|Year : 2022 | Volume
| Issue : 2 | Page : 75-81
Sub-axial cervical dislocation: Challenges and recommendations
Amit Shukla, Suyash Singh
Department of Neurosurgery, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
|Date of Submission||17-Jan-2022|
|Date of Acceptance||12-Mar-2022|
|Date of Web Publication||31-May-2022|
Associate Professor, Department of Neurosurgery, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
A cervical dislocation injury is unstable and defined by the ligamentous complex disruption with separation of the adjacent spine vertebrae. Dislocation is used when the articular facets of the apophyseal joints are no longer in contact with each other and both inferior articular facets of the upper vertebra are locked in front of the superior articular facets of the lower vertebra. Hence, dislocation can be unilateral or bilateral accordingly. It is usually the result of combined flexion and distraction moments most commonly caused by a road traffic accident. In this review article, we have made an attempt to simplify and brief the topic and collectively presented all available recommendations for practical usage.
Keywords: Cervical dislocation, facet dislocation, subluxation, fracture
|How to cite this article:|
Shukla A, Singh S. Sub-axial cervical dislocation: Challenges and recommendations. J Spinal Surg 2022;9:75-81
| Introduction|| |
Owing to natural flexibility and relatively fixed junctions at both ends (cranio-vertebral and thoracic); the sub-axial cervical spine injuries (SACSI) are commonly encountered in traumatic or accidental cases. Its accounts for nearly two-thirds of all cervical fractures and 75% of all dislocations. The cervical fracture or dislocation may occur independent or simultaneously (Fracture-dislocation injury). A cervical dislocation injury is unstable and defined by the ligamentous complex disruption with separation of the adjacent spine vertebrae. Another terminology that needs description herein is “subluxation.” Subluxation is anterior displacement of the superior vertebra in relation to the inferior one below, when articular surfaces of the apophyseal joints remain in contact. The inferior articular facets of the upper vertebra get displaced anteriorly in relation to the superior facets of the lower vertebra without interlocking (normally the orientation of superior articular facet is posterior). Dislocation is used when the articular facets of the apophyseal joints are no longer in contact with each other and both inferior articular facets of the upper vertebra are locked in front of the superior articular facets of the lower vertebra. Hence, dislocation can be unilateral or bilateral accordingly. It is usually the result of combined flexion and distraction moments most commonly caused by a road traffic accident. These injuries are more common in elderly population as the laxity of ligaments is more; however high energy injury mechanisms, such as motor vehicle collision, may lead to dislocation or subluxation in younger patients.,
| Terminologies Related to Different Biomechanics of Sub-Axial Cervical Spine Injuries|| |
Sub-axial injuries are more commonly seen below C5 level as a result of instant internal rotation between head and rigid thoracic spine in any trauma. Cervical facet dislocation usually occurs as a result of combined flexion and distraction forces. An additional element of rotation leads to unilateral rather than bilateral facet dislocation. In extreme cases, the inferior articular facet of upper vertebra sits directly superior to superior articular facet of lower vertebra (known as perched facets)., Compression fracture occurs as a result of mild flexion and axial loading and this causes failure of anterior column while sparing middle and posterior column. Tear drop fracture is a teardrop-shaped chip across the anteroinferior aspect of the vertebral body occurring due to hyperflexion or extreme axial loading when the spine is in a flexed position. Posterior ligamentous injuries due to hyperflexion often occurs concomitantly and this results in a highly unstable injury. Moreover, the hyperextension injuries may result in dislocation, fracture-dislocation, or laminar injuries.
[Table 1] shows the stages of facet joint dislocation as described by Allen and Ferguson et al. The initial survey of patient is done on the basis of SACSI Classification System. Numerous classification systems have been developed over time, but still, there is currently no widely accepted subaxial injury classification system. The first description of cervical spine injuries by Böhler described injury morphology based on plain radiographs. Holdsworth described injuries on the basis of mechanism of injury and stability and posterior longitudinal ligament complex (PLC) injury. The Subaxial Injury Classification and Severity Scale was developed in 2007 by the Spine Trauma Study Group. The system characterizes injuries based on morphology, discoligamentous complex, and neurological status. Currently, the AO Spine Subaxial Cervical Spine Injury Classification System is being used widely. Final score of 5–8 is indicative of surgical management, whereas patients with score of 1–3 are managed on medical conservative guidelines.
