CASE REPORT cervical spine, dislocation, bilateral
An Unusual Presentation of Bilateral Facet Dislocation of the Cervical Spine We report the case of a patient who presented complaining of neck pain after a fall. Initial physical examination was remarkable for an occipital scalp contusion and tenderness to palpation in the mid-cervical spine. Neurological examination demonstrated an absence of response to pinprick below approximately the T4 level. Upper extremities had equal withdrawal to pain and lower extremities were without movement. Initial cervical, thoracic, and lumbar spine films were normal. An emergency myelogram demonstrated a complete extradural block at the C6 level. Cross-table lateral cervical spine films revealed a C5-C6 bilateral facet dislocation. The patient subsequently underwent closed reduction with in-line traction. He had a prolonged hospital course and was eventually transferred for rehabilitation, with some improvement in neurologic status. [Salomone JA, Steele MT: An unusual presentation of bilateral facet dislocation of the cervical spine. Ann Emerg Med December 1987;16:1390-1393.]
INTRODUCTION Cervical spinal cord injuries with "normal" radiographic findings have been reported, i-4 but to our knowledge no cases of a patient developing bilateral facet dislocations while immobilized in a cervical collar have been described. We report the case of a patient with significant spinal trauma who presented with vague initial neurologic findings and normal cervical spine radiographs, and subsequently developed bilateral locked facets.
Joseph A Salomone, Iit, MD Mark I Steele, MD Kansas City, Missouri From the Department of Emergency Health Services, Truman Medical Center, Kansas City, Missouri. Received for publication April 13, 1987. Revision received June 24, 1987. Accepted for publication July 16, 1987. Address for reprints: Joseph A Salomone, III, MD, Department of Emergency Health Services, Truman Medical Center, 2301 Holmes Road, Kansas City, Missouri 64108.
CASE PRESENTATION A 39-year-old man presented to the emergency department by ambulance. Paramedics accompanying the patient reported that he had fallen backward onto the ground, landing on his head and neck. Information from bystanders indicated that he had consumed approximately one and one-half bottles of wine and that he had been pushed off a 6-foot-high wall. At the scene, the patient was found unconscious in a supine position and no other evidence of trauma was observed. He had a strong odor of alcohol on his breath; initial vital signs were blood pressure, 100/60 m m Hg; pulse, 80; and respirations, 24. The patient responded only to painful stimuli by withdrawing his upper extremities. He exhibited no lower extremity movement but would grimace to painful stimuli applied to his ankles. He was transported to the hospital in a Thomas ® extrication collar and on a long-spine board. On arrival at the ED, the patient was moaning and would not respond to verbal stimuli. Initial vital signs obtained were blood pressure, 64/40 m m Hg; pulse, 80; respirations, 20; and temperature, 36.7 C. An IV line of lactated Ringer's was initiated and a 500-mL fluid bolus was begun. Blood was drawn for CBC, electrolytes, glucose, and ethanol level, and a cross-table lateral cervical spine radiograph was obtained. The patient became more responsive and communicated that his neck hurt and that he wanted the collar removed. Initial physical examination revealed an occipital skull contusion without bony step-offs, depressions, or lacerations. Pupils were equal, round, and equally reactive to light with full extraocular movements; fundi were benign. Tympanic membranes were normal bilaterally, and the remaining facial examination was unremarkable. Neck examination elicited pain with palpation of the spinous processes of C5-C7 without deformities noted. Palpation 16:12 December 1987
Annals of Emergency Medicine
BILATERAL FACET DISLOCATION Salomone & Steele
