Spinal Dislocations Treatment & Management
- Author: J Allan Goodrich, MD; Chief Editor: Jeffrey A Goldstein, MD more...
Fracture dislocations are associated with the highest incidence of neurologic injury. In those individuals with incomplete or normal neurologic examination findings, the spinal injury has still resulted in significant instability. To allow for early mobilization and the chance for neurologic improvement, surgical management is almost always indicated. Closed reduction of these injuries is quite difficult, if not impossible. Maintenance of the reduction without operative intervention is problematic.
Most often, dislocation fractures can be managed using an entirely posterior approach. Reduction of the malalignment results in spinal canal clearance in most individuals. Significant residual compression can be addressed through an anterior approach in a staged manner or on the same day, depending on the circumstances. The posterior instrumentation and fusion allow for reestablishing the tension-band function of this segment of the spine; however, if significant anterior column loss (burst component) exists, then anterior reconstruction may be indicated. Daniaux described use of transpedicular bone grafting.[20, 21] In this way, the defect created by the reduction can be filled with autologous bone. The graft is intended to fill the anterior half of the body and to avoid posterior extravasation. Arnold has suggested a second means of posterior grafting, through a basal osteotomy of the transverse process and filling the body through aposterolateralwindow.[22, 23, 24, 25, 26, 27]
The patient's blood is usually typed and crossmatched, and 2 units of blood are made available preoperatively. Neuromonitoring would be warranted in the unusual case of a patient who is neurologically intact. The anesthesiologist may place an arterial line or may establish central access, depending on the individual patient and other injuries. A Foley catheter is inserted to monitor urinary output throughout the procedure.
The patient is placed prone on the operative table, and chest rolls or a Wilson frame may be used after careful logrolling. All bony prominences are padded carefully, and superficial nerves such as the ulnar nerve are protected. The arms are placed on arm boards, and hyperabduction of the shoulders should be avoided.
A midline incision extending one level above to one level below the proposed segments to be instrumented should be used. Once the incision has been carried down to the tips of the spinous processes, careful subperiosteal dissection should be continued bilaterally to the facet joints. Frequently, much of the dissection has occurred from the injury, with muscle and soft tissues displaced from the bony elements. A good rule is to start above and below in normal anatomy and work carefully towards the injured zone. Packing with gauze sponges helps to tamponade the bleeding, and packing can be replaced as the exposure continues. The transverse processes are then stripped of overlying muscle until the tips are exposed. Bipolar and unipolar cauteries are used to maintain hemostasis. Because the spinal canal may be open and the dura exposed, care must be taken when approaching this area. The exposed facet joints at the level of dislocation may be denuded of their articular cartilage prior to reduction.
Frequently, an associated fracture is present. Resection of bone should be avoided at the joint level as this further destabilizes the spine. Reduction is generally achieved by gentle distraction with a lamina spreader and manipulation with bone-holding forceps or towel clips. Once the reduction has been obtained, a single wire or cable may be passed through the adjacent spinous processes prior to definitive fixation. At this point, options for fixation include multiple hooks in a claw construct 2-3 levels above and 1-2 levels below. Depending on the individual anatomy, pedicle screw fixation may be used from 2 segments above to 1-2 segments below. The landmarks for insertion for pedicle screws in the lumbar spine include bisection of the transverse process as it abuts the superior articular facet. The angle of inclination varies from 10-15° at L1 to 25° at L5.
Thoracic screw insertion is 3 mm lateral to the center of the facet joint just below the articulation. Image intensification, in addition to surface landmarks, may be used in the thoracic region. Intraoperative stereotaxic guidance has been used in a number of centers but has not been universally applied. While a compression construct provides the most rigid stabilization, the risk of disk herniation increases, and this construct should be used with caution in the patient who is neurologically intact or not.
An autograft may then be harvested from the iliac crest, and decortication for fusion purposes generally is performed for the length of the instrumentation. Studies have demonstrated that instrumented segments not formally fused usually undergo ankylosis, and application of the graft may be limited to a segment above the disruption to a segment below. Closure is performed in a layered fashion over a Hemovac drain, which is removed 1-2 days postoperatively.