|Table 1: Stages of facet joint dislocation as described by Allen and Ferguson et al.|
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| Initial Evaluation and Management|| |
Initial management and resuscitation is done as per Advanced Trauma Life Support protocol, and emergent injuries should be treated first in the order of priority. Airway, breathing, and circulation are checked and addressed. Assessment tools like as the Canadian C-spine rules or the National Emergency X-Radiography Utilization Study rules to define patients with risk of blunt cervical trauma may be used.
| Classification|| |
The Allen-Ferguson proposed a scheme based on radiographic findings and inferred mechanisms of injury and described six injury types: compressive flexion, vertical compression, distractive flexion, compressive extension, distractive extension, and lateral flexion. Harris also described a mechanism-based injury system that includes flexion, flexion and rotation, hyperextension and rotation, vertical compression, extension, and lateral flexion. Aebi and Nazarian described a system based on anterior or posterior columns of the spine, or both. The Subaxial Injury Classification and Severity Scale was developed in 2007 by the Spine Trauma Study Group. The system characterizes injuries based on morphology, discoligamentous complex, and neurological status. Final score of 5–8 is indicative of surgical management; whereas patients with score of 1–3 are managed on medical conservative guidelines. Studies have shown the subaxial cervical spine injury classification (SLIC) system to be valid and reliable., Till date, there is no ideal subaxial cervical spine classification system that is widely accepted.
| Recent Recommendations for Initial or First Investigation to be Done in Emergency Room|| |
For the cervical spine injury, plain X-rays can detect nearly 60%–80% of fractures; 25% of unstable injuries are missed and an overall sensitivity ranges from 33% to only 77%. Current recommendations are against obtaining plain X-rays for screening or evaluation in the setting of suspected spinal instability. The Eastern Association for the Surgery of Trauma guidelines suggests level I recommendations for Computed tomography scanning as screening modality for spinal injuries in blunt trauma patients., Overall, the sensitivity and specificity of multidetector row computed tomography (CT) (2–3 mm cuts) were both more than 99.9%, whereas the negative predictive value of a normal CT scan was 100%. The magnetic resonance imaging (MRI) remains the most sensitive diagnostic tool to evaluate the soft tissues including associated disc herniation, ligament injury, and traumatic cord injury. MRI is also required for SLIC or Thoracolumbar injury classification and severity score (TLIC) and objective planning. MRI in an awake examinable patient who will undergo closed reduction is still debatable.
According to NICE guidelines, imaging is indicated if any “high-risk factor” for cervical spine injury is present as indicated by the Canadian C-spine rule; or a “low-risk factor” for cervical spine injury is present but the person is unable to actively rotate their neck 45° around. Furthermore, for a pediatric patient (age <16 years), MRI should be performed if there is a strong suspicion of cervical spinal cord injury. Plain X-rays in children should be considered who do not fulfil the criteria for MRI but clinical suspicion remains after repeated clinical assessment. CT should be the investigation of choice in adults (>16 years) if high risk factors (as indicated by Canadian C spine rule) are present and it should be followed by MRI irrespective of CT being normal. MRI should be performed within 72-h of injury as later on, the resolution of the edema and hemorrhage reduces sensitivity of MRI to detect ligamentous injuries.
Few authors believe on the role of screening evoked potentials; however, no level I evidence is available. Tsirikos et al. showed an improvement of 20% or greater in amplitude of SSEP's was correlated with postoperative improvement. Dhall and Hubli highlighted the role of magnetic MEP after spinal cord injury at the 25-d mark., Dhall et al. in their article showed that presence of MEPs significantly predicted American Spinal Injury Association (ASIA) grade at discharge. Patients with present intraoperative MEPs had higher ASIA grades at discharge in comparison to patients with absent MEPs. Complete spinal cord lesions do not always present with a complete loss of evoked potentials, i.e., electrophysiological profile differs. It is recommended to use electrophysiological assessments in parallel with clinical testing when determining lesion severity and its evolution over time.
| Role of Intra-Operative Monitoring|| |
Electrophysiological monitoring techniques allow the assessment of somatosensory evoked potentials (SSEP), Motor evoked potential (MEP), and spinal root function (electro-myographic potentials). Recording of these parameters after spinal cord injury or during operative procedures (IOM) has the potential to evaluate the integrity of the sensory and motor pathways and spinal roots in real-time fashion. Any alterations seen in these recordings during spinal cord/spinal column surgery indicate an impending spinal cord injury which could be reversed and stopped for a better outcome following surgery.
