The role of pre-reduction MRI in the management of complex cervical spine fracture-dislocations: an ongoing controversy?
© The Author(s). 2017
Received: 15 June 2017
Accepted: 5 September 2017
Published: 8 September 2017
Cervical spine fracture-dislocations in neurologically intact patients represent a surgical challenge due to the risk of inflicting iatrogenic spinal cord compression by closed reduction maneuvers. The use of MRI for early advanced imaging in these injuries remains controversially debated.
A 54-year old man sustained a fall over the handlebars of his racing bicycle. The helmeted patient sustained a fall on his head which resulted in a hyperflexion injury of the neck. He was neurologically intact on presentation. Initial CT imaging revealed a complex multisegmental cervical spine injury with a left-sided C6/C7 perched facet, a right sided C7/T1 fracture-dislocation, and a right-sided C6 and C7 traumatic laminotomy. The initial management consisted of temporary external Halo fixator application without closed reduction maneuver, to mitigate the risk of a delayed spinal cord injury. Subsequent advanced imaging by MRI revealed an acute traumatic C7/T1 disc herniation, with the intervertebral disc completely extruded into the spinal canal. Definitive surgical management was then accomplished by employing a three-stage anterior-posterior-anterior spinal decompression, realignment, fixation and fusion C4-T2 in one operative session. The patient recovered well and retained full neurological function. He resumed bicycle street racing within 10 months of the injury following successful spinal reconstruction.
The diagnostic evaluation of cervical fracture-dislocations should include advanced imaging by MRI in order to fully understand the injury pattern prior to proceeding with spinal reduction maneuvers which may impose the imminent threat of a devastating iatrogenic injury to the spinal cord. The presented staged management by initial Halo fixation without attempts for spinal reduction, followed by a surgical decompression and multilevel fusion, appears to represent a feasible and safe strategy for patients at risk of a delayed neurological injury.
Cervical spine fracture-dislocations continue to represent a significant challenge in trauma patients due to the imminent risk of neurological deterioration associated with potentially inadequate timing and modality of surgical management [1–3]. Fractures or dislocations of the posterior cervical elements are typically managed by an attempt for initial closed reduction with temporary external fixation in a Halo vest, followed by definitive posterior spinal fusion, as indicated [4–7]. However, a “classic” challenge for the management of cervical facet dislocations is represented by the potential of an associated injury to the anterior spinal column with a disc herniation into the anterior spinal canal . In this scenario, an imprudent closed reduction maneuver may lead to the iatrogenic compression of the spinal cord with the potential for subsequent devastating neurological consequences [9–12]. The option of obtaining advanced imaging by MRI prior to a closed reduction maneuver remains controversial [13, 14]. While MRI undoubtedly represents the most sensitive diagnostic tool to evaluate for associated disc herniation, ligament injury, and traumatic myelopathy [15, 16], concerns about the standard use of MRI in the work-up of cervical facet dislocations relate to the delayed timing of early spinal realignment, considerations related to cost effectiveness, resource utilization, and the restricted availability of MRI across the globe [13, 17, 18]. Impressively, early studies on the use of MRI in cervical spine injuries revealed a presence of traumatic disc herniation in more than 40% of all patients . In absence of MRI, the concept of closed reduction of the cervical spine in awake and alert patients has been largely proven safe and feasible [19–21], yet, selected cases of catastrophic deterioration of the neurological status after closed reduction maneuvers have been reported [10, 14, 22, 23]. In certain instances of cervical fracture-dislocations, patients owe an intact neurologic status to the fracture of the posterior elements, such as pedicle or lamina fractures (so-called “saving” laminotomy), which result in increased spinal canal space and thus prevent a traumatic spinal cord compression [21, 24]. The definitive surgical management of cervical fracture-dislocations with associated traumatic disc herniation is achieved via anterior, posterior or combined (anterior-posterior and anterior-posterior-anterior) approaches [2, 25, 26], however, in the setting of a neurologically intact patient, there is a general consensus to start the procedure through an anterior approach for spinal canal decompression . In the present case report, we present a rare injury pattern of a cervical spine fracture-dislocation with rotational instability, posterior perched facet, and complete anterior extrusion of the intervertebral disc in a young and active patient without associated spinal cord injury. A safe surgical management strategy is presented and placed into context of the peer-reviewed literature in the field.
The posterior perched facet requiring posterior approach and open reduction to restore anatomic sagittal alignment of the spine;
The extruded disc at C7/T1 requiring a C7 corpectomy and decompression through an anterior approach;
The sequence of surgery being dictated by the intraspinal disc which requires (1) anterior decompression, followed by (2) posterior fracture reduction, and ultimately (3) an anterior completion fusion after posterior reduction and instrumentation.
