cervical spine trauma initial management of facet dislocation paul licina brisbane
TRANSCRIPT
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Cervical spine trauma
Initial management offacet dislocation
Paul LicinaBrisbane
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evaluation
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historyexaminationimaging
• mechanism• neurological symptoms• neck• neurology• other injuries• x-ray• CT• MRI
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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
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classification
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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
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compression distraction lat. flexion
flexion
extension
flexion
vertical
extension
A CB
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DF DECF VC CE LF
compression distraction lat flexion
DF
distraction
AO
BFACET
DISLOCATION
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unifacetal dislocation
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bifacetal dislocation
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MRIsurgery
reduction
DECISIONS
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The herniated disc & MRI
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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
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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
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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
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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
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Gradual traction, rapid reduction, manipulation or
open reduction?
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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)
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Gradual traction
• advantages– patient awake so neurological
deterioration able to be assessed• disadvantages
– can take many hours or days– not always successful (55%)
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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
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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)
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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
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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
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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
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Surgery
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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
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