Risk of early closed reduction in cervical spine subluxation injuries

1999 ◽  
Vol 90 (1) ◽  
pp. 13-18 ◽  
Author(s):  
Gerald A. Grant ◽  
Sohail K. Mirza ◽  
Jens R. Chapman ◽  
H. Richard Winn ◽  
David W. Newell ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Mr Imaging ◽  
Disc Herniation ◽  
Closed Reduction ◽  
Spinal Cord Injuries ◽  
Spinal Injury ◽  
Neurological Deterioration ◽  
Neurological Deficits ◽  
Content Type ◽  
Fine Print

Object. The authors retrospectively reviewed 121 patients with traumatic cervical spine injuries to determine the risk of neurological deterioration following early closed reduction. Methods. After excluding minor fractures and injuries without subluxation, the medical records and imaging studies (computerized tomography and magnetic resonance [MR] images) of 82 patients with bilateral and unilateral locked facet dislocations, burst fractures, extension injuries, or miscellaneous cervical fractures with subluxation were reviewed. Disc injury was defined on MR imaging as the presence of herniation or disruption: a herniation was described as deforming the thecal sac or nerve roots, and a disruption was defined as a disc with high T2-weighted signal characteristics in a widened disc space. Fifty-eight percent of patients presented with complete or incomplete spinal cord injuries. Thirteen percent of patients presented with a cervical radiculopathy, 22% were intact, and 9% had only transient neurological deficits in the field. Early, rapid closed reduction, using serial plain radiographs or fluoroscopy and Gardner—Wells craniocervical traction, was achieved in 97.6% of patients. In two patients (2.4%) closed reduction failed and they underwent emergency open surgical reduction. The average time to achieve closed reduction was 2.1 ± 0.24 hours (standard error of the mean). The incidence of disc herniation and disruption in the 80 patients who underwent postreduction MR imaging was 22% and 24%, respectively. However, the presence of disc herniation or disruption did not affect the degree of neurological recovery, as measured by American Spinal Injury Association motor score and the Frankel scale following early closed reduction. Only one (1.3%) of 80 patients deteriorated, but that occurred more than 6 hours following closed reduction. Conclusions. Although disc herniation and disruption can occur following all types of traumatic cervical fracture subluxations, the incidence of neurological deterioration following closed reduction in these patients is rare. The authors recommend early closed reduction in patients presenting with significant motor deficits without prior MR imaging.

Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation

1993 ◽  
Vol 79 (3) ◽  
pp. 341-345 ◽  
Author(s):  
Stephen E. Doran ◽  
Stephen M. Papadopoulos ◽  
Thomas B. Ducker ◽  
Kevin O. Lillehei
Keyword(s):  
Cervical Spine ◽  
Magnetic Resonance ◽  
Mr Imaging ◽  
Disc Herniation ◽  
Closed Reduction ◽  
Clinical Status ◽  
Cord Compression ◽  
Herniated Disc ◽  
Content Type ◽  
Fine Print

✓ The coexistence of traumatic locked facets of the cervical spine and a herniated disc is not well described. The authors present a series of patients with traumatic locked facets who demonstrated a high incidence of associated disc herniation documented on magnetic resonance (MR) imaging. Thirteen patients with either unilateral (four cases) or bilateral (nine cases) locked facets of the cervical spine were analyzed retrospectively. Immediate closed reduction using traction and/or manipulation was attempted in the first nine cases treated and was successful in only three; however, the procedure was abandoned in three cases due to deterioration in the patient's clinical status. In the subsequent four patients, an MR image was obtained prior to attempts at closed reduction. All patients underwent MR imaging of the cervical spine. Of eight consecutive cases treated at the University of Michigan, frank disc herniation with fragmented disc in the canal was found in five while pathological disc bulging was found in the other three. All five cases contributed by other institutions had concurrent disc herniation. This series illustrates the importance of using MR imaging to document the presence of a herniated disc during the initial evaluation of a patient with traumatic locked facets of the cervical spine and prior to attempted reduction of the locked facets. Experience indicates that closed reduction of facet dislocation associated with disc rupture may result in increased spinal cord compression and neurological deficit. If a herniated disc is discovered. anterior discectomy and fusion would be favored as the initial therapy over attempts at closed reduction or operative posterior reduction.