Postoperatively, the patient should be turned frequently, and thromboembolic prophylaxis should be addressed with compression devices and, in certain instances, medically with either low molecular weight heparin or Coumadin. In certain cases in which anticoagulation therapy is contraindicated (gastrointestinal ulcers, intracranial injuries) or pulmonary embolism has occurred despite adequate anticoagulation, mechanical vena cava filters may be inserted. Early mobilization is encouraged, and, depending on the stability obtained during surgery, bracing may not be necessary. In the patient who is neurologically intact, close monitoring and early mobilization should minimize skin breakdown.
The Foley catheter should be removed, and intermittent catheterization should be performed as soon as the patient's general medical condition allows. An early bowel regimen should be initiated, and alternate day suppositories should be used. Once medically stable, transfer to a rehabilitation facility with special expertise in spinal injuries is beneficial to the recovery process. In such a facility, the physical and psychological issues facing the individual patient and the family can be addressed in an environment with others with similar problems.
The sutures generally can be removed after approximately 10 days, and rehabilitation can be initiated as soon as the general medical condition of the patient allows. Arthrodesis progresses over a 3- to 6-month period, and serial radiographs should be obtained to assess alignment and progressive union of the bone grafting. It is not uncommon to see gradual loss of 10° of correction with posterior only procedures. Bracing, which usually is a removable thoracolumbosacral orthosis, is used for 3-6 months. In individuals who are paraplegic, close attention to skin pressure and breakdown must be observed.
Complications can be subdivided into 2 major groups: those related to the operative procedure and those secondary to the spinal cord or cauda equina injuries. Surgical complications can be further classified as related to positioning, intraoperative occurrences, and postoperative complications.
Patients with spinal injuries should be positioned carefully at the time of surgery to avoid compression of bony prominences. The arms should be placed at right angles to the body or tucked by the sides. The ulnar nerve is particularly vulnerable, and pressure at the elbow should be avoided.
Intraoperative complications include dural tears, misdirected instrumentation, excessive bleeding requiring transfusions, and fluid replacement. While the level of injury is usually obvious at the time of surgery, intraoperative imaging can be extremely valuable to document the levels of stabilization and position of pedicle screws and hooks. Placement of hooks in the thoracic region may compromise canal space, and, if possible, a staggered hook construct avoids excessive canal stenosis at each level. With close attention to position of pedicle screws, malplacement can be avoided. The tip of the screw should not cross the midline on an AP radiograph but generally should point toward the midline.
Postoperative attention to adequate resuscitation is of utmost importance. Frequently, fluid and electrolyte concerns, including serum magnesium replacement, must be addressed. Correction of clotting abnormalities may require the administration of fresh frozen plasma and platelets; however, mild deficits usually correct rapidly in the absence of significant liver abnormalities.
Postoperative hematomas may require drainage, and persistent drainage should be aggressively managed to avoid an underlying deep infection. The appearance of the skin may be misleading, and, certainly if a spiking temperature occurs in this setting, early exploration is warranted. Unrecognized cerebrospinal fluid leakage may be heralded by postural headaches and clear drainage from the wound. Eismont has suggested open operative repair when possible, but closed drainage techniques for 3-5 days also have been recommended to manage this problem.
Outcome and Prognosis
Incomplete injuries at the cauda equina level tend to have a more favorable recovery rate compared to mixed conus and cauda equina lesions or lower spinal cord injury. According to a multicenter study reported by Gertzbein, the prognosis for bowel and bladder recovery appears to be improved with anterior decompression. Complete neurologic deficits continue to have a grim prospect for recovery, and emphasis on rehabilitation and incorporation of the individual with paraplegia into society is aided by regional spinal cord injury centers.
Long-term management of bowel and bladder dysfunction should include the use of stool softeners, suppositories, a high fiber diet, and intermittent urinary catheterizations to decrease the residual urine volume. Despite these efforts, chronic urinary tract infections continue to plague the patient with paraplegia.
The ultimate functional outcome may be affected significantly by the patient's age, body habitus, general medical condition, and cognitive and motivational factors. Depression is quite frequent in this patient population and can adversely affect the recovery and rehabilitative process. A multidisciplinary approach, including physical and occupational therapists as well as psychological support, is desirable.
