CERVICAL FACET INJURIES

NEW ENGLAND SPINE STUDY GROUP

January 8, 2011

JESSE G. EISLER, MD PhD

Connecticut Back Center

55 yo Male, s/p fall c/o neck pain,no neuro deficits

Treatment:Collar

Followup with flexion/extension views in 2-3 weeks

Goals of TreatmentCervical Spinal Segment

Healed motion segmentStable - mechanically, neurologicallyWell-alignedPainless

55 yo F, fell off golf cartRight elbow dislocationComplaining of neck pain at followup for elbowclosed reductionX-ray showed C5-6 subluxation

What is the next most appropriate imaging study?

1. Flexion-Extension Xrays

2. MRI

3. CT scan

4. Bone Scan

5. No additional Imaging

CT

Negative predictive value:

95% for all spinal injuries

100% for unstable spinal injuries

100% sensitivity when used to view specific areas of suspicion on plain films

Neurosurgery Supplement: 50(3), March 2002(Hadley, Walters, Grabb, Oyesiku, Przbylski, Resnick, Ryken)

Next Step?

1. External Bracing – no additional treatment 2. Immediate closed reduction – no MRI 3. MRI to assess for disc before closed

reduction 4. Immediate Surgery – Anterior approach 5. Immediate Surgery – Posterior approach

Awake Closed ReductionComplete Motor and sensory loss below C6

80 lbs traction

CR Literature Review

50 yr lit review:42 articles (retrospective case series)1200 pts treated with CR in the acute/subacute period

80% had restored anatomic alignment

11 pts/1200 (0.92%) had new permanent neuro deficits(2 root, 2 ascending cord injuries, 7 decreased ASIA scores post reduction with ?

cause )

• 20/1200 (1.7%) had transient deficits (improved after weight reduction/ open reduction)

Causes: overdistraction, noncontiguos lesion, disc herniation, epidural

hematoma, spinal cord edema

Food for Thought!(Awake CR)

Rizzolo (Spine 1991): 55 prereduction MRI:

54% incidence of hnp! No neuro comp in awake and alert pts who had CR

Grant (J Neurosurg 1999): 80 pts post-reduction MRI:

46 % had hnp No coorelation with outcome!

Vaccaro (Spine 1999): 11 pts, mri pre-post reduction MRI:

HNP 2 pre 5/9 post sucessful CR MRI did not predict neuro deterioration!

13

Unilateral Facet Dislocation C5/6 Immediate MRI ? Immediate Traction ? Immediate Operative Reduction ?

14

Unilateral Facet Dislocation C5/6 Immediate MRI - Is this possible at most centers ? Immediate ORIF - Is this possible at most centers ? GW tongs & traction can occur quickly at most hospitals

15

Unilateral Facet Dislocation C5/6:Immediate TractionThe real questions are is it safe to reduce the dislocation before you get MRI or should you wait ?

Is it better just to wait and fix them in OR ?

Do you go anterior or posterior ?

16

Literature Review Immediate Closed Reduction of Cervical Spine

Dislocations Using Traction. Star , Jones, Cotler, Balderson, Sinha. Spine 15 1068-72, 1990.

Bottom line closed reduction is safe when patients can undergo serial exams

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Literature ReviewExtrusion of an Intervertebral Disc Associated with

Traumatic Suluxation or Dislocation of Cervical Facets. Eismont, Arena, Green. JBJS 73A 1555-1560, 1991.

Raises question Should MRI be done on every patient prior to reduction ?

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Literature ReviewMRI Evaluation of the Intervertebral Disc, Spinal

Ligaments, and Spinal Cord Before and After Closed Reduction Of Cervical Spine Dislocations. Vaccaro, Falatyn, Flanders, Balderson, Northrup, Cotler. Spine 24 1210-1217, 1999.

Demonstrated 56% incidence of disk herniation after reduction

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Immediate Closed Reduction Allows spinal realignment to occur quick indirect neuro decompression Literature demonstrates safety in awake alert patients

Next Step?(after releasing traction & return to baseline neuro status)

1. External Bracing – no additional treatment

2. MRI

4. Immediate Surgery – Anterior approach

5. Immediate Surgery – Posterior approach

MRILarge Anterior Disk

Take-Home Recommendations

If CR fails there is a higher incidence of anatomic obstacles (facet fx/HNP)

These patients should undergo MRI prior to open reduction

Disc herniation in this setting is an indication for anterior decompression prior to reduction

MRI in patients who can’t be examined for neuro deterioration !

Next Step?

1. External Bracing – no additional treatment

2. Immediate Surgery – Anterior approach

3. Immediate Surgery – Posterior approach

Facet Dislocations:Why Operate? Closed Management

50 yr lit review: 28 articles, 701 pts

26% (181/701 pts) failed to achieve reduction with craniocervical traction

Reduction when accomplished could not be maintained in 28% (112/ 393 pts) treated with external immobilization

No differences in success rates of closed reduction and maintaining alignment in UFC or BFD injuries

Malalignment = Pain

Anterior Surgery

Is Additional Posterior Surgery Necessary?1. Yes

2. No

67 yo Male, s/p Motorcycle Crash

● Retired postal worker on motorcycle trip, lost control of bike

● Right open tibia fracture, s/p External Fixator● Right distal humerus fracture s/p ORIF● C5-6 facet/lamina fracture

