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

CT Scan in Subaxial Cervical Facet Injury: Is It Enough for Decision-Making?

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture.

METHODS

A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures.

RESULTS

There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%.

CONCLUSIONS

Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.

Fracture Dislocation at the Level of C6-C7: A Case Report and Literature Review

Fractures of the cervical spine can cause devastating long-term effects on patients. Spinal cord injuries can occur in up to 50% of cases in association with cervical spine fractures. Therefore, it is vital and of utmost importance to recognize cervical spine injuries early on to avoid the exacerbation of an existing injury and its detrimental effects on the patients. We report a case of a C6-C7 fracture dislocation with an associated neurological insult that improved dramatically following fixation and rehabilitation. Unfortunately, patients with this presentation may have long-term neurological insults rather than regain normal function; however, our case notes the importance of prompt intervention and its effect on the outcome.

Effectiveness of different surgical methods in the treatment of acute central cord syndrome without fractures and dislocations of the cervical spine

BACKGROUND

Acute central cord syndrome (ACCS) without fractures or dislocations is the most common form of incomplete spinal cord injury.

OBJECTIVE

To evaluate the effectiveness of different surgical methods in the treatment of acute central cord syndrome without fractures or dislocations of the cervical spine.

METHODS

A total of 164 patients with ACCS without fracture or dislocation of the cervical spine treated in our hospital from May 2012 to October 2019 were recruited and assigned to study group A and study group B according to different treatment modalities, with 82 cases in each group. Study group A underwent anterior cervical discectomy and fusion, and study group B was treated with posterior cervical laminectomy. The American Spinal Injury Association (ASIA) classification and motor scores of all cases at admission and at discharge were recorded, and the treatment outcomes of the two groups were compared.

RESULTS

No significant differences were found in the ASIA classification and ASIA motor scores between the two groups at admission (P> 0.05). One year after surgery, the ASIA motor scores and sensory scores were not statistically significant between the two groups (P> 0.05) but showed significant improvement compared to the preoperative scores (P< 0.05).

CONCLUSION

Both anterior cervical discectomy and fusion and posterior cervical laminectomy can improve the ASIA classification, ASIA motor scores, and sensory scores of ACCS patients without fractures or dislocations of the cervical spine. Therefore, surgical methods should be adopted based on the patients' conditions.

Traumatic intradural disc herniation following a cervical facet dislocation: a case report

We report a unique case of a patient who sustained an intradural disc herniation from a left C5-6 unilateral facet dislocation after a fall. This was not easily identified on pre-operative imaging. We explain the details of our surgical approach in this case report. A 65-year-old male fell into a 2 m drain and sustained a left C5/6 unilateral facet dislocation. He then sustained an American Spinal Injury Association (ASIA) B cord injury. His power was 0/5 from C8 downwards bilaterally but sensation was intact throughout. Magnetic resonance imaging (MRI) showed severe compression at C5/6 but no overt intradural disc herniation. This patient subsequently underwent a closed reduction in the operating theatre followed by a combined anterior and posterior approach for the disc herniation. Cerebral spinal fluid (CSF) leakage was noted upon completion of the C5/6 discectomy and it was discovered that there was a traumatic dural tear from the traumatic disc herniation. The decision was made not to repair the dural tear due to the friable nature of the dura and the potential for adhesive glue to propagate through the spinal cord. An anterior drain was placed for 3 days and then removed, he subsequently underwent rehabilitation and was able to regain power in the affected myotomes. Intradural disc herniations can be easily missed on MRI in the setting of cervical spinal trauma. Hence, the anterior approach is an increasingly acceptable approach to tackle disc herniations in unilateral cervical facet dislocations (CFD) surgery.

External Orthopaedic Implants in the Magnetic Resonance Environment: Current Concepts and Controversies

MRI provides diagnostic three-dimensional imaging and remains extremely important in the diagnosis and management of spinal trauma as well as other acute traumatic injuries, including those of the extremities. The American Society for Testing and Materials has created standards against which all implantable medical devices are tested to ensure safety in an MR environment. Most implantable passive orthopaedic devices can undergo MRI without consequence to the patient. However, the American Society for Testing and Materials has recently updated its terminology resulting in confusion among providers and institutions. Primary safety concerns are radiofrequency-induced heating and magnetically induced torque or displacement. These safety concerns have emerged as a recent source of debate, particularly regarding the imaging of patients with external fixation and cervical immobilization devices in place. Surveys have shown a lack of consensus among radiologists regarding this issue. Having an institutional protocol in place for the imaging of these patients streamlines the diagnosis and early stabilization of certain polytraumatized patients. The purpose of this review is to summarize the pertinent literature as well as the current industry recommendations regarding the safety of commonly used external fixation, cervical immobilization, and traction devices in the MR environment.