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

image The pins are angled upward slightly and simultaneously tightened until the spring-loaded force indicator (found on one of the two pins) protrudes 1 mm above the flat surface of the pinhead (Figure 1-4).

image

FIGURE 1-4

Step 1 Pearls

• Standing at the head of the bed during tong placement facilitates symmetric positioning of the tongs.

Step 1 Pitfalls

• Overtightening can result in penetration of the inner table of the calvarium, leading to cerebral abscess or hemorrhage.

• Check for all proper components before starting the procedure. Occasionally, the spring-loaded pin may be missing from the set!

Equipment

• MRI-compatible graphite tongs and titanium pins have lower failure loads because of deformation. Stainless steel tongs are therefore recommended if greater than 50 lb of traction are anticipated.

Step 2

image An initial weight of 10 lb is applied.

image The neurologic examination is repeated and a lateral radiograph is taken.

Step 2 Pearls

• Small doses of intravenous diazepam can be administered to aid in muscle relaxation. The patient should, however, be kept awake and conversive throughout.

Step 2 Pitfalls

• A small amount of weight (10 lb) is used initially to avoid overdistraction of unstable injury patterns, such as occult instability at the occipital-cervical junction.

Step 3

image Weights are increased at 5- to 10-lb increments at intervals of 20 to 30 minutes to overcome muscle spasm and to obtain a soft tissue creep effect.

image Serial neurologic examinations and radiographs are obtained after each increase in weight.

Step 3 Pearls

• To reduce a facet dislocation that is not associated with a fracture, a flexion moment helps unlock the dislocated facet(s) (Figures 1-5 and 1-6).

• This can be achieved by posteriorly placed pins or by raising the height of the pulley.

image

FIGURE 1-5

image

FIGURE 1-6

Step 3 Pitfalls

• If overdistraction or neurologic deterioration occurs, the weights should be immediately removed.

Equipment

• In general, the amount of weight required depends on the level of the injury (5 kg per level).

• More weight is generally required to reduce a unilateral facet dislocation than a bilateral facet dislocation.

Controversies

• Some authors have recommended weight limits of 66 to 70 lb. Other authors have reported use of up to 140 lb.

Step 4: Reduction of Unilateral Facet Dislocation

image Manipulation may assist in the final reduction of dislocated facets.

image An axial load is applied to the normal facet while the head is rotated 30 to 40 degrees past midline in the direction of the dislocated facet (Figure 1-7).

image Stop the reduction once resistance is felt, and verify the reduction radiographically.

image

FIGURE 1-7

Step 4 Pearls

• Facets should be distracted to a perched position before attempting manipulative reduction.

Step 5: Reduction of Bilateral Facet Dislocation

image An anteriorly directed force is applied just caudal to the level of the dislocation, which is usually palpable as a stepoff in the spinous processes (Figure 1-8).

image The head is rotated 30 to 40 degrees beyond midline toward one side, then the maneuver is repeated toward the opposite side if successful.

image

FIGURE 1-8

Step 5 Pearls

• Facets should be distracted to a perched position before attempting manipulative reduction.

Step 5 Pitfalls

• An irreducible bilateral facet dislocation is unstable and should be treated with urgent open reduction (after MRI evaluation is performed).

Postoperative Care and Expected Outcomes

image After reduction is achieved, traction weight typically can be reduced to about 10 to 20 lb.

image After removal of the tongs, the pin sites should be cleaned with a saline-soaked gauze. In rare cases where significant bleeding is encountered, stapling the pin site can achieve hemostasis.

Postoperative Pearls

• A Rota-Rest bed can be useful at this stage, while the patient awaits definitive treatment.

Postoperative Pitfalls

• Tongs should be retightened 24 hours after initial application until the indicator again protrudes 1 mm from the flat surface of the pinhead.

Evidence

Cotler HB, Miller LS, DeLucia FA, Cotler JM, Davne SH. Closed reduction of cervical spine dislocations. Clin Orthop Rel Res. 1987;214:185-199.

A cadaver study was performed to delineate the anatomy of pin placement, in addition to a review of 24 patients with cervical facet dislocations treated with closed reduction and traction. Ninety percent of patients improved at least one Frankel grade, and 71% were treated successfully with closed reduction.

Cotler JM, Herbison GJ, Nasuti JF, et al. Closed reduction of traumatic cervical spine dislocation using traction weights to 140 pounds. Spine. 1993;18:386-390.

This review of 24 cases demonstrates that traction weights of up to 140 lb can be used safely in the reduction of facet dislocations without associated fractures. Seventeen patients in this series required more than 50 lb for successful reduction, with total time to successful reduction ranging from 8 to 187 minutes. None of the patients had worsening neurologic status during or after the procedure.

Grauer JN, Vaccaro AR, Lee JY, et al. The timing and influence of MRI on the management of patients with cervical facet dislocations remains highly variable: a survey of members of the Spine Trauma Study Group. J Spinal Disord Tech. 2009;22:96-99.

Questionnaire study presented to 25 fellowship-trained spine surgeons. Substantial variability in the timing and utilization of magnetic resonance imaging (MRI) and closed reduction techniques for patients with cervical facet dislocations was demonstrated. Neurosurgeons were significantly more likely than orthopedic surgeons to order an MRI before open or closed treatment.

Hadley MN. Initial closed reduction of cervical spine fracture-dislocation injuries. Neurosurgery. 2002;50:S44-S50.

Qualitative review of English language citations until 2001 found insufficient evidence to support formal treatment standards or guidelines on initial closed reduction of cervical fracture dislocations. Patients who cannot be examined during attempted closed reduction or open reduction by posterior approach should undergo MRI before the procedure.

Littleton K, Curcin A, Novak V, Belkoff S. Insertion force measurement of cervical traction tongs: a biomechanical study. J Orthop Trauma. 2000;14:505-508.

Biomechanical study on cadaver specimens that demonstrated that overtightening of pins can result in substantial increases in force exceeding that needed to penetrate the skull. In addition, the possible complications of tong placement are discussed.

Vaccaro AR, Falatyn SP, Flanders AE, et al. Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine. 1998;24:1210-1217.

Prospective study utilizing MRI to evaluate the incidence of intervertebral disk herniations and ligamentous injuries before and after closed traction reduction of facet dislocations. Of 11 patients in the study, nine had successful closed reduction, two had disk herniations on pretraction MRI, and five had disk herniations on post-traction MRI. None of the patients who sustained disk herniations during the reduction developed neurologic deficits.

Vital J, Gille O, Sénégas J, Pointillart V. Reduction technique for uniarticular and biarticular dislocations of the lower cervical spine. Spine. 1998;23:949-954.

This is a review of 168 consecutive cases of lower cervical facet dislocations treated with gradual traction, followed by closed reduction under anesthesia and, finally, open reduction when necessary. Fifty-nine percent of unilateral dislocations and 73% of bilateral dislocations were treated successfully with closed reduction techniques or traction alone.

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