Cervical spine trauma

Initial management offacet dislocation

Paul LicinaBrisbane

evaluation

historyexaminationimaging

• mechanism• neurological symptoms• neck• neurology• other injuries• x-ray• CT• MRI

are any present?1. GCS < 142. neurological deficit (or history of

neurological symptoms at any time)3. other major injury that may mask

neck pain4. 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

normal1. consultation2. ? flex/ext

views

Rxabnormal

1. one attempt with traction on arms

2. must show C7-T1

3. no AP4. no swimmers5. no oblique

Y

1. lateral C spine film2. CT whole C spine

with CT head / other region

1. consultation2. ? flex/ext

views

normal

abnormal

unconscious or multitrauma requiring ICU ?Y

Y

MRI and/or CT in consultation

abnormal

N

classification

0

1234

5

6

7

upper cervical spine

lower cervical spine

• ‘atypical’ vertebrae• distinct injury patterns• separate classifications

• ‘typical’ vertebrae• complex injury patterns• classified together

compression distraction lat. flexion

flexion

extension

flexion

vertical

extension

A CB

DF DECF VC CE LF

compression distraction lat flexion

DF

distraction

AO

BFACET

DISLOCATION

unifacetal dislocation

bifacetal dislocation

MRIsurgery

reduction

DECISIONS

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– 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– 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– 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– 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

– 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