Closed reduction of bilateral locked facets of the cervical spine under general anaesthesia

Immediate Closed Reduction Technique for Cervical Spine Dislocations

STUDY DESIGN

Retrospective study.

PURPOSE

This research aimed to assess the clinical outcomes of patients with traumatic cervical spine dislocation who underwent closed reduction employing our approach.

OVERVIEW OF LITERATURE

Bedside closed reduction is the quickest procedure for repairing traumatic cervical spine dislocations; nevertheless, it also possesses the risk of neurological deterioration.

METHODS

For closed reduction, the patient's head was elevated on a motorized bed, the cervical spine was placed at the midline, traction of 10 kg was applied, the motorized bed was gradually returned to a flat position, the head was lifted off the bed, and the cervical spine was slowly adjusted to a flexed position. The weight of traction was elevated by 5-kg increments until the positional shift was attained. Subsequently, the bed was gradually tilted while traction was applied again to return the cervical spine to the midline position.

RESULTS

Of the 43 cases of cervical spine dislocation, closed reduction was carried out in 40 cases, of which 36 were successful. During repositioning, three patients experienced a temporary worsening of their neck pain and neurological symptoms that enhanced when the cervical spine was flexed. Closed reduction was conducted while the patient was awake; nevertheless, sedation was needed in three cases. Among the 24 patients whose pretreatment paralysis had been characterized by American Spinal Injury Association Impairment Scale (AIS) grades A-C, seven patients (29.2%) demonstrated an enhancement of two or more AIS grades at the last observation.

CONCLUSIONS

Our closed reduction approach safely repaired traumatic cervical spine dislocations.

Reduction of Lower Cervical Facet Dislocation: A Review of All Techniques

Objective: The surgical treatment of lower cervical facet dislocation is controversial. Great advancements on reduction techniques for lower cervical facet dislocation have been made in the past decades. However, there is no article reviewing all the reduction techniques yet. The aim is to review the evolution and advancements of the reduction techniques for lower cervical facet dislocation.Methods: The application of all reduction techniques for lower cervical facet dislocation, including closed reduction, anterior-only, posterior-only, and combined approach reduction, is reviewed and discussed. Recent advancements on the novel techniques of reduction are also described. The principles of various techniques for reduction of cervical facet dislocation are described in detail.Results: All reduction techniques are useful. The anterior-only surgical approach appears to be the most popular approach. Moreover, many novel or modified reduction and fixation methods have been introduced in recent years.Conclusion: The selection of surgical approach depends on a combination of factors, including surgeon preference, patient factors, injury morphology, and inherent advantages and disadvantages of any given approach.

Efficacy, Safety, and Reliability of the Single Anterior Approach for Subaxial Cervical Spine Dislocation

Background Though there is ongoing controversy regarding the best treatment option for cervical spine dislocation (CSD), anterior cervical surgery with direct decompression is becoming widely accepted. However, managing all cases of subaxial CSD entirely by a single anterior approach is rarely seen in the published literature. Methods The study comprised patients with subaxial CSD who underwent surgical stabilization utilizing a single anterior approach. Most of the CSD was reduced and anterior cervical discectomy and fusion (ACDF) were performed. Anterior cervical corpectomy and fusion (ACCF) were done in unreduced dislocations. The patient's neurological condition, radiological findings, and functional outcomes were assessed. SPSS version 25.0 (IBM Corp., Armonk, NY) was used for statistical analysis. Results The total number of operated cases was 64, with an average of 42 months of follow-up. The mean age was 34.50±11.92 years. The most prevalent level of injury was C5/C6 (57.7%). Reduction was achieved in 92.2% of cases; only 7.8% of patients needed corpectomy. The typical operative time was 84.25±9.55 minutes, with an average blood loss of 112.12±25.27 ml. All cases except complete spinal cord injury (CSI) were improved neurologically (87.63%). The mean Neck Disability Index (NDI) was 11.14±11.43, and the pre-operative mean visual analog score (VAS) was finally improved to 2.05±0.98 (P<0.05). In all cases, fusion was achieved. The most common complication was transient dysphagia (23.4%). After surgery, no patient developed or aggravated a neurological impairment. Implant failure was not observed at the final follow-up except for two cases where screws were pulled out partially. Conclusion Based on the results of this study, a single anterior approach is a safe and effective procedure for subaxial CSD treatment with favorable radiological, neurological, and functional outcomes.