Spinal cord concussion

1990 ◽  
Vol 72 (6) ◽  
pp. 894-900 ◽  
Author(s):  
Thomas J. Zwimpfer ◽  
Mark Bernstein
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injuries ◽  
Spinal Injury ◽  
Cord Compression ◽  
Neurological Deficits ◽  
Content Type ◽  
Young Males ◽  
Cord Injury ◽  
Sensory Disturbances ◽  
Fine Print

✓ The hallmark of concussion injuries of the nervous system is the rapid and complete resolution of neurological deficits. Cerebral concussion has been well studied, both clinically and experimentally. In comparison, spinal cord concussion (SCC) is poorly understood. The clinical and radiological features of 19 SCC injuries in the general population are presented. Spinal cord injuries were classified as concussions if they met three criteria: 1) spinal trauma immediately preceded the onset of neurological deficits; 2) neurological deficits were consistent with spinal cord involvement at the level of injury; and 3) complete neurological recovery occurred within 72 hours after injury. Most cases involved young males, injured during athletics or due to falls. Concussion occurred at the two most unstable spinal regions, 16 involving the cervical spinal and three the thoracolumbar junction. Fifteen cases presented with combined sensorimotor deficits, while four exhibited only sensory disturbances. Many patients showed signs of recovery with the first few hours after injury and most had completely recovered within 24 hours. Only one case involved an unstable spinal injury. There was no evidence of ligamentous instability, spinal stenosis, or canal encroachment in the remaining 18 cases. Two patients, both children, suffered recurrent SCC injuries. No delayed deterioration or permanent cord injuries occurred. Spinal abnormalities that would predispose the spinal cord to a compressive injury were present in only one of the 19 cases. This suggests that, as opposed to direct cord compression, SCC may be the result of an indirect cord injury. Possible mechanisms are discussed.

Outcome of 51 cases of unilateral locked cervical facets: interspinous braided cable for lateral mass plate fusion compared with interspinous wire and facet wiring with iliac crest

1999 ◽  
Vol 91 (1) ◽  
pp. 19-24 ◽  
Author(s):  
Scott Shapiro ◽  
William Snyder ◽  
Kevin Kaufman ◽  
Todd Abel
Keyword(s):  
Cervical Spine ◽  
Mr Imaging ◽  
Neck Pain ◽  
Internal Fixation ◽  
Closed Reduction ◽  
Iliac Crest ◽  
Lateral Mass ◽  
Reduction Procedure ◽  
Content Type ◽  
Fine Print

Object. To increase knowledge about unilateral facet dislocation, including presentation, radiological findings, management, and outcome, the authors reviewed the cases of 51 consecutive patients with unilateral locked facets of the cervical spine who underwent treatment over an 11-year period. With the development of internal fixation devices, the authors compared the procedure of using interspinous wire and facet wiring of iliac crest to fix unilateral locked facets with that in which interspinous braided cable and lateral mass plates were used. Methods. Thirty-seven patients (73%) presented with radiculopathy, eight (16%) with neck pain only, and six (12%) with spinal cord injuries (SCIs). Plain x-ray films demonstrated subluxation in only 44 (86%) of 51 cases. All patients underwent cervical computerized tomography (CT) scanning, and in all patients with SCI, a magnetic resonance (MR) image was obtained. Fracture in addition to facet locking was seen on 24 (47%) of 51 CT scans. Disc disruption with cord compression was seen in five cases (10%). Based on CT and/or MR imaging findings, a closed reduction procedure was believed to be contraindicated in 11 cases (22%). Of the remaining 40 patients, 13 (33%) underwent closed reduction procedures. Two patients who underwent a closed reduction procedure were placed in a halo brace but experienced resubluxation. Thus, all cases were surgically treated. Forty-six patients underwent posterior reduction and/or internal fixation alone (in 24 cases spinous process fixation with facet wiring was connected to struts of iliac crest, and in 22 cases interspinous braided cable for lateral mass plating was used). Initial surgery, regardless of technique, was successful in 45 (98%) of 46 cases. One patient experienced a resubluxation and underwent reoperation in which anterior cervical fusion and plating were performed. Four of six patients with SCI underwent an emergency combined anterior—posterior decompressive procedure in which internal fixation was performed, and the patients experienced immediate neurological improvement. Overall there were no cases of neurological worsening or death, and there were three cases of wound infection. At 1 year postsurgery, all deficits had improved. Of 37 cases of radiculopathy, three patients (8%) experienced persistent 4/5 weakness, and the remaining patients were normal, including four patients in whom diagnosis was delayed. The six patients with SCI all improved significantly by 1 year. Persistent neck pain was seen in nine cases (18%). Although the lateral mass plates and interspinous cable are stronger, easier to place, and significantly lessened the amount of resultant kyphosis (p < 0.02), the results of chi-square analysis demonstrated only a slight trend for improved clinical outcome compared with the use of wire and iliac crest (p = 0.1). Conclusions. Cervical CT and MR imaging provide information that aids in the diagnosis and management of patients with unilateral locked facets of the cervical spine. The authors' experience strongly suggests that a reduction procedure in which internal fixation and bone fusion are performed will be the most successful treatment for this injury.

