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Cervical jumped facets


Introduction

Fractures of the subaxial spine are typically caused by high-velocity injuries such as motor vehicle collisions, falls, and high-impact sports. The subaxial spine consists of the cervical vertebra numbered three to seven and is more mobile than the upper cervical and upper thoracic spine. The incidence of traumatic spinal cord injuries is about 40 per million persons per year with fractures of the subaxial spine accounting for approximately two-thirds of all cervical spinal cord fractures. In this chapter, we discuss the presentation and management of a patient with bilateral jumped facets and then relevant surgical anatomy and possible treatment options.

Example case

  • Chief complaint: neck pain after fall

  • History of present illness: 81-year-old male who fell from a 5-foot ladder onto his back. He has neck pain and midline tenderness to palpation. He has a pacemaker and cannot undergo magnetic resonance imaging (MRI). He underwent a cervical spine computed tomography (CT) that was concerning for spinal fractures ( Fig. 33.1 ).

  • Medications: warfarin, diuretics

  • Allergies: no known drug allergies

  • Past medical history: congestive heart failure, atrial fibrillation

  • Past surgical history: pacemaker, coronary bypass graft

  • Family history: none

  • Social history: former smoker

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: Bilateral upper extremity 2+ in bilateral biceps/triceps/brachioradialis and Hoffman’s present bilaterally; ataxic gait

  • Laboratories: all within normal limits

  • Carlos A. Bagley, MD

  • Neurosurgery

  • University of Texas Southwestern

  • Dallas, Texas, United States

  • Alvaro Camparo, MD

  • Ramiro Barrera, MD

  • Neurosurgery

  • Hospital Padilla – Tucuman

  • Universidad Nacional de Tucuman

  • Tucuman, Argentina

  • Peter Jarzem, MD

  • Orthopaedic Surgery

  • McGill University

  • Montreal General Hospital

  • Montreal, Canada

  • Alexander R. Vaccaro, MD, PhD, MBA

  • Orthopaedic Surgery

  • Thomas Jefferson University

  • Philadelphia, Pennsylvania, United States

Preoperative
Additional tests requested

  • C-spine upright x-rays

  • CT T-L spine

  • Trauma evaluation

  • Medicine evaluation

  • Cardiology evaluation

  • Cervical traction with x-rays

  • CT angiography

  • CT angiography

  • Medicine evaluation

  • Hematology evaluation

  • CT C-spine with contrast

  • Potential CT myelogram

Surgical approach selected C7 laminectomy, C4-T2 fusion Posterior C6-7 fusion Awake closed reduction with traction, C7 laminectomy C4-T2 fusion C6-7 ACDF

  • Surgical approach if 25

  • Surgical approach if 60

  • Anterior approach

  • Anterior approach

  • Same approach

  • Same approach

  • Similar approach with less levels

  • Similar approach with less levels

  • Same approach

  • Same approach

Goal of surgery Stabilize spine, decompress neural structures Stabilize spine, fusion Reduce dislocation, avoid spinal cord injury, stabilize spine Stabilize spine
Perioperative
Positioning Prone, in pins Prone, in Mayfield pins Supine for traction with Gardner-Wells tongs, prone for fusion Supine
Surgical equipment

  • IOM (MEP/SSEP)

  • Fluoroscopy

Fluoroscopy Fluoroscopy

  • IOM (MEP/SSEP)