Sub-Axial Cervical Facet Dislocation: A Review of Current Concepts

Cervical facet dislocation is a serious injury that carries risks of short- and long-term morbidity. The optimal management of these injuries remains controversial with the ongoing debate regarding indications and requirements for closed reduction, timing, type of surgical approach and method of fixation. This review gives an update on the relevant anatomy, classification systems for sub-axial cervical facet dislocation and an overview of the current concepts regarding their management, including surgical approaches and the choice of implants.

An Experimental Study on the Safety and Mechanism of Reduction of Subaxial Cervical Facet Dislocation Using Z-Shape Elevating-Pulling Reduction Technique

OBJECTIVE

We sought to clarify the safety and unlocking mechanism of the Z-shape elevating-pulling closed reduction (ZR) technique and to analyze the differences in facet contact force and intraspinal pressure during subaxial facet dislocation reduction using the ZR technique and traditional skull traction closed reduction (SR).

METHODS

In 15 human cadaveric skull-neck-thorax specimens, reproducible unilateral and bilateral facet dislocations (UFDs/BFDs) were created at the C5-C6 level and then reduced by applying the ZR and SR techniques, respectively. Tekscan FlexiForce A-201 pressure sensors were used to measure the anterior and posterior intraspinal pressure and injured facet contact force under physiological conditions and before and after reduction. The maximum pressures during the reduction process were recorded.

RESULTS

After creation of the facet dislocation, the anterior and posterior intraspinal pressure and facet contact force were significantly increased relative to normal (P < 0.001). The UFDs and BFDs of all specimens were successfully reduced by both ZR and SR, and the intraspinal pressure and facet contact force were significantly reduced compared with before reduction (P < 0.001). Compared with SR, the maximum posterior intraspinal pressure during BFD reduction (P = 0.027) and the maximum facet contact force during UFD reduction (P < 0.001) were lower when ZR was used for closed reduction.

CONCLUSIONS

Our findings suggest that ZR and SR can both be used to reduce subaxial facet dislocation and decompress the spinal cord. However, the ZR technique appears to safer and more effective than the SR technique for closed reduction of subaxial facet dislocations.

Is Anterior-Only Fixation Adequate for Three-Column Injuries of the Cervical Spine?

Study Design

Retrospective case series.

Purpose

To analyze the clinical and functional outcomes of patients who have undergone anterior cervical discectomy/corpectomy and fusion (ACDF/ACCF) for a three-column cervical spine injury (CSI).

Overview of Literature

The treatment of choice for a three-column CSI is an area of contention; however, combined anterior and posterior fixation is the preferred method explored in the literature. Studies have shown the superior biomechanical stability of posterior fixation over that of anterior fixation, but anterior-only approach in CSI has been proving its efficacy in recent times by providing reasonable stability with the maximum achievable decompression and fusion.

Methods

Twenty-one patients undergoing ACDF/ACCF with a bone graft/metallic cage treatment for cervical injuries involving all three columns from January 2016 to July 2018 were included in the study. All of the patients were followed up monthly for the first 3 months and then every 6 months, until their last follow-up visit.

Results

Nineteen patients had AO type C injuries and were managed with ACDF, and two patients with AO type B injuries were managed with ACCF. Fifteen had a complete spinal cord injury, while six had an incomplete spinal cord injury (American Spinal Injury Association B, C, and D). The mean segmental kyphosis at presentation of 12.2°±4.4° improved in the postoperative period to -7.2°±2.5°. At their final follow-up, all the patients showed clinical improvements when assessed by the Visual Analog Scale (6.8–1.8), Oswestry Disability Index score (59.7–34.9), and Spinal Cord Independence Measure score (24.8–36.4). One patient in the ACDF group needed a secondary posterior fixation because of instability.

Conclusions

An anterior approach to the cervical spine in cervical fracture dislocations is an effective treatment showing an optimal recovery rate in terms of patient-reported outcomes and structural stability, with the added advantages of less blood loss and the fact that the technique requires less instrumentation.

