Management of Traumatic Bilateral Jumped Cervical Facet Joints in a Patient with Complete Myelopathy

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Chapter 227 Management of Traumatic Bilateral Jumped Cervical Facet Joints in a Patient with Complete Myelopathy

Closed Traction Reduction Then Surgery

Experimental evidence in animals suggests that persistent compression of the spinal cord is a potentially reversible form of secondary injury and that earlier timing of decompression can lead to improved neurologic outcomes.13 The general conclusion is that the less severe the neurologic injury and the quicker the decompression and stabilization, the greater the chance and extent of recovery. These basic science data continue to be the foundation that supports many clinicians’ rationale for performing urgent decompression and fixation in patients with spinal cord injury (SCI). A recent systematic review of the literature failed to establish guidelines for timing of surgical decompression and fixation in the setting of SCI, owing to the lack of high-quality evidence.4 However, the authors concluded that the evidence supports guidelines for urgent closed reduction in patients with bilateral locked facets and an incomplete SCI to maximize the potential for enhanced neurologic outcome.49 While there may be no single best method of treatment for all patients with bilateral locked facets, this chapter discusses the goals of treatment and methods for reaching those goals, particularly in patients with complete SCI. Discussion is focused on early closed reduction followed by surgery. Evidence to support early closed reduction followed by surgery is presented. Traction and reduction techniques, as well as surgical treatment algorithms, are described.

Patients with complete, or grade A, American Spinal Injury Association (ASIA) SCIs are often considered to have little capacity for neurologic recovery. However, Frankel et al. reported on a cohort of over 600 patients that showed that almost 30% of the complete SCIs improved at least one grade and that the number of patients with neurologic deterioration was minimal.10 It might be more accurately stated that some patients with ASIA A injuries are likely to have neurologic recovery, the extent of which tends to be unpredictable or more limited than is the case for patients with incomplete injuries. It should also be noted that it is often difficult to be certain of the presence or absence of sacral sparing in the initial assessment of a patient because of confounding factors such as polytrauma, obtunded state, or spinal shock. Mirza et al. and others concluded that it is quite difficult to differentiate a complete and an incomplete SCI in the early postinjury time frame.8,11 Late conversion from complete to incomplete can also occur.11 Therefore, Mirza et al. recommended treating all SCIs as potentially incomplete SCIs.8

The level of SCI should always be taken into context in making decisions about the utility of treatments that may influence neurologic recovery. A patient that is classified as T1 ASIA A who regains some sensation or an extra two caudal root levels may not have much functional difference, while a patient that is classified as C4 ASIA A, if able to recover one or two motor root levels, may have a very clinically meaningful functional difference. For the patient with a C4 level injury, recovery of one or two levels may mean the difference between ventilator dependence and not or the difference between having the ability to feed one’s self and not.

Patient Assessment

In any patient standard, ATLS guidelines should be employed to initially assess patients with SCI. Airway and circulatory system management are of particular concern in cervical SCI patients but are beyond the scope of this chapter. Application of traction will require the patient to be recumbent and unable to be rapidly turned if the patient were to vomit. The authors find it useful to consider use of nasogastric suction in patients who may be at high risk of aspiration such as elderly patients, those who have recently eaten, or those who are even marginally intoxicated (to name a few). A complete neurologic exam based on the standards outlined by ASIA is one of the most important sets of criteria to accurately document in the initial patient assessment. There will invariably be confounding factors that will impose limits, such as the patient’s mental status, multiple limb injuries, or previous neurologic deficit. However, the neurologic exam remains one of the most critical components with respect to decision making in treating spine trauma.

When a fracture or dislocation is diagnosed in the cervical spine, complete imaging of the spinal axis is recommended, owing to the relatively high risk of noncontiguous fractures.12 In the radiographic assessment of the patient, particular attention should be paid to assessing fracture or potential instability cephalad to the known injury. This is especially important if the use of traction or closed manipulation is planned for reduction. CT scan has gained wide acceptance for its ability to rapidly image the bony structures of the spine with excellent detail.13 Despite a general increase in frequency of CT scan usage for diagnostic cervical trauma imaging, it is still vitally important to appreciate the subtleties of radiologic findings on plain radiographs, as these images are often important in determining the effect of closed reduction attempts or intra-operative alignment.

The use of MRI in the setting of bilateral locked facets continues to be a source of considerable debate. While the diagnostic accuracy and information provided to the treating surgeon are not in question,14 the patient selection, timing, and application of treatment algorithms are still not completely standardized. In considering application of traction for attempted closed reduction, MRI or CT myelogram have been advocated.15,16 The primary concern is that an unrecognized cervical disc herniation, in the setting of bilateral facet dislocation, may produce spinal cord compression if closed reduction is attempted.17 The case reports of neurologic deterioration after closed reduction of facet dislocation, secondary to disc herniation, tended to involve reductions that were performed under general anesthesia or were done openly during operative reduction.16,18,19 Some authors suggest that performing an MRI prior to reduction not only delays time to reduction but also puts the patient at risk of further injury during transport.17,20 Ordonez et al. found that disc herniations occurred in up to 50% of patients with facet dislocations, but fewer than 1% sustained permanent neurologic deficit following reduction.21 Potential causes of worsening neurologic condition included overdistraction, failure to appreciate more rostral injuries, epidural hematoma, and spinal cord edema. Therefore, Ordonez et al. stated that an MRI does not need to be obtained prior to reduction in the alert, examinable patient. However, they did recommend MRIs in patients who cannot be examined during reduction or in patients that fail closed reduction. Vaccaro et al. documented a higher frequency of disc herniations after closed reduction in awake, alert patients, compared to patients who had prereduction imaging. In this series, they did not show any correlation with neurologic deterioration.14 Darsaut et al. performed traction on 17 patients under MRI guidance. Four of 17 patients initially had dorsal disc displacement, and 15 had disc disruption prior to attempted closed reduction. Darsaut et al. were able to show that canal dimension improved in 11 of 17 cases and that the process of reduction under traction and improvement of canal dimensions was a gradual one.22