TREATMENT OPTIONS:O

NON-OPERATIVECOLLARHALO

OPERATIVEPOSTERIOR INSTRUMENTATIONANTERIOR

CERVICAL ORTHOSIS

REHAB HOSPITAL

Neurological exam

● Left C6 motor and sensory deficits● No spinal cord injury

TREATMENT OPTIONSMORE IMAGING

CLOSED REDUCTION

SURGICAL APPROACH

Cervical Cervical ReductionsReductions

Reduction < 8 hrs Reduction < 8 hrs post injury-NApost injury-NAIndirect Indirect decompression of the decompression of the Spinal CordSpinal CordGreater Neuro Greater Neuro recovery compared to recovery compared to age, injury matched age, injury matched controlscontrols

Treatment OptionsSurgicalAnteriorDisc presentPlate

Posterior (+/-) Post-closed reduction

Wires/plates

Non-surgicalNo/ minimal root findings

MRI: (+) disc integrity

Reduction NOT NEC

• Halo• Posterior fusion with wiring• Posterior fusion with lateral

mass fixation• Posterior fusion with

pedicle screws• Anterior fusion with plating.• Anterior and posterior

fusion with fixation

Treatment Options

Treatment

● Awake closed reduction with traction using Barton tongs- 40-50lbs.

● Surgical fixation , C5-6 posterior instrumentation, unilateral and C5-6 ACDF

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Classification of Subaxial Cervical Spine Injuries

1.1. OTAOTA2.2. AOAO3.3. Allen-FergusonAllen-Ferguson4.4. CSISS – Cervical CSISS – Cervical

Spine Injury Severity Spine Injury Severity ScaleScale

5.5. SLIC – Subaxial SLIC – Subaxial Cervical Spine Injury Cervical Spine Injury Classification SystemClassification System

Sub-Axial Cervical SpineSub-Axial Cervical Spine

• Allen and Ferguson• Mechanistic

• Static radiographs

• Seven categories• Position of spine • Dominant load to failure• Graduated increments of

tissue failure

• 24 different classifiers

Allen, Ferguson Spine 1982.

Sub-Axial Cervical SpineSub-Axial Cervical Spine

• AO• Mechanistic• Type A

• Compressive

• Type B• Flex/Ext Distraction

• Type C• Rotation

AOAO Type AType A

CompressionCompressionType I – Anterior Type I – Anterior CompressionCompression

Type II – Comminuted Type II – Comminuted FracturesFractures

Type III – Teardrop Type III – Teardrop FracturesFractures

No translationNo translation

No rotationNo rotation No ligamentous injuryNo ligamentous injury

II

III

AO

Type BFlex/Ext Distraction I – Moderate Strain II – Severe Strain III – Bilateral Fracture Dislocation

III

AOAO

Type CRotational injury I – Unilateral facet

fracture II – Fracture

separation of the articular pillar

III – Unilateral facet dislocation

III

II

White & Panjabi Instability ScoreWhite & Panjabi Instability Score

Points

Anterior Element Destruction

Posterior Element Destruction

2

2

Translation > 3.5 mm

Rotation > 11°

2

2

+ Stretch Test

Cord Injury

2

2

Root Injury

Disk Narrowed

1

1

Anticipated Loads 1

5 points = unstable

White, Panjabi, 1990

Sub-Axial Cervical TraumaSub-Axial Cervical Trauma• Sub-axiaL Cervical Spine Injury

Classification (“SLIC”)

SLICSLIC• Three Major

Components

• Injury Morphology• Compression

• Distraction

• Translation/Rotation

• Discoligamentous Status

• Neurological Status

Injury Morphology

Points

Compression

- Burst

1

1

Distraction 3

Translation/

Rotation

4

Total Injury Morphology

Max 4

SLICSLIC• Three Major

Components

• Injury Morphology• Compression

• Distraction

• Translation/Rotation

• Discoligamentous Status

• Neurological Status

DLC status Points

Intact 0

Indeterminate 1

Disrupted 2

Total DLC Score Max 2

SLICSLIC• Three Major

Components

• Injury Morphology• Compression

• Distraction

• Translation/Rotation

• Discoligamentous Status

• Neurological Status

Neurologic Status Points

Intact 0

Nerve Root Deficit 1

Complete Spinal Cord

2

Incomplete Spinal Cord

3

Add-on:Persistent compression or stenosis with neuro deficit

1

Total Neurologic Score

Max 4

SLICInjury Morphology Points

Compression

- Burst

1

2

Distraction 3

Translation/

Rotation

4

Total Injury Morphology

Max 4

DLC status Points

Intact 0

Indeterminate 1

Disrupted 2

Total DLC Score Max 2

Neurologic Status Points

Intact 0

Nerve Root Deficit 1

Complete Spinal Cord 2

Incomplete Spinal Cord 3

Add-on:

Persistent compression or stenosis with SCI

1

Total Neurologic Score Max 4

SLIC Recommended SLIC Recommended TreatmentTreatment

• Score > 4 OperativeScore > 4 Operative• Score < 4 Non-Score < 4 Non-

operativeoperative

Vaccaro et al Spine. 2007

SLICSLIC C6/7 unilateral dislocationC7 root injury

• Morphology• Translation 4 pts

• DLC• Disrupted 2 pts

• Neurological Status• Root injury 1 pt

Total Score: 7 pts

Operative Treatment

SLIC Treatment Threshold

Assign Points

Conservative Surgery

< 4 points > 4 points