  • Fluoroscopy

Medications Pregabalin NSAIDs Steroids, tranexamic acid, maintain MAP Steroids, MAP >85
Anatomical considerations C7 nerve root, thecal sac, spinal cord, vertebral artery Vertebral artery, cervical lateral masses Spinal cord, C5/C7/C8 nerve roots Vertebral artery, anterior epidural space
Complications feared with approach chosen C8 radiculopathy, spinal cord injury, dysphagia, cardiac event Vertebral artery injury, cervical spine lateral mass rupture Spinal cord injury, infection, hematoma, C5 palsy Neurological injury
Intraoperative
Anesthesia General General General General
Exposure C4-T2 C5-T1 C4-T2 C6-7
Levels decompressed C7 None C7 None
Levels fused C4-T2 C6-7 C4-T2 C6-7
Surgical narrative Fiberoptic intubation in cervical collar, position prone, confirm neutral head position, obtain IOM, linear incision from C4-T2, subperiosteal dissection to expose spinous processes/lamina/lateral masses/facets/transverse processes, drill pilot holes for T1-2 bilateral pedicel screws using anatomical landmarks, cannulate and palpate Position prone, cervical traction with fluoroscopy, vertical midline incision from C5-T1, subcutaneous tissue and muscle dissection, subperiosteal dissection of C6 and C7, place C6 and C7 lateral mass screws using high-speed drill and fluoroscopy, place bars and close system, placement of autologous bone graft from iliac crest, closure with drain Stage 1: supine position, apply Gardner-Wells tongs on Jackson table, place bolster under shoulder, apply traction while monitoring neurological examination and frequent lateral or oblique x-rays, start with 10 lb and add 10 lb at 3–5 minute intervals until reduced, reduce weight to 20 lb once reduced Position supine, anterior approach if unable to adequately visualize anterior epidural space, x-ray to identify level, transverse incision, dissection between carotid sheath and trachea/esophagus, place first Caspar pin in a convergent manner to allow leveraged manipulation of the dislocated facet with help of a Cloward spreader, gentle
screw holes and confirm trajectory with intraoperative x-ray, place T1-2 pedicle screws bilaterally, drill pilot holes and place lateral mass screws in C4-6 using Magerl technique, drill troughs in C7 lamina at junction of lamina and lateral mass, remove spinous process and lamina, widen laminectomy with Kerrison rongeur, ensure satisfactory decompression of canal centrally and both C7 and C8 nerve roots, ensure satisfactory alignment by readjusting Mayfield if necessary, secure contoured rods, irrigate with bacitracin lactate ringers, decorticate remaining cortical surfaces, pack mixture of local autograft and graft extender on decorticated surfaces, disperse vancomycin powder throughout wound, layered closure with subfascial drain Stage 2 (same day): if reduction still required, awake fiberoptic intubation, position prone with Jackson sandwich and flip onto horseshoe headrest, expose C2-T2, keep muscle attachments to C2, detach muscles to C7/T1/T2, place pedicle screws at T1 and T2 with aid of fluoroscopy, drill lateral mass screws C4-6 and decompress C6 and C7, place screws, realign spine if needed, ensure head position is optimal, attach rods to screws and lock down, close wound over drain distraction of the interspace, rotate left-sided dislocated facet to allow it to pivot on right facet while distracting and reducing dislocated facet, x-ray to confirm successful reduction, place interbody spacer, shave down anterior surface of C6 vertebral body to make it flush with C7 vertebral body, place C6-7 plate, standard closure, posterior approach if unable to reduce, position prone, midline incision based on x-ray, subperiosteal dissection, confirm level with x-ray, decompress partially reduced facet, place C6 lateral mass and C7 pedicle screws, reduce deformity, instrumentation two levels above and below, standard closure
Complication avoidance Magerl technique for lateral mass screws, ensure satisfactory decompression of canal centrally and both C7 and C8 nerve roots Screws under fluoroscopy, limit fusion to two levels Reduce fracture with traction, posterior reduction if needed, keep muscle attached to C7 Anterior approach if unable to visualize anterior epidural space, use Caspar spin to distract disc space, posterior approach added if necessary
Postoperative
Admission Intermediate care ICU ICU Floor
Postoperative complications feared Wound infection, medical complication, pseudoarthrosis Implant loosening or migration, pseudoarthrosis Spinal cord injury, infection, hematoma, C5 palsy Pseudoarthrosis, neurological worsening
Anticipated length of stay 3 days 3 days 3–5 days 2–3 days
Follow-up testing C-spine x-rays within 1 day, 6 weeks, 12 weeks, 6 months, 12 months after surgery Cervical x-ray after surgery, 1 month after surgery Cervical CT 3 months after surgery Cervical x-rays within 1 day after surgery Cervical x-rays after surgery, 6 weeks, 3 months, 6 months after surgery
Bracing None Philadelphia collar for 1 month None Hard collar for 6 weeks
Follow-up visits 6 weeks, 12 weeks, 6 months, 12 months after surgery 7 days, 1 month, 3 months after surgery 6 weeks after surgery 2 weeks, 6 weeks, 3 months, 6 months after surgery
ACDF , Anterior cervical decompression and fusion; CT , computed tomography; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potential; NSAIDs , nonsteroidal antiinflamatory drugs; SSEP , somatosensory evoked potential.

Differential diagnosis

  • ▪

    Cervical facet dislocation

  • ▪

    Acute disc herniation

  • ▪

    Cervical muscle strain

  • ▪

    Cervical stenosis

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