Session VII - Spine

Closed Reduction without MRI for Bilateral Cervical Facet Dislocation

Carlo Bellabarba, MD; Paul R. Meyer Jr., MD, Northwestern University, Chicago, IL

Purpose: We evaluated the incidence of neurological deterioration after closed reduction of bilateral facet dislocation in the cervical spine, with the goal of assessing the need for pre-reduction MRI in evaluating patients at risk for acute post-reduction neurological compromise.

Methods: A total of 118 patients with isolated bilateral facet dislocation of the cervical spine (OTA type 51-B3.3) were treated at Northwestern Memorial Hospital. We reviewed the records of these patients collected prospectively in a spine trauma database. Sixty-seven patients had complete neurological injury and were excluded. Four patients who had chronic dislocations for which closed reduction was not attempted were also excluded. Of the remaining 47 patients, 11 were neurologically intact, and 36 had sustained incomplete neurological injury. These 33 men and 14 women comprised this prospective study. All but three patients were transferred to our institution, with an average 9-hour delay (range, 2 to 42) from the time of injury. Upon arrival, a thorough neurological examination was performed independently by the orthopaedic and neurosurgery services, followed by evaluation of plain radiographs. For all patients, closed reduction was attempted in the emergency department using Gardner-Wells tongs and an incremental 5-pound increase in traction. Once reduction had been confirmed radiographically, traction was reduced according to the injury level to maintain stability. Staff of both the orthopaedic and neurosurgery services performed detailed neurological examinations after reduction and a minimum of once each day during hospitalization. Definitive fixation, either by anterior or posterior fusion, was performed at an average of 3 days after transfer (range, 1 to 11).

Results: A successful reduction was achieved in the emergency department in 45 of the 47 patients. The average weight required for successful reduction was 52 pounds (23.4 kg, range, 35 to 95; 15.75 to 42.75 kg). The cervical facets of two patients could not be reduced in the emergency department and were subsequently reduced in the operating room. There was no case of acute worsening of the neurological level after reduction, or over the average 19-day hospitalization (range, 9 to 53). The majority of patients with incomplete injuries (89%) had significant return of neurological function upon discharge.

Discussion: Concern has arisen regarding the safety of performing a closed reduction in bilateral facet dislocation of the cervical spine without prior MRI evaluation. A reported complication has been spinal cord compression with neurological compromise at the time of reduction due to retropulsion of extruded intervertebral disc material into the canal. Pre-reduction MRI has therefore been recommended to allow identification of patients who have a disc herniation with potential for canal compromise, permitting appropriate measures to prevent this complication. Surgeons resistant to routinely obtaining pre-reduction MRI cite the high incidence of disc disruption without apparent complication, reducing the study's predictive value. The presumed need for pre-reduction discectomy also renders treatment somewhat more complicated, especially among surgeons favoring posterior stabilization of facet injuries.

Conclusion: On the basis of our experience, we conclude that MRI prior to closed reduction of bilateral facet dislocation of the cervical spine is not routinely necessary. Closed reduction was obtained reliably in this consecutive series without post-reduction neurological deterioration.