Anterior Approach Following Intraoperative Reduction for Cervical Facet Fracture and Dislocation

OBJECTIVE

The purpose of this study was to evaluate the efficacy of the anterior approach following intraoperative reduction under general anesthesia in patients with cervical facet fracture and dislocation.

METHODS

Twenty-three patients with single level cervical facet fracture and dislocation who were subjected to the anterior approach alone following immediate intraoperative reduction under general anesthesia from March 2013 to December 2017 were enrolled in this study. Neurological status, clinical outcome, and radiological studies were evaluated preoperatively, postoperatively, and during the follow-up period.

RESULTS

The cohort comprised 15 men and eight women with a mean age of 57 years (from 24 to 81). All patients were operated on within the first 8 hours following the injury. After gentle manual reduction or closed reduction with Gardner-Wells traction, under general anesthesia monitored by somatosensory-evoked potentials, all operations were successfully completed using the anterior approach alone except in two patients, who had a risk of over-distraction. In them, a satisfactory gentle manual reduction or closed reduction was not possible, and required open posterior reduction of the locked facets followed by anterior cervical discectomy and fusion. In one patient, screw retropulsion was observed in 1 month after surgery. There were no reduction-related complications or neurological aggravations after surgery. All patients showed evidence of stability at the instrumented level at the final follow-up (mean follow-up, 12 months).

CONCLUSION

Anterior approach following intraoperative reduction monitored by somatosensory-evoked potentials under general anesthesia for cervical dislocation and locked facets is a relatively safe and effective alternative when cervical alignment is achieved by intraoperative reduction.

Immediate anterior open reduction and plate fixation in the management of lower cervical dislocation with facet interlocking

Lower cervical dislocation with facet interlocking is one of the most drastic injuries to the cervical spine. The early reduction is thought critical in preventing progressive secondary spinal cord injury. The authors report a new surgical procedure in the management of lower cervical dislocation with facet interlocking. A total of twenty-one cases received immediate single-staged anterior open reduction, realignment and plate fixation under general anesthesia. After the procedures, most cases exhibited improved neurological function. All patients showed stable fusion at 1-year follow-up. Loss of spinal alignment or kyphotic deformity was not found in any case. Hardware failure including screw loosening or penetrating was not observed. In conclusion, the immediate anterior open reduction and plate fixation is a safe and effective procedure in the management of lower cervical dislocation with facet interlocking.

The role of pre-reduction MRI in the management of complex cervical spine fracture-dislocations: an ongoing controversy?

Background

Cervical spine fracture-dislocations in neurologically intact patients represent a surgical challenge due to the risk of inflicting iatrogenic spinal cord compression by closed reduction maneuvers. The use of MRI for early advanced imaging in these injuries remains controversially debated.

Case presentation

A 54-year old man sustained a fall over the handlebars of his racing bicycle. The helmeted patient sustained a fall on his head which resulted in a hyperflexion injury of the neck. He was neurologically intact on presentation. Initial CT imaging revealed a complex multisegmental cervical spine injury with a left-sided C6/C7 perched facet, a right sided C7/T1 fracture-dislocation, and a right-sided C6 and C7 traumatic laminotomy. The initial management consisted of temporary external Halo fixator application without closed reduction maneuver, to mitigate the risk of a delayed spinal cord injury. Subsequent advanced imaging by MRI revealed an acute traumatic C7/T1 disc herniation, with the intervertebral disc completely extruded into the spinal canal. Definitive surgical management was then accomplished by employing a three-stage anterior-posterior-anterior spinal decompression, realignment, fixation and fusion C4-T2 in one operative session. The patient recovered well and retained full neurological function. He resumed bicycle street racing within 10 months of the injury following successful spinal reconstruction.

Conclusions

The diagnostic evaluation of cervical fracture-dislocations should include advanced imaging by MRI in order to fully understand the injury pattern prior to proceeding with spinal reduction maneuvers which may impose the imminent threat of a devastating iatrogenic injury to the spinal cord. The presented staged management by initial Halo fixation without attempts for spinal reduction, followed by a surgical decompression and multilevel fusion, appears to represent a feasible and safe strategy for patients at risk of a delayed neurological injury.