With motor grade strength improvement greater than a 3 (antigravity level), ambulation may be possible with the use of adjunctive orthoses. This may result in extreme energy requirements and may interfere with the performance of upper extremity activities while standing. Simplification of daily routines can help in conserving energy and improving the lifestyles of patients with spinal injuries.
Future and Controversies
Spinal cord injury continues to be a significant source of morbidity and mortality among the young adult population in this country. Each year, approximately 10,000 new patients with spinal cord injuries are added to the 180,000-200,000 individuals already living with spinal cord injuries.
Treatment methods have evolved over the last 50 years, and means to minimize the extent of injury are employed. This has included the acute administration of high-dose steroids based on the results of 3 studies published by the National Acute Spinal Cord Injury Study (NASCIS) and the use of gangliosides as reported by Geisler et al.[30, 31, 32, 33, 34, 35, 36]
Timely canal decompression and stabilization of the affected areas have been made possible by the introduction of modern instrumentation systems and improved surgical approaches. Research continues to address spinal cord recovery and has included laboratory experiments in neural element transplantation and fetal cell transplants. Firm supportive data for these efforts remain to be clinically proven; however, research must continue in order to aid this growing population of patients.
Breasted JH. The Edwin Smith surgical papyrus. Chicago: Univ. Chicago Press,; 1980,. 2 vols. (see 1: pp. xvi, 6, 480-485, 487-489, 446-448, 451-454, 466; 2: pi. XVII, XVIIA).
Wilkins RH. Neurosurgical Classic-XVIIEdwin Smith Surgical Papyrus. Cyber Museum of Neurosurgery. Available at http://www.neurosurgery.org/cybermuseum/pre20th/epapyrus.html. Accessed: August 28, 2008.
NICOLL EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Am. 1949 Aug. 31B(3):376-94. [Medline].
Dunn RN, van der Spuy D. Rugby and cervical spine injuries - has anything changed? A 5-year review in the Western Cape. S Afr Med J. 2010 Mar 30. 100(4):235-8. [Medline].
Kemp AM, Joshi AH, Mann M, Tempest V, Liu A, Holden S, et al. What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review. Arch Dis Child. 2010 May. 95(5):355-60. [Medline].
Liu P, Yao Y, Liu MY, Fan WL, Chao R, Wang ZG, et al. Spinal trauma in mainland China from 2001 to 2007: an epidemiological study based on a nationwide database. Spine (Phila Pa 1976). 2012 Jul 1. 37(15):1310-5. [Medline].
Fellrath RF, Jr, Hanley EN, Jr. Multitrauma and thoracolumbar fractures. Semin Spine Surg. 1995. 7:103-108.
Levine AM. Facet fractures and dislocations of the thoracolumbar spine. Spine Trauma. 1998. 415-427.
Whitesides TE Jr. Traumatic kyphosis of the thoracolumbar spine. Clin Orthop. 1977 Oct. (128):78-92. [Medline].
Schouten R, Albert T, Kwon BK. The spine-injured patient: initial assessment and emergency treatment. J Am Acad Orthop Surg. 2012 Jun. 20(6):336-46. [Medline].
Silva CT, Doria AS, Traubici J, Moineddin R, Davila J, Shroff M. Do additional views improve the diagnostic performance of cervical spine radiography in pediatric trauma?. AJR Am J Roentgenol. 2010 Feb. 194(2):500-8. [Medline].
Radcliff K, Kepler C, Reitman C, Harrop J, Vaccaro A. CT and MRI-based diagnosis of craniocervical dislocations: the role of the occipitoatlantal ligament. Clin Orthop Relat Res. 2012 Jun. 470(6):1602-13. [Medline]. [Full Text].
Grauer JN, Vaccaro AR, Lee JY, Nassr A, Dvorak MF, Harrop JS, et al. The timing and influence of MRI on the management of patients with cervical facet dislocations remains highly variable: a survey of members of the Spine Trauma Study Group. J Spinal Disord Tech. 2009 Apr. 22(2):96-9. [Medline].
