1: Closed Cervical Skeletal Tong Placement and Reduction Techniques

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Procedure 1 Closed Cervical Skeletal Tong Placement and Reduction Techniques

Michael J. Vives, Colin Harris

Indications

image Subaxial cervical fractures with malalignment

image Unilateral and bilateral subaxial cervical facet dislocations

image Displaced odontoid fractures, selected types of hangman’s fractures, and C1-2 rotary subluxations

Pitfalls

• Patient must be awake, alert, and cooperative.

• Coexistence of skull fractures in the areas of pin placement may contraindicate tong placement.

Controversies

• Magnetic resonance imaging (MRI) before closed reduction of dislocated facets, to exclude an associated disk herniation, is advocated by some.

• For awake, alert patients, closed reduction may be attempted without MRI. If closed reduction fails, MRI should be obtained before operative reduction under general anesthesia.

Treatment Options

• Open reduction by anterior or posterior approach

• Anterior (or combined anterior-posterior) approach is commonly recommended if MRI shows large associated disk herniation at the level of the dislocation.

Examination/Imaging

image A thorough neurologic examination should be documented before the procedure.

image High-quality imaging of the cervical spine (including visualization of the occipital-cervical and cervical-thoracic junctions) should be obtained before the reduction attempts (Figure 1-1).

image

FIGURE 1-1

Surgical Anatomy

image Correct pin placement site is 1 cm above the pinna, in line with the external auditory meatus and below the equator of the skull (Figures 1-2 and 1-3).

image The temporalis muscle and superficial temporal artery and vein are at risk if pins are placed too anterior.

image

FIGURE 1-2

image

FIGURE 1-3

Anatomy Pearls

• Posterior pin placement will apply a flexion moment to the cervical spine.

• Anterior pin placement will apply an extension moment to the cervical spine.

Anatomy Pitfalls

• Placement of the pins too superior (above the equator) increases risk of pullout.

• Placement of the pins too anterior may result in injury to the superficial temporal vessels.

Positioning

image The patient is positioned supine on the operative table, Stryker table, or Roto-Rest bed.

Positioning Pearls

• Reverse Trendelenburg position or the use of arm and leg weights can help prevent the patient from sliding to the top of the bed as weights are added.

Positioning Pitfalls

• Frequent radiographs and close monitoring are necessary during reduction attempts; thus the emergency room (trauma bay), the operating room, or an intensive care unit are preferred settings.

Portals/Exposures

• The skin is prepped with a povidone-iodine solution.

• Shaving or skin incisions are not necessary with the use of tapered Gardner-Wells pins. Hair, however, can get wrapped around the pin during insertion. Thoroughly soaking the area with the preparation solution facilitates parting long hair in the area and helps prevent this.

• Local anesthetic is used to infiltrate the skin and down to the skull periosteum.

Procedure

Step 1

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