Introduction Represent spectrum of osteoligamentous pathology that includes unilateral facet dislocation most frequently missed cervical spine injury on plain xrays leads to ~25% subluxation on xray associated with monoradiculopathy that improves with traction bilateral facet dislocation leads to ~50% subluxation on xray often associated with significant spinal cord injury facet fractures more frequently involves superior facet may be unilateral or bilateral Epidemiology location ~75% of all facet dislocations occur within the subaxial spine (C3 to C7) 17% of all injuries are fractures of C7 or dislocation at the C7-T1 junction this reinforces the need to obtain radiographic visualization of the cervicothoracic junction Pathophysiology mechanism flexion and distraction forces +/- an element of rotation Classification Descriptive classification (subaxial cervical spine injuries) includes compression fracture burst fraction flexion-distraction injury facet dislocation (unilateral or bilateral) facet fracture more commonly used in clinical setting Allen and Ferguson classification (of subaxial cervical spine injuries) typically used for research and not in clinical setting based solely on static radiographs and mechanisms of injury Allen and Ferguson Classification (of subaxial spine injuries) 1. Flexion-compression 2. Vertical compression 3. Flexion-distraction Stage 1: Facet subluxation Stage 2: Unilateral facet dislocation Stage 3: Bilateral facet dislocation with 50% displacement Stage 4: Complete dislocation (100% displacement) 4. Extension-compression 5. Extension-distraction 6. Lateral flexion Presentation Physical exam monoradiculopathy seen in patients with unilateral dislocations C5/6 unilateral dislocation usually presents with a C6 radiculopathy weakness to wrist extension numbness and tingling in the thumb C6/7 unilateral dislocation usually presents with a C7 radiculopathy weakness to triceps and wrist flexion numbness in index and middle finger spinal cord injury symptoms seen with bilateral dislocations symptoms worsen with increasing subluxation Imaging Radiographs lateral shows subluxation of vertebral bodies unilateral dislocations lead to ~ 25% subluxation bilateral facet dislocation leads to ~ 50% subluxation on xray loss of disc height might indicated retropulsed disc in canal CT scan essential to demonstrate bony anatomy of the injury malalignment or subtle subluxation of facet facet fracture associated fractures of the pedicle or lamina MRI indications are controversial but include acute facet dislocation in patient with altered mental status failed closed reduction and before open reduction to look for disc herniation any neurologic deterioration is seen during closed reduction timing timing of MRI depends on severity and progression of neurologic injury an MRI should always be performed prior to open reduction or surgical stabilization if a disc herniation is present with compression on the spinal cord, then you must go anterior to perform a anterior cervical diskectomy valuable in demonstrating disc herniations extent of posterior ligamentous injury spinal cord compression or myelomalacia Treatment Nonoperative cervical orthosis or external immobilization (6-12 weeks) indications facet fractures without significant subluxation, dislocation, or kyphosis Operative immediate closed reduction, then MRI, then surgical stabilization indications bilateral facet dislocation with deficits in awake and cooperative patient unilateral facet dislocation with deficits in awake and cooperative patient technique never perform closed reduction in patient with mental status changes surgical stabilization following successful closed reduction unilateral dislocations are more difficult to reduce but more stable after reduction bilateral dislocation are easier to reduce (PLL torn) but less stable following reduction always obtain MRI prior to surgical stabilization PSF or ACDF can be performed in the absence of significant disc herniation ACDF performed if significant disc herniation present outcomes 26% of patients will fail closed reduction and require open reduction immediate MRI then open reduction surgical stabilization indications facet dislocations (unilateral or bilateral) in patient with mental status changes patients who fail closed reduction technique always obtain MRI prior to open reduction and stabilization if disc herniation with presence of spinal cord compression then you must use an anterior approach and do a discectomy Techniques Closed reduction requirements adequate anesthesia sedation supervision of respiratory function serial cross table laterals technique gradually increase axial traction with the addition of weights a component of cervical flexion can facilitate reduction perform serial neurologic exams and plain radiographs after addition of each weight abort if neurologic exam worsens and obtain immediate MRI Anterior open reduction & ACDF indications facet dislocations reduced through closed methods with a MRI showing cervical disc herniation with significant compression on the spinal cord unilateral facet dislocations that fail closed reduction with a disc herniation with significant compression on the spinal cord anterior open reduction techniques can be used to reduce a unilateral facet dislocation reduction technique involves distracting vertebral bodies with caspar pins and then rotating the proximal pin towards the side of the dislocation not effective for reducing bilateral facet dislocations Posterior reduction & instrumented stabilization indications when unable to reduce by closed or anterior approach no anterior compression of spinal cord(no disc herniation) technique performed with lateral mass screws usually have to fuse two levels due to inadequate lateral mass purchase at level of dislocation Combined anterior decompression and posterior reduction / stabilization indications when disc herniation present that requires decompression in patient that can not be reduced through closed or open anterior technique technique go anterior first, perform discectomy, position plate but only fix plate to superior vertebral body this way the plate will prevent graft kick-out but still allows rotation during the posterior reduction this technique eliminates the need for a second anterior procedure
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.264) 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? Review Topic QID: 4624 FIGURES: A B C D E 1 Closed reduction under anesthesia 14% (571/4029) 2 Open reduction under anesthesia 10% (395/4029) 3 Overnight monitoring 2% (79/4029) 4 Closed reduction with internal stabilization 6% (235/4029) 5 MRI 68% (2730/4029) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ10.228) Cervical facet dislocations are characteristically caused by which of the following mechanisms of injury? Review Topic QID: 3327 1 Flexion-compression 4% (117/3069) 2 Vertical compression 0% (13/3069) 3 Flexion-distraction 86% (2654/3069) 4 Extension-compression 1% (40/3069) 5 Extension-distraction 8% (237/3069) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.40) 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? Review Topic QID: 426 FIGURES: A 1 MRI 13% (358/2705) 2 Immediate closed reduction with cervical traction 73% (1980/2705) 3 Immediate anterior open reduction and surgical fixation 7% (177/2705) 4 Spinal dose steroids 3% (92/2705) 5 Cervical immobilization, observation, and serial neurologic exams 3% (88/2705) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ11.89) 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? Review Topic QID: 3512 FIGURES: A B C D E 1 Figure A 2% (49/2178) 2 Figure B 18% (401/2178) 3 Figure C 74% (1613/2178) 4 Figure D 4% (98/2178) 5 Figure E 0% (3/2178) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
C5/6 Bilateral Facet Dislocations - Closed reduction and Anterior Stabilization. Dr. Zitouni Spine - Cervical Facet Dislocations & Fractures - Surgical Cases Shows a bilateral C5-6 facet dislocation treated with closed reduction with axia... 3/2/2012 683 views
Nicargaua - Chronic Unilateral Perched Facet (C1160) Spine - Cervical Facet Dislocations & Fractures 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. 2/27/2012 173 1 4 Unilateral C6-7 Perched Facet with facet fracture of inferior articular process of C6. (C1044) Spine - Cervical Facet Dislocations & Fractures 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 6/11/2011 0 0 0