A fatal, chronically growing basilar artery: a new type of dissecting aneurysm

1996 ◽  
Vol 84 (6) ◽  
pp. 962-971 ◽  
Author(s):  
Tohru Mizutani
Keyword(s):  
Mr Imaging ◽  
Basilar Artery ◽  
Dissecting Aneurysm ◽  
Neurological Deficits ◽  
Vertebrobasilar Insufficiency ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Basilar Arteries ◽  
Fine Print

✓ A long-term follow-up study (minimum duration 2 years) was made of 13 patients with tortuous dilated basilar arteries. Of these, five patients had symptoms related to the presence of such arteries. Symptoms present at a very early stage included vertebrobasilar insufficiency in two patients, brainstem infarction in two patients, and left hemifacial spasm in one patient. Initial magnetic resonance (MR) imaging in serial slices of basilar arteries obtained from the five symptomatic patients showed an intimal flap or a subadventitial hematoma, both of which are characteristic of a dissecting aneurysm. In contrast, the basilar arteries in the eight asymptomatic patients did not show particular findings and they remained clinically and radiologically silent during the follow-up period. All of the lesions in the five symptomatic patients gradually grew to fantastic sizes, with progressive deterioration of the related clinical symptoms. Dilation of the basilar artery was consistent with hemorrhage into the “pseudolumen” within the laminated thrombus, which was confirmed by MR imaging studies. Of the five symptomatic patients studied, two died of fatal subarachnoid hemorrhage (SAH) and two of brainstem compression; the fifth patient remains alive without neurological deficits. In the three patients who underwent autopsy, a definite macroscopic double lumen was observed in both the proximal and distal ends of the aneurysms within the layer of the thickening intima. Microscopically, multiple mural dissections, fragmentation of internal elastic lamina (IEL), and degeneration of media were diffusely observed in the remarkably extended wall of the aneurysms. The substantial mechanism of pathogenesis and enlargement in the symptomatic, highly tortuous dilated artery might initially be macroscopic dissection within a thickening intima and subsequent repetitive hemorrhaging within a laminated thrombus in the pseudolumen combined with microscopic multiple mural dissections on the basis of a weakened IEL. The authors note and caution that symptomatic, tortuous dilated basilar arteries cannot be overlooked because they include a group of malignant arteries that may grow rapidly, resulting in a fatal course.

