Facet dislocation management
- 1. Cervical spine trauma Initial management of facet dislocation Paul Licina Brisbane
- 2. evaluation
- 4. are any present? 1. GCS < 14 2. neurological deficit (or history of neurological symptoms at any time) 3. other major injury that may mask neck pain 4. 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 1. consultation 2. ? flex/ext views Rx 1. one attempt with traction on arms 2. must show C7-T1 3. no AP 4. no swimmers 5. no oblique Y 1. lateral C spine film 2. CT whole C spine with CT head / other region 1. consultation 2. ? flex/ext views normal abnormal unconscious or multitrauma requiring ICU ? Y Y MRI and/or CT in consultation abnormal N
- 6. 0 1 2 3 4 5 6 7 upper cervical spine lower cervical spine •‘atypical’ vertebrae •distinct injury patterns •separate classifications •‘typical’ vertebrae •complex injury patterns •classified together
- 7. compression distraction lat. flexion flexion extension flexion vertical extension A CB
- 9. DF DECF VC CE LF compression distraction lat flexion DF distraction AO B FACET DISLOCATION
- 13. The herniated disc & MRI
- 14. 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
- 15. 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
- 16. 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
- 17. 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
- 18. Gradual traction, rapid reduction, manipulation or open reduction?
- 19. 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)
- 20. Gradual traction • advantages – patient awake so neurological deterioration able to be assessed • disadvantages – can take many hours or days – not always successful (55%)
- 21. 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
- 22. 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)
- 23. 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
- 24. 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
- 25. 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
- 26. Surgery
- 27. 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