Management of Sub-axial Cervical Spine Injuries

Sub-axial cervical spine injuries are commonly seen in patients with blunt trauma. They may be associated with spinal cord injury resulting in tetraplegia and severe permanent disability. Immobilization of the neck, maintenance of blood pressure and oxygenation, rapid clinical and radiological assessment of all injuries, and realignment of the spinal column are the key steps in the emergency management of these injuries. The role of intravenous methylprednisolone administration in acute spinal cord injuries remains controversial. The definitive management of these injuries is based upon recognition of the fracture pattern, assessment of the degree of instability, the presence or absence of neurologic deficit, and other patient related factors that may influence the outcome. Nonoperative treatment comprises of some form of external immobilization for 8 to 12 weeks, followed by imaging to assess fracture healing, and to rule out instability. The goals of surgery are realignment of the vertebral column, decompression of the neural elements and instrumented stabilization.

Dorsal open reduction with pedicle screw rod internal fixation for lower cervical spine dislocation: A retrospective analysis of 12 cases

BACKGROUND

Lower cervical spine dislocation remains a surgical challenge.

METHODS

Twelve patients with lower cervical dislocation due to articular process injury underwent dorsal open reduction and manual pedicle screw rod fixation. Patients with cervical spinal cord injury received simultaneous open door expansive laminoplasty. Neurological function was evaluated using ASIA Impairment Scale 12.

RESULTS

Median time from injury to operation was 10 days (range, 5 to 52 days). Anatomic reduction was achieved in all patients. In nine patients with cervical spinal cord injury, 55.5% (5/9) showed improvement in ASIA grade following surgery. Unilateral numbness of the superior radicular area in one patient resolved 2 weeks post-surgery and two cases (11.1%, 2/9) had postoperative leakage of the cerebrospinal fluid, which resolved in 11 days and 13 days, respectively.

CONCLUSION

Dorsal open reduction and manual pedicle screw rod fixation is safe and effective for lower cervical spine dislocation due to articular process injury.

Immediate reduction under general anesthesia and single-staged anteroposterior spinal reconstruction for fracture-dislocation of lower cervical spine

Fracture-dislocation of the lower cervical spine is a severe traumatic lesion, most frequently resulting in tetraplegia. Treatment is usually painful and time consuming. This retrospective study evaluated the clinical curative effect of immediate reduction under general anesthesia and single-staged anteroposterior spinal reconstruction for fracture-dislocation of the lower cervical spine. Twelve cases of traumatic lower cervical spinal fracture-dislocation were retrospectively analyzed from January 2006 to December 2011. The injury level was C4/C5 in 4, C5/C6 in 5, and C6/C7 in 3 patients. The spinal cord function grades according to the American Spinal Injury Association impairment scale (2000 edition amended) before operation were as follows: grade A in 2 cases, grade B in 2 cases, grade C in 5 cases, grade D in 2 cases, and grade E in 1 case. On admission, all patients underwent immediate reduction under general anesthesia and single-staged anteroposterior spinal reconstruction by circumferential fixation/fusion. The spinal cord function grades according to American Spinal Injury Association after operation were as follows: grade A in 1 case, grade B in 1 case, grade C in 3 cases, grade D in 3 cases, and grade E in 4 cases. All 12 patients showed evidence of stability at the instrumented level on the final follow-up examination (mean follow-up, 3.7 y). Immediate reduction under general anesthesia followed by a single-stage combined anteroposterior spinal reconstruction is a safe and reliable way of treating patients with lower cervical spine fracture-dislocations.

Treatment of traumatic spondylolisthesis of the lower cervical spine with concomitant bilateral facet dislocations: risk of respiratory deterioration

BACKGROUND

This study aimed to retrospectively examine 36 cases of bilateral cervical facet dislocations (BCFD) of the lower cervical spine who were at risk for respiratory deterioration.

METHODS

The cases of 36 subjects with BCFD of the lower cervical spine who failed to achieve closed reduction were retrospectively studied. The extents of neurological injuries included posterior neck pain without neurological deficit (n=2), incomplete spinal cord injury (ISCI) (n=21), and complete spinal cord injury (CSCI) (n=13).