Intramedullary ependymoma of the spinal cord

1990 ◽  
Vol 72 (4) ◽  
pp. 523-532 ◽  
Author(s):  
Paul C. McCormick ◽  
Roland Torres ◽  
Kalmon D. Post ◽  
Bennett M. Stein
Keyword(s):  
Spinal Cord ◽  
Mr Imaging ◽  
Tumor Recurrence ◽  
Neurological Deficits ◽  
Functional Improvement ◽  
Consecutive Series ◽  
Intramedullary Spinal Cord ◽  
Content Type ◽  
Fine Print

✓ A consecutive series of 23 patients underwent operative removal of an intramedullary spinal cord ependymoma between January, 1976, and September, 1988. Thirteen women and 10 men between the age of 19 and 70 years experienced symptoms for a mean of 34 months preceding initial diagnosis. Eight patients had undergone treatment prior to tumor recurrence and referral. Mild neurological deficits were present in 22 patients on initial examination. The location of the tumors was predominantly cervical or cervicothoracic. Radiological evaluation revealed a wide spinal cord in all cases. Magnetic resonance (MR) imaging was the single most important radiological procedure. At operation, a complete removal was achieved in all patients. No patient received postoperative radiation therapy. Histological examination revealed a benign ependymoma in all cases. The follow-up period ranged from 6 to 159 months (mean 62 months) with seven patients followed for a minimum of 10 years after surgery. Fourteen patients underwent postoperative MR imaging at intervals ranging from 8 months to 10 years postoperatively. No patient has been lost to follow-up review and there were no deaths. No patient showed definite clinical or radiological evidence of tumor recurrence during the follow-up period. Recent neurological evaluation revealed functional improvement from initial preoperative clinical status in eight patients, no significant change in 12 patients, and deterioration in three patients. The data support the belief that long-term disease-free control of intramedullary spinal ependymomas with acceptable morbidity may be achieved utilizing microsurgical removal alone.

Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury

1992 ◽  
Vol 76 (2) ◽  
pp. 218-223 ◽  
Author(s):  
Dale M. Schaefer ◽  
Adam E. Flanders ◽  
Jewell L. Osterholm ◽  
Bruce E. Northrup
Keyword(s):  
Cervical Spine ◽  
Mr Imaging ◽  
Prognostic Significance ◽  
Spinal Segment ◽  
Content Type ◽  
Group 3 ◽  
Group 2 ◽  
Fine Print ◽  
Group 1

✓ Fifty-seven patients with acute cervical spine injuries and associated major neurological deficit were examined within 2 weeks of injury by magnetic resonance (MR) imaging. All patients had abnormal scans, indicating intramedullary lesions. This study was undertaken to determine if the early MR imaging pattern had a prognostic relationship to the eventual neurological outcome. Three different MR imaging patterns were observed in these patients: 21 patients had patterns characteristic of intramedullary hematoma (Group 1); 17 had intramedullary edema over more than one spinal segment, but no hemorrhage (Group 2); and 19 had restricted zones of intramedullary edema involving one spinal segment or less (Group 3). The neurological state was determined using standard motor index scores at admission and at follow-up examination. Characteristically, the patients in Group 1 had admission motor scores significantly lower than the other two groups. At follow-up examination, the median percent motor recovery was 9% for Group 1, 41% for Group 2, and 72% for Group 3. These studies suggest that the MR imaging pattern observed in the acutely injured human spinal cord has a prognostic significance in the final outcome of the motor system. It is only when an accurate prognosis can be given at the outset that useful treatment data might be collected for homogeneous injury groups, and accurately based long-term planning made for the best patient care.

Fractures of the C-2 vertebral body

1994 ◽  
Vol 81 (2) ◽  
pp. 206-212 ◽  
Author(s):  
Edward C. Benzel ◽  
Blaine L. Hart ◽  
Perry A. Ball ◽  
Nevan G. Baldwin ◽  
William W. Orrison ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Soft Tissue ◽  
Mr Imaging ◽  
Upper Cervical Spine ◽  
Content Type ◽  
Body Fracture ◽  
Pars Interarticularis ◽  
Upper Cervical ◽  
Type 3 ◽  
Fine Print