Congress of neurological aurgeons (CNS) have recommended that “Multimodal intra-op monitoring (MIOM), including somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) recording, during spinal cord/spinal column surgery is a reliable and valid diagnostic adjunct to assess spinal cord integrity and is recommended if utilized for this purpose.” MEP recordings are superior to SSEP recordings during spinal cord/spinal column surgery as diagnostic adjuncts for the assessment of spinal cord integrity and are recommended by CNS. In their research, Dhall et al. showed that the presence of MEPs significantly predicted ASIA grade at discharge. Patients with present intraoperative MEPs had higher ASIA grades at discharge in comparison to patients with absent MEPs. In a similar retrospective analysis of 720 patients, Traynelis et al. concluded that surgical decompression and reconstruction for symptomatic cervical spine disease may be safely performed without utilizing IONM. There is no study which showed effects of IONM on cervical dislocation surgeries. With all the available literature, it can be emphasized that large study needs to be conducted to come to a final consensus. Finally, it can be concluded that multimodal intraoperative monitoring (MIOM) is an effective method of monitoring the spinal cord functional integrity during cervical spine surgery and can help to reduce the risk of neurological deficit by alerting the surgeon when monitoring changes are observed.
| Management|| |
Role of steroids
The National Acute Spinal Cord Injury Studies II and III, a Cochrane Database of Systematic Reviews article of all randomized clinical trials had verified significant improvement in motor function and sensation in patients with complete or incomplete spinal cord injuries who were treated with high doses of methylprednisolone within 8-h of injury. CNS and the American Association of Neurological Surgeons recommend against the use of steroids (methylprednisolone) within the first 24–48 h following injury. The previous standard was revised because of a lack of medical evidence supporting the benefits of steroids in clinical settings and evidence that high-dose steroids are associated with harmful adverse effects. NICE guidelines have excluded the use of steroids in acute spinal cord injury cases. CNS published the following level III recommendations with respect to treatment of SACSI-“Use of prolonged bed rest in traction to treat subaxial cervical fractures and dislocations is recommended if more contemporary treatment options are unavailable.”
A cervical orthosis is only indicated for cervical facet fractures without significant subluxation, dislocation or kyphosis, or poor operative candidates.,
Cervical dislocation is mainly treated by surgical therapy. The three prime objectives of surgical management are as follows: (a) decompression of neural elements; (b) stabilization of spine; and (c) early mobilization.
Role of closed reduction
In our traditional teaching methods, closed reduction is not tried in emergency room. There is Level III recommendation by CNS that early closed reduction of cervical spinal fracture/dislocation injuries with craniocervical traction for the restoration of anatomic alignment of the cervical spine in awake patients is recommended while it is not recommended in patients with an additional rostral injury. Owing to facet dislocation; the reduction of cervical facet dislocation can be achieved closed or open. Contraindications to closed reduction include an uncooperative or comatose patient and cases with imaging studies showing evidence of offending disc prolapse or bony fragments that can potentially compress the cervical cord during reduction. Few authors believe that closed reduction in an awake and alert patient may be safe without obtaining a prereduction MRI.
In cases without contraindications, closed reduction may be done as soon as possible. There is no time protocol but certain reports suggest that if reduction done within 24 h, the neurological outcome is better and ideally if done under 4 h, results are much better. Closed reduction should be performed in the operating room, in intensive or high dependency units where vitals monitoring, resuscitation, medications, and equipment are readily available including traction kits, traction weights, and fluoroscopy machine.,
Role of cervical traction
In 1929, Taylor introduced the halter device as a method of applying traction for the reduction of cervical injuries. In 1973, Gardner improvised the system described by Crutchfield in 1933 by creating tongs with cranial pin angulation for improved skeletal fixation. The most common cranial attachments for spinal traction are halter, tongs, and halo devices. Tongs are temporary devices, whereas halo ring are for long-term traction. Traction provides indirect decompression of the spinal cord. It may also be used for temporary immobilization and stabilization while a patient awaits definitive fixation. Patients who have sustained a traumatic injury should be assessed for any skull fracture with CT before the placement of cranial fixation pins. Traction is contraindicated in cases of occipitocervical dissociation. For this reason, whenever traction is applied to the cervical spine in the setting of trauma, a lateral radiograph should be made immediately after the application of light traction (approximately 10 lb [4.5 kg]) to rule out distraction of the occipitocervical joint).,
| Cervical Facet Dislocation: Traction in Flexion Position|| |
Unilateral or bilateral cervical facet dislocation in an awake and cooperative patient is typically treated with an initial attempt at closed reduction followed by internal fixation.