RESULTS

Among the subjects, 26 (72.22%) had dyspnea, 6 required mechanical ventilation due to respiratory muscle paralysis, 11 required tracheostomy, and 9 required intubation. All patients received posterior approach reduction, stabilization, and fusion treatment for BCFD in one operative session. For the 26 quadriparetic patients with dyspnea, priority was given to treating their respiratory problems. For the other 10 patients without dyspnea, surgical treatment for irreducible lower cervical spine dislocation was given priority. After an average follow-up period of 63 months, 21 complications were found, but all patients exhibited fusion. Twenty-one patients with ISCI exhibited improvements in their conditions of 1 or 2 grades on the American Spinal Injury Association scale, whereas those with CSCI did not improve. All 26 apnea cases improved. The majority (26) of the 36 cases with BCFD of the lower cervical spine suffered dyspnea.

CONCLUSIONS

Although further study is required, our study suggests that the posterior surgical approach to the cervical spine is safe and effective for patients with traumatic spondylolisthesis of the lower cervical spine concomitant with BCFD who are at risk of respiratory deterioration.

Novel reduction technique for thoracolumbar fracture-dislocations

Thoracolumbar fracture-dislocations are devastating injuries. They usually require surgical reduction and stabilization. The authors present a novel technique for reducing these injuries that is predictable and reproducible.

Controversies in the treatment of cervical spine dislocations

BACKGROUND CONTEXT

Cervical spine dislocations represent an area of great controversy among spine surgeons.

PURPOSE

The purpose of this review is to present the specific areas of controversy and to provide a review of the literature.

STUDY DESIGN

A case of cervical spine dislocation is presented to illustrate the major controversies related to the treatment of cervical spine dislocations.

METHODS

A review of the literature is presented regarding the major controversial aspects of the treatment of cervical spine dislocations.

RESULTS

The major areas of controversy include the choice of imaging, closed versus open reduction and surgical approach.

CONCLUSIONS

Guidelines for the management of cervical spine dislocations are presented based on evidence-based medicine.

The management of bilateral interfacetal dislocation with anterior fixation in cervical spine : comparison with combined antero-posterior fixation

OBJECTIVE

Combined antero-posterior fixation has been a standard method for bilateral interfacetal dislocation in cervical spine. The purpose of this study is to evaluate the efficacy and complication of anterior cervical stabilization in treatment of bilateral interfacetal dislocation.

METHODS

A total of 65 cases of traumatic bilateral interfacetal dislocation in cervical spine who were managed in our institution, from Mar. 1997 to Feb. 2006, were included in this study. Closed reduction was tried in all cases before operation. If closed reduction was accomplished successfully, only anterior cervical fixation was performed (Group I), and attempted to place screws bicortically as possible with unicortical screws. If failed, posterior open reduction with fixation was first tried, followed by anterior cervical fixation (Group II). All patients were evaluated for neurological outcome and radiological evidence of healing.

RESULTS

The Group I included 47 patients and the Group II, 18 patients. The improvement of Frankel grade and increase of mean cervical lordosis angles were not statistically different between two groups. Screw-plate system used did not influence the outcome. On follow up, solid bone fusion was evident and there were no cases of instability in both groups.

CONCLUSION

Our study demonstrated that anterior cervical fixation on BID is safe and effective in comparison with combined antero-posterior cervical fixation.

[Reduction of traumatic dislocations and facet fracture-dislocations in the lower cervical spine]

BACKGROUND

Traumatic facet dislocations and facet-fracture dislocations in the lower cervical spine (C2/C3 to C7/T1) are frequently associated with devastating neurological symptoms. A good outcome can only be achieved if the operator has wide and sound knowledge of reduction techniques and the best possible strategy is devised for the subsequent treatment of these severe lesions.

PATIENTS AND METHODS

Between 1973 and 1997 a total of 117 of our patients met at least one of the following inclusion criteria: unilateral locked facet dislocation (48%), bilateral locked facet dislocations (23%), unilateral "perched" facet subluxation (14%), bilateral perched facet subluxation (12%), uni- or bilateral dislocation/perched subluxation with facet fractures (3%).

RESULTS

Most of the lesions were located at the levels of C5/C6 and C6/7 (n=46 for each). Associated neurological deficits were present initially in 65% of patients: 35% had complete or incomplete spinal cord injuries (tetraplegia), 2% were paraplegic, and 28% had cervical radiculopathies.