Neurologic Case for Rapid Closed Reduction by Means of Traction

In 1987, Brunette and Rockswold presented a report of complete neurologic recovery following C3 on C4 fracture dislocation.23 Upon initial presentation, the patient was awake and alert and had slight difficulty breathing. He was initially able to flicker his left foot but was otherwise flaccid in both upper and lower extremities, had no sensation distal to the C4 distribution, and had absent rectal tone. The patient had gentle traction and immobilization applied on the scene by paramedics. Thirty minutes after the injury, the patient was no longer able to flicker his left foot.

Upon arrival at the hospital, approximately 90 minutes after injury, reduction was achieved by progressive cervical traction. The patient had gradual improvement in his neurologic exam over the next 24 hours and was placed in a halo. By discharge to rehabilitation, he had almost complete neurologic recovery. The patient did not tolerate the halo well and underwent a dorsal fusion 2 weeks after the injury. At the 8-month follow-up, he was completely neurologically intact. The authors point to the appropriate initial recognition of the injury and the rapid reduction of the dislocation as the reason for the patient’s remarkable recovery. They use this case to recommend emergent reduction of fracture-dislocations of the spine.

Although these results are quite impressive, two factors must be considered. This patient did not have a complete cord injury at initial presentation, as is evident by the ability to flicker his left foot. Also, the patient underwent decompression and stabilization by traction extremely quickly at 90 minutes. Of note, traction was not delayed for a prereduction MRI, as the patient was alert and capable of reporting neurologic changes during traction. For a multitude of reasons, it is rarely possible to reduce patients so quickly; however, this study suggests that emergent traction management, when possible, may lead to improved neurologic recovery. In 1994, Lee et al. evaluated two mechanisms of closed reduction of facet dislocations in addition to the significance of time to reduction.24 They performed a retrospective review of 210 patients with either unilateral or bilateral facet dislocations. None of the patients received MRIs prior to reduction. Ninety-one patients underwent manipulation under anesthesia (MUA), while 119 underwent rapid traction, 5 pounds every 1 to 2 minutes up to 20 pounds followed by 10-pound increments up to 150 pounds until reduction was achieved, at which point the weight was reduced to 5 pounds. The average patient with bilateral facet dislocations was reduced at 81 pounds. MRI-compatible tongs bend and lose fixation at weights above 55 pounds; therefore, reductions requiring more than 55 pounds require consideration of four pins, halo, or double tongs. This study evaluated the timing of reduction via traction. Reduction within 12 hours led to improved Frankel grades (26%) as compared to reduction delayed more than 12 hours (8%). However, it is important to note that neurologic improvement was observed in both the immediate and delayed-reduction groups. Time to reduction did not affect neurologic recovery in the MUA group. Of failures of reduction in the traction group, 14 (12%) were related to associated fractures, delayed presentation, or tong pull-out. Seventy-three percent of MUA patients were successfully reduced. Six patients had deteriorating neurologic level after MUA, which is believed to be related to general anesthesia causing decreased blood supply to the cord in the acute phase of injury. The authors promote avoiding MUA in the conscious patient, as it increases the risk of worsening neurologic status and had a lower rate of successful reduction. They also argued that MRI/CT myelography or open ventral surgery is not necessary prior to reduction because neurologic deterioration after reduction occurs in fewer than 1% of cases. They state that the risk of delayed reduction is more detrimental than the risks of rapid reduction. Therefore, these authors advocated immediate rapid reduction, without prereduction MRI or CT myelography, with weights up to 150 pounds for the initial management of cervical spine dislocations.

The role of traction and the importance of timing were evaluated in 2002 in a systematic literature review.25 The authors concluded that early closed reduction by traction was safe and effective in awake patients with approximately an 80% success rate. The focus of this review was to suggest that obtaining MRI presents an unnecessary delay to reduction. While the evidence presented suggested that prereduction MRI was not valuable, no evidence was presented to suggest that the time delay of the MRI was relevant to neurologic recovery. Therefore, this study recommended early closed reduction with limited evidence of the significance of timing to reduction.

In 2004, Anderson et al. focused on the significance of time to reduction in a retrospective review of patients who sustained traumatic unilateral and bilateral facet dislocations.20 The medical records of 45 patients were reviewed to assess the significance of age, gender, initial motor score, and time to reduction in predicting neurologic recovery. In this analysis, 88.8% of patients were successfully reduced using closed traction. The authors reported that younger age (P = .01) and better initial summed motor score (P < .01) correlated significantly with greater motor recovery after traumatic facet dislocation. They also found an overall average improvement in motor score of approximately 30% after 6 months. This study did not find that time to reduction was a significant predictor of neurologic recovery. However, they acknowledge the limitation that the study evaluated only 45 patients and did not look at subsets of patients such as those with narrow therapeutic windows or specific ASIA scores. These studies show the controversial role of timing of reduction in facet dislocations.