Traction with use of Gardner-Wells tongs is an effective means of reducing dislocated facets, with reported success rates of as high as 80%., A slightly posterior pin position provides for neck flexion, which can aid facet relocation. Routinely, traction is initiated at 10 lb (4.5 kg), followed by sequential increases of 10–15 lb (4.5–6.8 kg) every few minutes. A lateral cervical radiograph is made after each weight increase to monitor spinal alignment and occipitocervical joint congruity, and a thorough neurological examination is performed after the initial application and after each subsequent weight increase. The weight must be immediately decreased if over-distraction is identified or neurological symptoms or signs develop. Reduction of a flexion-distraction injury pattern may require large traction weights, and manual flexion and/or rotational maneuvers may be necessary to unlock the facets. Standard teaching practice is that 10 lb (4.5 kg) per cervical spinal level is required in order to achieve reduction of facet dislocations, although an additional 20–30 lb (9.1–13.6 kg) is often needed and total weights of as much as 140 lb (63.5 kg) may be needed. Greater loads are needed for lower cervical spine injuries and unilateral facet dislocation., After closed reduction is successfully obtained, traction may be reduced to 10–20 lb (4.5–9.1 kg) and the traction force-vector can be changed to neutral or slight extension. If the relocation attempt is unsuccessful, early operative reduction is undertaken.,
Open reduction and cervical fusion are indicated in cases of failed closed reduction and cases contraindicated for closed reduction. Even in cases with a successful closed reduction, surgical fixation has become the standard care for treatment. The nonoperative management of reduced facet dislocation in the form of halo traction and collar immobilization is no longer followed due to the reportedly high rates of instability, later disability in the terms of pain, delayed neurological injury, and stiffness. The options of surgical approach for unilateral or bilateral facet injuries include (a) anterior-only approach, (b) posterior-only approach; and (c) combined anterior and posterior approach; or (d) staged approach. The right approach is controversial and depends upon (1) degree of instability of injury, i.e., unilateral versus bilateral and degree of osteo-ligamentous injury; (2) the presence of anterior disc herniation; (3) whether the dislocation is reducible from a single anterior or posterior approach alone; and (4) surgeon's expertise.
Timing for surgery
The timing of the surgery is another controversial aspect of the surgical treatment of cervical facet dislocation. The factors such as failed closed reduction and/or progressive neurological deficits urge surgeons for urgent surgery. In 1999, Mirza et al. recommended surgery within 72 h following the injury to increase the chance of recovery of early neurological function and avoid delayed neurological recovery. In 2016, the Surgical Timing in Acute Spinal Cord Injury Study showed that early reduction and decompression (24 h) had improved outcome; wherein a total of 182 patients had early surgery (vs. 131 patients with late procedures) and 6-months postsurgery, 19.8% of the patients in the early group had at least a 2-grade improvement on the American Spine Injury Association Impairment Scale compared with 8.8% rate of improvement in the late decompression group.
Anterior-only cervical approaches
Anterior cervical decompression and fusion (ACDF) is indicated in cases where ruptured or extruded disc compresses the spinal cord and where anterior decompression is required to reduce the risk of cord injury before facet reduction. Anterior cervical stabilization offers certain benefit [Table 2]. It is better to completely visualize the extent of disc extrusion for adequate decompression before the trial of reduction.
Most commonly, caspar pins are placed in both rostral and caudal vertebral body and linked to distraction device. The pins are inserted in diverging directions to add bending movement with distraction. Rostral vertebra is pushed posteriorly to aid reduction. In cases of unilateral facet dislocation, the pins are applied at an angle to each other in the coronal plane to allow for rotation during reduction. Another technique is using of a blunt instrument inserted in the superior endplate of the caudal vertebra and used as leverage to push the rostral vertebra backwards. An alternative maneuver for reducing a locked facet joint is continuous intraoperative external cranial traction. After achieving reduction and confirming with X-rays, the next step is to fix the injured cervical level.