CONCLUSIONS

Closed reduction (e.g. with the aid of a halo ring) should be carried out as soon as possible after lower cervical spine dislocation or facet-fracture dislocation, as both the success rate of reduction and the potential for recovery from neurological deficits are clearly higher when reduction is achieved within the first 4 h after the initial injury.

Delayed surgical management of a traumatic bilateral cervical facet dislocation by an anterior–posterior–anterior approach

Delayed diagnosis (more than one month after injury) of a bilateral cervical facet dislocation is exceptional, and delayed treatment is different from treatment in the acute stage. We describe a neurologically intact 51-year-old patient, in whom the diagnosis of bilateral cervical facet dislocation at C5/6 was made 10 weeks after the trauma. An anterior-posterior-anterior approach was performed, with repositioning during the posterior approach, and with anterior and posterior C5/6 fixation. The patient remained neurologically intact, and radiographic fusion was observed 3, 6, and 12 months postoperatively. Additionally, the (English) literature is reviewed and discussed.

A historical hypothesis of the first recorded neurosurgical operation: Isis, Osiris, Thoth, and the origin of the djed cross

✓A new textual analysis of the central religious aspect of the ancient Egyptian creation myth reveals what appears to be a description of the oldest recorded neurosurgical operation, occurring circa 3000 BC. The analysis results in a hypothesis suggesting that traction reduction was used successfully to reverse a paralyzing cervical spine injury of an early Egyptian leader (Osiris), which inspired the story of his resurrection. The Egyptian mother god Isis, working with the god Thoth (the inventor of medicine), resurrects Osiris by treating his damaged cervical spine. Numerous references in the Papyrus of Ani (Book of the Dead) to Osiris regaining the strength and control of his legs are linked textually to the treatment of his spine. The connection between the intact spine and the ability to rise and stand is used as a distinct metaphor for life and death by the spinal representation of the “djed column” painted on the back of the numerous Egyptian sarcophagi for thousands of years. Controversy over the translation of the vertebral references in Egyptian texts is clarified by considering the specific neurosurgical meanings of hieroglyphs appearing in both the Edwin Smith medical papyrus and in the Papyrus of Ani, and in light of recent scholarly reassessments of those hieroglyphs in the Egyptological literature.

Complication avoidance: thoracolumbar and lumbar burst fractures

Most thoracolumbar and lumbar burst fractures can be treated conservatively. Unstable fractures or fractures resulting in neurologic deficits usually require surgical treatment. Choosing an appropriate surgical approach requires a thorough understanding of the various techniques for decompression, fusion, and stabilization. Surgical options include an anterior approach, a posterior approach, or a combined anteroposterior approach. Each surgical option has unique advantages and disadvantages. Generally, the anterior approaches are best used at the thoracolumbar junction, posterior approaches are ideal for low lumbar injuries and lumbar injuries that result in complete spinal cord injuries,and anteroposterior surgeries typically are reserved for highly unstable fracture subluxations. Case illustrations show the various treatment options.

Anterior reduction for cervical spine dislocation

STUDY DESIGN

Retrospective analysis of a prospectively followed cohort.

OBJECTIVE

Long-term evaluation of patients with anterior stabilization for dislocations of the cervical spine.

SETTING

Level 1 trauma center.

SUMMARY OF BACKGROUND DATA

Anterior stabilization of unstable cervical spine injuries is gaining popularity. However, the method of open reduction is controversial.

METHODS

Forty-one consecutive patients with unstable dislocations/subluxations of the subaxial cervical spine were included. Closed reduction was attempted in all patients using Gardner-Wells traction. If this failed, an anterior open reduction was performed. Tricortical iliac crest autograft and anterior plating was used. Patients were assessed for: 1) rate of successful reduction and stabilization using only the anterior surgical approach; and 2) complications and long-term clinical and radiologic outcome.

RESULTS

Two of eight (25%) anterior open reductions failed requiring posterior surgery. One of these patients had associated pedicle fractures with horizontal rotation of the lateral masses. All grafts had healed successfully at the most recent follow-up visit. Moderate neck discomfort was found in 5 of 41 patients. Significant neurologic improvement was observed.

