Review Question - QID 216228

Patients with cervical facet dislocations and altered mental status should undergo an immediate MRI of the cervical spine to assess for a herniated disc, which would necessitate an anterior reduction, discectomy, and interbody fusion.

Cervical facet dislocations are the result of a flexion-distraction mechanism, usually high-energy, that can result in significant spinal cord injury. Initial management either consists of immediate closed reduction followed by MRI and surgical fixation in awake and cooperative patients or immediate MRI followed by surgical reduction and stabilization in patients with altered mental status. Preoperative MRI is useful to determine surgical planning in cases where herniated discs are present. This would require an anterior discectomy, reduction, and internal fixation rather than a posterior reduction and stabilization.

Vaccaro et al. performed a prospective study of 11 patients that underwent pre- and postreduction MRI of the cervical spine for cervical spine dislocations. The authors reported a successful closed reduction in nine patients with two patients having herniated discs prior and five having herniated discs after reduction without any neurologic worsening. They concluded that closed reduction appears to increase intervertebral disc herniations but with questionable clinical consequences.

Hart argued for the necessity of obtaining an MRI prior to the treatment of cervical facet injuries. The author stated that the reduction of facet dislocations can potentially worse herniated discs leading to a significant worsening of neurologic injury, which has been documented in case reports. The author concluded that the 2- to 3-hour delay may not have a significant impact on neurologic recovery, but the author's preferred treatment for complete spinal cord injuries is immediate reduction given there is little to lose in this setting.

Cotler et al. retrospectively reported on 24 patients with cervical spine dislocations that were closed reduced with the patient awake. The authors reported traction weights up to 140 lbs without worsening neurologic status and 17 patients requiring weights more than 50 lbs. The authors concluded awake closed reduction of cervical spine dislocations is safe and effective.

Figure A is a sagittal CT scan of the cervical spine with dislocation of the facet joint at C6-7.

Incorrect answers
Answers 1, 3, 4, and 5: These would all be concerning finding on magnetic resonance imaging, but would not alter surgical management if present.