Different techniques have been described in literature such as conventional plates, locking plate system, bone graft, and disc cages, for the fusion and fixation. The locking plates with cages or bone graft are one of the most popular techniques in facet dislocation. It provides a stable rigid fixed-angle construct against the deforming kyphotic forces on the cervical spine.,, The anterior-only approach for bilateral facet dislocation is difficult as the amount of posterior ligamentous injury is severe and there is nearly complete loss of the tension band effect of the PLC. Such surgical effort may result in loss of reduction and postoperative kyphosis. Johnson et al. have reported a loss of postoperative cervical alignment in 13% of 87 patients with fracture facet subluxation treated by ACDF due to mechanical failure of posterior elements, especially in distractive lesions. These outcomes could be attributed to the extent of bony injury associated with the facet dislocation where additional facet fracture and/or endplate fractures increase the risk of mechanical failure of standalone anterior fusion. In his series of 36 patients, Anissipour et al. reported that there were only three treatment failures (8%); all three had an associated endplate fracture and one of them had an additional facet fracture. The authors further advised that using longer screws within 2 mm of the posterior vertebral cortex in a locking fashion and maintaining cervical lordosis should be taken as surgical measures to decrease the risk of mechanical failure.
Posterior cervical approaches
Posterior cervical reduction and fixation offers the advantages of direct visualization and reduction of dislocation and decompression of any offending bony fragment compressing the cord such as a lamina fragment into the canal [Table 3]. Biomechanically, this procedure provides a stronger fixation and is preferred in osteoporotic bones. Unilateral facet dislocation is more difficult to reduce more likely to need direct posterior reduction. The external traction provides leverage and facet dislocation may be reduced using a blunt instrument. In cases of irreducible locked facet, the apex of facet is drilled to assist the manual reduction. Posterior fixation can be achieved using wire ropes, lateral mass screws, or pedicular screws. The posterior reduction can cause neurological deterioration in cases of anterior compressive lesions such as disc herniation. In a series of 40 traumatic disc herniation patients, Nakashima et al. used posterior-only approach and found no postoperative neurological deterioration. Another concern with the posterior approach is an increased risk of wound infections and the poly-trauma and clinically unstable patients may also have problems with prone position needed.
Combined anterior and posterior cervical approach
Combined approach is planned for severe unstable injuries. The surgeon may have to stage the fixation of the spine (depending upon expertise, general condition of patient and severity of injury). In cases of failed reduction through an anterior approach, the surgeon may have to turn the patient to prone position for posterior reduction followed by anterior ACDF. Furthermore, after successful reduction and fixation through either posterior or anterior approach, the surgeon may add combined anterior or posterior fixation to achieve fixation with higher rates of union. This combined approach is considered where the mechanical stability of the construct is at question especially in osteoporotic bones, ankylosing spondylitis, and in the case of associated endplate and facet fractures. The drawback with combined approaches is the increased iatrogenic injury and further restricted spinal movement.
Recommendations by different societies
The Spine Section of the German Society for Orthopedics and Trauma (2018) recommended that facet injuries and to be specific F4-Injuries (Subluxation or Perched/Dislocated Facet) require a safe reduction without neurological deficits. Furthermore, they recommended that a closed reduction under fluoroscopy by an experienced spine surgeon “in the operating room” should be done as early as possible. In case a closed reduction is not feasible, immediate anterior decompression and an open reduction attempt with a distractor should be done. If an anterior open reduction is not successful, it must be followed by an open posterior approach.
In the World Federation of Neurosurgery Consensus of management of Traumatic Locked Facets (2019); the following important suggestions were laid-
- Traction help in immobilizing the unstable segment and may help reduce (100% consensus)
- In the majority of acute (≤3 days) locked facets, anterior surgical techniques are sufficient to manage successfully (82% consensus)
- In chronic locked facet (>2 weeks), lower cervical locked facets with no/insignificant disc prolapse, and in conditions where the anterior approach is not feasible, a posterior approach is indicated (100% consensus)
- All locked facets should be reduced in an emergency, and surgery should be performed as soon as possible (100% consensus)
- Surgery is indicated for the presence of progressive neurological deficit or stable incomplete deficit with significant spinal canal compromise (100% consensus)
- Anterior surgeries are recommended for significant anterior column injuries (92% consensus)
- Additional posterior surgeries should be considered for patients who require multilevel corpectomy and for patients with severe dissociation (complex) injuries (100% consensus)
- In the management of locked facets, if a posterior approach is considered, preoperative MRI is recommended (100% Consensus).
| Conclusion|| |
The optimum treatment strategy of cervical facet dislocation is still a matter of debate as there is no Class 1 evidence studies. Surgical open reduction, either anterior or posterior; depending upon the extent and severity of radiological injury and neurological status of patient is best line of management. We recommend individualized approach depending on clinical expertise of surgeon and stress on the fact that it is not the technique but timing of treatment which is more important. A well-designed randomized controlled trial is warranted for better acceptance of facts present in bits and pieces.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]