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A 21-year-old patient is evaluated in the trauma bay after a motor vehicle accident. He was found to have a GCS of 3 on the scene and is presently intubated. His bulbocavernosus reflex is not intact. Radiographs and representative CT scan sequences are shown in Figures A through E. What is the next best step in management?
Closed reduction under anesthesia
Open reduction under anesthesia
Closed reduction with internal stabilization
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Based on clinical findings and the imaging shown, this patient has bilateral facet dislocations at C5-6. Considering that he is intubated with concern for spinal cord injury, obtaining an MRI is the next best step.
Facet dislocations predominantly occur in the subaxial spine via flexion distraction mechanisms. Bilateral facet dislocations are often associated with severe spinal cord injury. In a patient who has an altered mental status, obtaining an MRI is critical. This will help identify injuries to the posterior ligamentous complex and the presence of myelomalacia. Of particular importance is the ability to identify disc herniations. Closed reductions completed in the setting of disc herniations can cause further injury to the spinal cord.
Kwon et al. review subaxial cervical spine trauma. They indicate that closed reduction prior to obtaining an MRI should only be completed in a patient who is awake, cooperative and neurologically intact. Open reduction should be completed when closed reduction fails (ie. Fractured facet or lateral mass dissociation) or neurologic deterioration occurs.
Patel et al. review a new classification scheme for subaxial cervical spine trauma. The SLIC (Subaxial Injury Classification and Severity Score) system defines morphology of the injury, status of the discoligamentous complex and neurologic status. The recommend clinical use of this system as it overcomes limitations faced by prior classifications.
Figure A shows a lateral radiograph of the cervical spine with translation of the C5 inferior facet anterior to the superior facet of C6. Figures B, C and D show CT scan sequences of the upper cervical spine. They demonstrate bilateral facet dislocations at the level of C5-6. Figure E is an axial image at the C5-6 level showing the inferior facet of C5 lying anterior to the superior facet of C6 (the inverted hamburger sign) bilaterally.
A video is provided below that reviews cervical spine trauma and management.
Answers 1, 4: In a neurologically intact, awake and cooperative patient, closed reduction is warranted without anesthesia. Internal fixation may be applied after closed reduction is completed.
Answer 2: Open reduction is indicated when fractures of the facets or lateral mass dissociation have prevented closed reduction. Progressive neurologic decline is an indication to proceed with an open reduction
Answer 3: Observation alone is not indicated.
Kwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF
J Am Acad Orthop Surg. 2006 Feb;14(2):78-89. PMID: 16467183 (Link to Abstract)
Patel AA, Dailey A, Brodke DS, Daubs M, Anderson PA, Hurlbert RJ, Vacccaro AR.
Neurosurg Focus. 2008;25(5):E8. PMID: 18980482 (Link to Abstract)
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A 35-year-old female is involved in a high speed motorcycle crash. Work-up reveals the presence of an open right femur fracture, and neck pain. A CT scan of the cervical spine is obtained and shows a right sided C6/7 facet dislocation. Which of the following images is most representative of this injury?
Figure C shows a right sided C6/C7 facet dislocation represented by the abnormal articular facet relationship. This is demonstrated by the labeled image in Illustration B, compared to the normal anatomic facet relationships shown in Illustration A. When viewing the cervical spine on the axial cuts of a CT, the superior facet lies anterior to the inferior facet.
Daffner et al describe two new signs, the "hamburger bun" sign of normal facet joints and the "reverse hamburger bun" sign that should be useful in establishing a diagnosis of facet dislocation. They state that normal facet joints are oriented on a CT examination so that they resemble the sides of a hamburger bun, whereas facet dislocations upset this relationship and reverse the orientation of the "bun" halves to each other.
Pal et al performed a cadaveric study to evaluate the orientation of the superior articular facets in relation to their inclination with the sagittal and transverse planes between C3 and T3 vertebrae in each column. They then associated their findings with various cervical movements and associated clinical conditions.
Answer 1-Figure A shows normal facet anatomy.
Answer 2-Figure B shows a left sided facet dislocation
Answer 4 and 5-Figures D and E show bilateral facet dislocations
Daffner SD, Daffner RH.
