BILATERAL CERVICAL FACET DISLOCATION
A 32yearold woman is brought to the emergency department following a road traffic collision. She complains of neck pain and is immobilised in a cervical collar with blocks and on a spinal board. The initial ATLS assessment suggests that this is an isolated injury and there is no obvious neurologic deficit. She is imaged with CT and cuts of this study are shown here.1. Describe the initial investigation and management of this patient.
This CT image shows an anterolisthesis of the vertebral bodies of C6 on C7 of approximately 100% of the width of the vertebral body. This suggests a bilateral facet dislocation. Spinal precautions should be maintained and the neurologic status con firmed. I would discuss this patient with the local spinal surgery team and my initial management would be guided depending on their advice and local arrangements as the patient is likely to need specialist input and surgery. In general terms, for an awake and responsive patient able to understand and comply with instructions and without neurologic deficit, an attempt at closed reduc tion can be made using Gardner–Wells tongs and I would perform this in the operat ing theatre. An initial load of 10 lbs is applied and a lateral cervical spine radiograph is taken to identify any overdistraction, occult cervical spine fracture or occip tocervical instability. The weight is increased by 10–15 lbs every 15 minutes with repeat xrays and assessments of the neurology until reduction is achieved. A slight extension moment can help to maintain the reduction once achieved. The weight is then reduced to 10–15 lbs and a rigid cervical collar applied. I would arrange a post reduction MRI to help with surgical planning and would temporarily remove the tongs for this to be performed. If the patient develops abnormal neurology during the traction procedure I would stop and slowly release the traction continuing to monitor the patient to determine if the neurology normalises, remains static or is progressive. I would then immobil ise the cervical spine and obtain an MRI. In situations where the patient is not awake or able to provide feedback during the procedure, reduction should be preceded by an MRI scan to exclude a posteri orly herniated disc.
2. Following reduction of this injury, how would you proceed?
Bilateral facet dislocations are potentially associated with a significant posterior ligamentous injury and are likely to need definitive operative treatment. While awaiting this I would maintain rigid collar immobilisation and traction with the Gardner–Wells tongs and 10–15 lbs of weight. I would arrange post reduction radio graphs to confirm the reduction, a postreduction MRI to exclude disc herniation, spinal haematoma or other occult pathology and I would discuss this patient again with the local spinal service. I would choose an anterior cervical approach to allow a discectomy to be per formed in the case of an extruded disc followed by a posterior cervical stabilisa tion with segmental screws. If the MRI shows no evidence of disc herniation then I would proceed directly to a posterior cervical stabilisation.