This report describes the rare case of a young active patient who sustained a complex cervical injury challenged by concomitant anterior disc protrusion and posterior facet dislocation in presence of intact neurological exam. This patient would have likely suffered a detrimental adverse neurological outcome if a standard closed reduction maneuver would have been performed in absence of MRI imaging. Even when performed under standard precautions in the awake patient, once the posterior perched facet jumps back into place with a conventional reduction maneuver by traction, hyperflexion and rotation, the large intraspinal disc fragment (Fig. 1g,h) would have likely led to an irreversible spinal cord compression with subsequent quadriplegia. The findings from the current case report on the successful management of a complex cervical spine fracture-dislocation without intra−/perioperative complications leading to an excellent long-term patient outcome provide a further argument towards the mandatory advanced imaging with MRI for the initial work-up of such risky traumatic conditions.
A prospective observational study by Vaccaro and colleagues from 1999 assessed the safety of awake closed reduction maneuvers in 11 patients with cervical spine dislocations who had a pre- and post-reduction MRI performed to assess for presence of intervertebral disc herniation . Of these, 2 patients had disc herniations identified before reduction, 5 patients showed new disc herniations after the closed reduction maneuver, and 2 patients had irreducible dislocations . While none of the patients in their study suffered from neurological worsening during or after closed reduction, these data raise some concern related to “blind” reduction maneuvers in absence of a re-reduction MRI. Suitably, Vaccaro stated in the conclusion of the article that the implications related to the “neurologic safety of awake closed reduction traction reduction remains unclear” . Other studies on closed reduction of locked facets were performed in patients with complete or incomplete spinal cord injury , which represent a different entity compared the neurologically intact patient described in our case report, as it relates to the imminent risk of iatrogenic spinal cord compression leading to a preventable neurologic injury. Other groups have recommended MRI-guided reduction due to their observation of an incidence of 88% cervical disc disruption before closed reduction .
A similar case report as described here, on a neurologically intact patient with a C7/T1 cervical dislocation described the safe reduction in traction which was attributed to the associated fractures of the posterior spinal elements . Arguably, the patient presented in our current case report retained his neurologically function due to the posterior “saving” traumatic laminotomy (Fig. 1e,f) which allowed for a temporary functional decompression of the spinal canal. The risk of a catastrophic neurological deterioration due to intervertebral disc herniation leading to iatrogenic cord compression during closed reduction of cervical spine dislocations is well documented in the peer-reviewed literature [9, 22].
In spite of the high risk of inducing preventable severe neurologic complications by inconsiderate reduction maneuvers, the timing and utilization of advanced diagnostics by MRI appears highly variable and remains contested . Therefore, the conservative and cautious staged approach applied to our patient in the present case report appears justified and safe. First, we performed a preliminary stabilization of the cervical spine in a Halo vest with traction, which allowed monitoring the neurologic status in the awake patient until advanced imaging was obtained. The subsequent MRI indeed demonstrated a large posterior herniation of the entire C7/T1 disc into the spinal canal (Fig. 1g,h). Once diagnosis is established, different surgical treatment concepts have been described to mitigate the risk of intraoperative spinal cord compression in patients with cervical facet dislocations [6, 28–30]. Associated disc herniation appears to be treated by most spine surgeons through an anterior approach, either alone or in combination with a posterior approach for fracture reduction and stabilization/fusion . In our case, we performed a three-stage anterior-posterior-anterior spinal decompression and C4-T2 spinal fusion; (1) in supine position, the herniated disc was removed through an anterior C7 corpectomy; (2) in prone position, a completion laminectomy of the traumatic laminotomy was performed prior to reduction of the locked facet on one side, and a facetectomy on the other side, and multilevel posterior instrumentation and fixation; (3) in supine position, a completion anterior fusion was performed. The anterior-posterior-anterior approach has been previously described and effectively applied in the management of complex cervical spine dislocations [26, 31]. A valid alternative consists of a posterior-anterior-posterior approach, which has been previously described in the following sequence; (1) a posterior approach for a complete facetectomy without attempts at fracture reduction; (2) an anterior discectomy with reduction of the dislocation and anterior fusion; and (3) posterior completion reduction and fixation/fusion . Independent of the final surgical management strategy, we believe that the key to successful management of neurologically intact patients with cervical spine fracture-dislocations consists of early recognition of the presence of a herniated intervertebral disc prior to receding either with a temporary closed reduction or early definitive surgical decompression and stabilization.
We strongly recommend obtaining advanced imaging with a pre-reduction MRI in neurologically intact patients with cervical spine dislocations for early recognition of an intraspinal herniated disc which places the spinal cord at risk for iatrogenic compression during closed reduction maneuvers, with the potential for catastrophic subsequent neurological complications.
There was no external funding for this article.
Availability of data and materials
All data and material are available by request through the corresponding author.
PFS and HF performed the surgical procedure on the patient described in this case report. SB provided the first draft of the manuscript. PFS, EEM and TVH revised the manuscript and finalized the case report. All authors approved the final version of the manuscript prior to submission.
Ethics approval and consent for participation.
Written informed consent was obtained by the patient described in this article for publication of the content and the accompanying images shown in Figs. 1-4. The consent is available for review by the journal’s editor upon request. No ethical board approval was required for a case report.
Consent for publication.
Written informed consent was obtained by the patient described in this article for publication of the content and the accompanying images shown in Figs. 1-4. The consent is available for review by the journal’s editor upon request.
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