J Emerg Med. 2002 Nov;23(4):387-94. PMID: 12480021 (Link to Abstract)
Pal GP, Routal RV, Saggu SK
J. Anat.. 2001 Apr;198(Pt 4):431-41. PMID: 11327205 (Link to Abstract)
Average 3.0 of 26 Ratings
Cervical facet dislocations are characteristically caused by which of the following mechanisms of injury?
The Allen and Ferguson classification of cervical spine injuries breaks injuries of the subaxial spine into six phylogenic groups based on mechanism of injury. These include: 1) flexion-compression 2) vertical-compression 3) flexion-distraction 4) extension-compression 5) extension-distraction 6) lateral flexion. Facet dislocation is caused by flexion-distraction forces. Therefore, in a facet dislocation the posterior structures (interspinous ligament, facet capsule, liagmentum flavum, posterior annulus) are likely disrupted, whereas the anterior structures (anterior longitudinal ligament) are usually preserved. Sutterlin et al showed in a biomechanical bovine model, and Coe et al in a cadaveric model, that anterior plating was inferior to posterior techniques (Rogers' wiring method, Bohlman's triple-wire technique, sublaminar wiring, and posterior hook plate stabilization) for stabilization of flexion-distraction injuries of the cervical spine.
Sutterlin CE 3rd, McAfee PC, Warden KE, Rey RM Jr, Farey ID.
Spine (Phila Pa 1976). 1988 Jul;13(7):795-802. PMID: 3194788 (Link to Abstract)
Coe JD, Warden KE, Sutterlin CE 3rd, McAfee PC.
Spine (Phila Pa 1976). 1989 Oct;14(10):1122-31. PMID: 2588063 (Link to Abstract)
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An awake and cooperative patient presents to the emergency room with the injury seen in the CT scan in Figure A. Prior to the CT scan he had an ASIA Impairment Scale of E. Upon returning from the CT scanner he has an ASIA Impairment Scale of D. What is the most appropriate first step in management?
Immediate closed reduction with cervical traction
Immediate anterior open reduction and surgical fixation
Spinal dose steroids
Cervical immobilization, observation, and serial neurologic exams
The patient presents with a deteriorating neurologic exam in the presence of a bilateral C5-6 facet dislocation. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake.
An ASIA Impairment Scale of E is a normal exam. An ASIA Impairment Scale of D shows preserved motor function below the neurological level, but with more than half of key muscles below the neurological level showing weakness but with a muscle grade greater than 3. Therefore his exam is worsening. You know it is a bilateral facet dislocation as there is 50% subluxation of the vertebral bodies. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake. Because of his rapid decline in neurologic function you would not want to delay reduction by obtaining an MRI. All facet dislocations need to be stabilized surgically following reduction. Following closed reduction an MRI should be obtained to look for a cervical disc herniation, as the presence of one will determine the approach for stabilization.
The cited reference by Star et al is a case series (LOE4) of 53 patients who underwent closed reduction. They found that contrary to prior beliefs, adding weights of > 50 lbs and up to 100 lbs was safe and effective. In their series, 39 patients required greater than 50 lbs to obtain reductions and there was no associated complications with this additional weight.
Vaccaro et al performed prereduction and postreduction magnetic resonance imaging in eleven consecutive patients with cervical spine dislocations. They found the process of closed traction reduction appears to increase the incidence of intervertebral disc herniations. The relation of these findings, however, to the neurologic safety of awake closed traction reduction remain unclear.
Illustration A shows a simple algorithm to determine the ASIA Impairment Score (AIS).
Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R
Spine. 1990 Oct;15(10):1068-72. PMID: 2263974 (Link to Abstract)
Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE, Cotler JM
Spine. 1999 Jun;24(12):1210-7. PMID: 10382247 (Link to Abstract)
Average 4.0 of 26 Ratings
HPI - The patient is a 32-year-old male mechanic that fell 8 mm from a tree in late December. Since then he has had persistent and severe neck pain, paresthesia in this middle and index finger, and reports his right hand no longer has the strength it use to.
How would you approach this, anterior or posterior. We are in Nicaragua and have very few implants available.
HPI - The patient is a 30-yearmale that was a restrained driver in an MVA. There was no LOC. Her was brought to the ER via an ambulance. On presentation he had symptoms of mild neck pain and numbness and tingling in his right hand. He denied subjective wea
Shows a bilateral C5-6 facet dislocation treated with closed reduction with axia...