fusion are discussed as surgical stabilization options after reduction.

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