✓ Vertical C-2 body fractures are presented in 15 patients with clinical and imaging correlations that suggest the existence of a variety of mechanisms of injury. In these patients, clinical and imaging correlations were derived by: 1) defining the point of impact by clinical examination; 2) defining the point of impact by soft-tissue changes on cranial magnetic resonance (MR) imaging or computerized tomography (CT); 3) obtaining an accurate history of the mechanism of injury; and 4) spine imaging (x-ray studies, CT, and MR imaging) of the C-2 body fracture and surrounding bone and soft tissue. The cases presented involve the region located between the dens and the pars interarticularis of the axis. Although these fractures are rarely reported, they are not uncommon. An elucidation of their pathological anatomy helps to further the understanding of the mechanistic etiology of upper cervical spine trauma. A spectrum of mechanisms of injury causing upper cervical spine fractures was observed. The type of injury incurred is determined predominantly by the force vector applied during impact and the intrinsic strength and anatomy of C-2 and its surrounding spinal elements. From this clinical experience, two types of vertical C-2 body fractures are defined and presented: coronally oriented (Type 1) and sagittally oriented (Type 2). A third type of C-2 body fracture, the horizontal rostral C-2 fracture (Type 3), is added for completeness; this Type 3 fracture is the previously described Type III odontoid process fracture described by Anderson and D'Alonzo.

Magnetic resonance imaging evaluation of the cervical spine in the comatose or obtunded trauma patient

1999 ◽  
Vol 91 (1) ◽  
pp. 54-59 ◽  
Author(s):  
Mark D. D'Alise ◽  
Edward C. Benzel ◽  
Blaine L. Hart
Keyword(s):  
Cervical Spine ◽  
Soft Tissue ◽  
Mr Imaging ◽  
Trauma Patient ◽  
Cervical Spine Injury ◽  
Tissue Injury ◽  
Soft Tissue Injury ◽  
Spine Injury ◽  
Content Type ◽  
Fine Print

Object. Confirmation of cervical spine stability is difficult to obtain in the comatose or obtunded trauma patient. Concurrent therapies such as endotracheal intubation and the application of rigid cervical collars diminish the utility of plain radiographs. Bony as well as supportive soft-tissue structures must be evaluated before the cervical spine can be determined to be uninjured. Although major injuries to extradural soft-tissue structures in the awake trauma patient are frequently excluded by physical examination, when the patient is obtunded the physical examination may be unreliable. Therefore, an enhanced diagnostic method for the evaluation of soft-tissue injury is desirable. The authors conducted a study in which magnetic resonance (MR) imaging was used as such a method to assess posttraumatic spinal stability in the comatose or obtunded patient. Methods. Early, limited (sagittal T1- and T2-weighted) MR imaging was performed posttruama in 121 patients to assess soft-tissue injury. In all patients the mechanism of injury potentially could be associated with cervical spine instability, and each patient was endotracheally intubated because of head injury or severe multisystem injuries. All patients underwent imaging studies within 48 hours of injury and were either treated or cleared and spinal precautions were discontinued. Patients were excluded from this study if they had an obvious cervical spine injury identified on the initial radiographic studies or if they were determined to be too medically unstable to undergo MR imaging within the acute period (<48 hours postinjury). Thirty-one (25.6%) of the 121 patients were found to have sustained significant injury to the paravertebral ligamentous structures, the disc interspace, or the bony cervical spine. These injuries were undetected by plain radiography. The other 90 patients (74.4%) were determined within 48 hours not to have sustained a soft-tissue injury. Eight patients (6.6%) ultimately underwent surgery to treat the cervical spine injury, and MR imaging was the first test that identified the injury in each of these patients. There were no complications related to imaging procedures. Conclusions. Sagittal T1- and T2-weighted MR imaging appears to be a safe, reliable method for evaluating the cervical spine for nonapparent injury in comatose or obtunded trauma patients. In the early postinjury period, nursing and medical care are thereby facilitated for patients in whom occult injury to the spine is ruled out and for whom those attendant precautions are unnecessary.