Christopher M. Bono, M.D.Marie D. Rinaldi, M.D. Thoracolumbar Trauma. Jeffery Spivak,MD and Patrick J. Connolly MD. Orthopaedic Knowledge Update Spine 3. Third. Rosemont, Illinois: American Academy of Orthopaedic Surgeons; 2006. 201-216/23.
Arnold PM, Brodke DS, Rampersaud YR, Harrop JS, Dailey AT, Shaffrey CI, et al. Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries and making assessment and treatment decisions: a multicenter reliability study. Am J Orthop (Belle Mead NJ). 2009 Oct. 38(10):E156-61. [Medline].
Noonan V, Thorogood NP, Fingas M, Batke J, Belanger LM, Kwon BK, et al. The Validity of Administrative Data to Classify Patients with Spinal Column and Cord injuries. J Neurotrauma. 2012 Sep 24. [Medline].
Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am. 1970 Dec. 52(8):1534-51. [Medline].
Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994. 3(4):184-201. [Medline].
Rajasekaran S. Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment. Eur Spine J. 2010 Mar. 19 Suppl 1:S40-7. [Medline].
Daniaux H. [Transpedicular repositioning and spongioplasty in fractures of the vertebral bodies of the lower thoracic and lumbar spine]. Unfallchirurg. 1986 May. 89(5):197-213. [Medline].
Daniaux H, Seykora P, Genelin A, Lang T, Kathrein A. Application of posterior plating and modifications in thoracolumbar spine injuries. Indication, techniques, and results. Spine. 1991 Mar. 16(3 Suppl):S125-33. [Medline].
Bedbrook GM. Treatment of thoracolumbar dislocation and fractures with paraplegia. Clin Orthop. 1975 Oct. (112):27-43. [Medline].
Bohlman HH. Treatment of fractures and dislocations of the thoracic and lumbar spine. J Bone Joint Surg Am. 1985 Jan. 67(1):165-9. [Medline].
Lewis J, McKibbin B. The treatment of unstable fracture-dislocations of the thoraco-lumbar spine accompanied by paraplegia. J Bone Joint Surg Br. 1974 Nov. 56-B(4):603-12. [Medline].
Vialle R, Rillardon L, Feydy A, Levassor N, Lavelle G, Guigui P. Spinal trauma with a complete anterior vertebral body dislocation: a report of three cases. Spinal Cord. 2008 Feb. 46(2):154-8. [Medline].
Reindl R, Ouellet J, Harvey EJ, Berry G, Arlet V. Anterior reduction for cervical spine dislocation. Spine. 2006 Mar 15. 31(6):648-52. [Medline].
Wang HC, Yang YL, Lin WC, Chen WF, Yang TM, Lin YJ, et al. Computer-assisted pedicle screw placement for thoracolumbar spine fracture with separate spinal reference clamp placement and registration. Surg Neurol. 2008 Jun. 69(6):597-601; discussion 601. [Medline].
Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am. 1981 Sep. 63(7):1132-6. [Medline].
Gertzbein SD. Scoliosis Research Society. Multicenter spine fracture study. Spine. 1992 May. 17(5):528-40. [Medline].
Bracken MB, Holford TR. Neurological and functional status 1 year after acute spinal cord injury: estimates of functional recovery in National Acute Spinal Cord Injury Study II from results modeled in National Acute Spinal Cord Injury Study III. J Neurosurg. 2002 Apr. 96(3 Suppl):259-66. [Medline].
Coleman WP, Benzel D, Cahill DW, Ducker T, Geisler F, Green B, et al. A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury. J Spinal Disord. 2000 Jun. 13(3):185-99. [Medline].
Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials. J Trauma. 1998 Dec. 45(6):1088-93. [Medline].
Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997 May 28. 277(20):1597-604. [Medline].
Young W. NASCIS. National Acute Spinal Cord Injury Study. J Neurotrauma. 1990 Fall. 7(3):113-4. [Medline].
Geisler FH. GM-1 ganglioside and motor recovery following human spinal cord injury. J Emerg Med. 1993. 11 Suppl 1:49-55. [Medline].
Geisler FH, Dorsey FC, Coleman WP. Recovery of motor function after spinal-cord injury--a randomized, placebo-controlled trial with GM-1 ganglioside. N Engl J Med. 1991 Jun 27. 324(26):1829-38. [Medline].