CONCLUSIONS

Most subluxations/dislocations of the subaxial cervical spine can be reduced using Gardner-Wells traction and successfully stabilized with anterior surgery alone. If closed reduction fails, anterior open reduction is successful in the majority of cases.

Analysis of patient variables affecting neurologic outcome after traumatic cervical facet dislocation

BACKGROUND CONTEXT

Traumatic cervical facet dislocation accounts for a disproportionate rate of neurologic disability. The relative importance of patient and management variables, including the timing of spinal reduction, in ultimate neurologic outcome has not been well defined.

PURPOSE

To analyze data from a cohort of patients sustaining traumatic cervical facet dislocation to determine the relative importance of several patient and management variables in neurologic recovery after injury.

STUDY DESIGN/SETTING

A retrospective study was conducted at a major referral center for spinal-cord-injured patients.

PATIENT SAMPLE

Forty-five patients sustaining traumatic cervical facet dislocation.

OUTCOME MEASURES

Using improvement in American Spinal Injury Association (ASIA) motor score as the primary outcome measure, patient data were used to construct a statistical model allowing the analysis of several clinically relevant variables.

METHODS

The records of patients sustaining a traumatic cervical facet dislocation over a 5-year period were reviewed. Clinical data were collected for all patients with adequate follow-up. The data were used to construct a statistical model designed to analyze the contribution of the variables age, gender, time to reduction of the spine and initial motor score to neurologic improvement (the outcome measure). In addition, the effect of variable interaction was studied.

RESULTS

Most patients demonstrated neurologic improvement over the course of follow-up after cervical facet dislocation. For this data set, the variables age and initial motor score were significantly associated with neurologic improvement. However, time to reduction of the spine did not demonstrate a significant independent relationship to neurologic outcome. No significant interaction was found between patient age or gender and the time to reduction with regard to predicting neurologic recovery.

CONCLUSION

The present study uses a statistical model to determine the relative importance of clinically relevant variables for a population of patients after traumatic cervical facet dislocation. This model confirms the clinical impression that younger patients with lesser degrees of neurologic injury tend to achieve the best neurologic recovery after a traumatic facet dislocation. Although a strong benefit from earlier spinal column reduction did not emerge from the present data set, additional study is needed to define those patients who would benefit from immediate reduction of the spinal column.

Delayed management of traumatic bilateral cervical facet dislocation: surgical strategy. Report of three cases

Postinjury cervical spine instability typically requires surgical treatment in the acute or semiacute stage. The authors, however, report on three patients with older (> 8 weeks) untreated bilateral cervical facet dislocation. In two patients they attempted a classic anterior-posterior-anterior approach but failed. The misalignment in the second stage of the procedure could not be corrected, and they had to add a fourth, posterior, stage. To avoid the fourth stage, thereby reducing operating time and risk of neurological damage while turning the patient, they propose the following sequence: 1) a posterior approach to perform a complete facetectomy bilaterally with no attempt to reduce the dislocation; 2) an anterior microscopic discectomy with reduction of the dislocation and anterior fixation; and 3) posterior fixation. This sequence of procedures was successfully performed in the third patient. Based on this experience, they suggest that in cases of nonacute bilateral cervical facet dislocations the operating sequence should be posterior-anterior-posterior.

Initial closed reduction of cervical spine fracture-dislocation injuries

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines. Early closed reduction of cervical spine fracture-dislocation injuries with craniocervical traction is recommended to restore anatomic alignment of the cervical spine in awake patients. Closed reduction in patients with an additional rostral injury is not recommended. Patients with cervical spine fracture-dislocation injuries who cannot be examined during attempted closed reduction, or before open posterior reduction, should undergo magnetic resonance imaging (MRI) before attempted reduction. The presence of a significant disc herniation in this setting is a relative indication for a ventral decompression before reduction. MRI study of patients who fail attempts at closed reduction is recommended. Prereduction MRI performed in patients with cervical fracture dislocation injury will demonstrate disrupted or herniated intervertebral discs in one-third to one-half of patients with facet subluxation. These findings do not seem to significantly influence outcome after closed reduction in awake patients; therefore, the usefulness of prereduction MRI in this circumstance is uncertain.