Magnetic resonance imaging for the evaluation of patients with occult cervical spine injury

1996 ◽  
Vol 85 (5) ◽  
pp. 824-829 ◽  
Author(s):  
Edward C. Benzel ◽  
Blaine L. Hart ◽  
Perry A. Ball ◽  
Nevan G. Baldwin ◽  
William W. Orrison ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Magnetic Resonance ◽  
Soft Tissue ◽  
Mr Imaging ◽  
Soft Tissue Injury ◽  
Spine Injury ◽  
Ligamentous Injury ◽  
Radiographic Findings ◽  
Content Type ◽  
Fine Print

✓ Because it is often difficult to diagnose accurately the structurally intact cervical spine after acute trauma, a series of patients was evaluated with magnetic resonance (MR) imaging to assess its efficacy for the evaluation and clearance of the cervical spine in a trauma victim in the early posttrauma period. Ultralow-field MR imaging was used to evaluate 174 posttraumatic patients in whom physical findings indicated the potential for spine injury or minor radiographic findings indicated injury. This series includes only those patients who did not appear to harbor disruption of spinal integrity on the basis of a routine x-ray film. None had clinically obvious injury. Of the 174 patients, 62 (36%) had soft-tissue abnormalities identified by MR imaging, including disc interspace disruption in 27 patients (four with ventral and dorsal ligamentous injury, three with ventral ligamentous injury alone, 18 with dorsal ligamentous injury alone, and two without ventral or dorsal ligamentous injury). Isolated ligamentous injury was observed in 35 patients (eight with ventral and dorsal ligamentous injury, five with ventral ligamentous injury alone, and 22 with dorsal ligamentous injury alone). One patient underwent a surgical fusion procedure, 35 patients (including the one treated surgically) were placed in a cervical collar for at least 1 month, and 27 patients were placed in a thermoplastic Minerva jacket for at least 2 months. All had a satisfactory outcome without evidence of instability. The T2-weighted sagittal images were most useful in defining acute soft-tissue injury; axial images were of minimal assistance. Posttraumatic soft-tissue cervical spine injuries and disc herniations (most likely preexisting the trauma) are more common than expected. A negative MR image should be considered as confirmation of a negative or “cleared” subaxial cervical spine. Diagnostic and patient management algorithms may be appropriately tailored by this information. Thus, MR imaging is useful for early acute posttrauma assessment in a very select group of patients.

Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases

2005 ◽  
Vol 3 (6) ◽  
pp. 450-458 ◽  
Author(s):  
Feyza Karagöz Güzey ◽  
Erhan Emel ◽  
N. Serdar Bas ◽  
Selim Hacisalihoglu ◽  
Hakan Seyithanoglu ◽  
...  
Keyword(s):  
Spinal Injury ◽  
Posterior Instrumentation ◽  
Neurological Deficits ◽  
Easy Access ◽  
Tuberculous Spondylitis ◽  
Content Type ◽  
The Mean ◽  
Posterior Debridement ◽  
Fine Print

Object. Surgical treatment of thoracic and lumbar tuberculous spondylitis is controversial. An anterior approach is usually recommended. The aim of the present study was to assess the efficacy of posterior debridement and the placement of posterior instrumentation for the treatment of patients with thoracic and lumbar tuberculous spondylitis. Methods. Nineteen patients with thoracic and lumbar tuberculous spondylitis underwent single-stage posterior decompression and debridement as well as the placement of posterior interbody grafts if necessary, instrumentation and posterior or posterolateral grafts. No postoperative neurological deterioration was noted. One patient died of myocardial infarction on Day 10. The mean follow-up duration, excluding the one death, was 52.7 months (range 16–125 months). In a 70-year-old patient, a single pedicle screw broke after 3 months. All patients were in better neurological condition after surgery and at the last follow-up examination. Neurological deficits were present in only two patients at the last follow up (one American Spinal Injury Association Grade B and one Grade C deficit preoperatively). Three other patients suffered intermittent back or low-back pain. The mean angulation measured in 13 patients with kyphotic deformity was 18.2° (range 5–42°) preoperatively; this was reduced to 17.3° (range 0–42°) after surgery. There was a 2.8° loss of correction (range 2–5°) after 44.3 months (16–64 months). Kyphosis did not progress beyond 15 months in any patient. Conclusions A posterior approach in combination with internal fixation and posterior or posterolateral fusion (with or without placement of posterior interbody grafts) may be sufficient for the debridement of the infection and to allow spinal stabilization in patients with thoracic and lumbar tuberculous spondylitis. This procedure is associated with easy access to the spinal canal for neural decompression, prevention of loss of corrected vertebral alignment in the long term, and facilitation of early mobilization.

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