FIGURE 1. A normal cross-table lateral cervical spine radiograph. FIGURE 2. A normal thoracic and lumbar radiograph. of upper thoracic spine revealed tenderness of T1-T4. Chest, abdomen, and pelvis were unremarkable. Genital examination revealed a semipriapetic penis, and rectal e x a m i n a t i o n showed poor sphincter tone. Extremity examination was unremarkable. Neurologic examination revealed an alert patient who was oriented to person only, and was i n t o x i c a t e d and uncooperative. Motor examination showed symmetrical motion of both upper extremities with equal withdrawal to pain. The lower extremities were without spontaneous motion or withdrawal. Sensory examination was intact to pinprick and light touch in the face, upper extremities, and upper torso with absence of responses below approximately the T4 level. The exa m i n a t i o n varied w i t h the patient's degree of cooperation. Deep-tendon reflexes were present and symmetric in biceps, but were absent in triceps, patella, and ankle. A cross-table lateral cervical spine 116/1391
radiograph was normal. The patient was placed in a Philadelphia ® collar. Additional cervical, thoracic, and lumbar views were obtained, all of which were n o r m a l (Figures 1 and 2). A n emergency computed tomography scan of the head was also normal. A WBC count showed 4,700 m m 3 with 47% polys, 2% bands, 29% lymphoc y t e s , 14% m o n o c y t e s , a n d 8% eosinophils. Hemoglobin and hematocrit were 12.8 and 37.9, respectively. Urinalysis was unremarkable, as were serum electrolytes, glucose, BUN, and creatinine. Blood ethanol level was 255 mg/dL. The patient was m a i n t a i n e d in a cervical collar and on a board despite continued attempts by the patient to remove them. His blood pressure stabilized at 112/78 m m Hg with approximately 1,000 mL of crystalloid; at no time was he tachycardic, but had a pulse rate ranging from 72 to 84. The patient was admitted to the surgical ICU by the neurosurgical service for observation. The following morning he was more alert and cooperative, but there was a definite T3-T4 sensory level and n e w bilateral u p p e r extremity weakness. Emergency lumbar myelogram showed a complete extradural block at the C6 level. A crossAnnals of Emergency Medicine
table lateral plain film obtained at t h a t t i m e s h o w e d bilateral locked facets at the C5-C6 level (Figure 3). The patient had been maintained in the Philadelphia ® collar t h r o u g h o u t the procedure, and the myelogram was done w i t h the aid of the neurosurgeon. The patient was immediately placed in Gardner-Wells tongs and closed reduction with in-line traction was attempted. Traction w e i g h t was progressed slowly over 12 hours to 25 pounds w i t h o u t spontaneous reduction. The patient then was sedated w i t h 10 mg IV diazepam, and the weight increased to 30 pounds, with spontaneous reduction occurring w i t h o u t manipulation. The patient had immediate return of some upper extremity m o v e m e n t and return of perianal s e n s a t i o n and bulbocavernosus reflex. After reduction, weight was reduced and the patient was maintained in 15 pounds of traction and followed. He subsequently developed p n e u m o n i a and required intubation and ventilatory assistance. After recovery from his initial pneumonia he underwent anterior cervical fusion. Postoperatively, the patient had a very s t o r m y and prolonged hospital 16:12 December 1987
FIGURE 3. A cross-table radiograph shows an extradural block at the C5C6 level at lumbar myelogram.
course, suffering repeated episodes of pneumonia requiring prolonged periods of ventilatory assistance. He was transferred to a rehabilitation center w h e n his m e d i c a l c o n d i t i o n stabilized. At the time of transfer, he had regained further upper extremity and some lower extremity movement and sensation. DISCUSSION Cervical spinal cord injuries with "normal" radiographic findings have been described, l-4 as have facet dislocations without significant spinal cord injury.5-7 Bilateral facet dislocations are extremely unstable injuries, and late instability is a problem. To 16:12 December 1987
the best of our knowledge, no case of "spontaneous" facet dislocations during immobilization in a cervical collar has been reported. The mechanism of injury that produces bilateral facet dislocations and the associated clinical findings have been described, sq5 This injury requires forceful hyperflexion with or without rotation of the cervical spine to significantly distract the vertebra and cause multiple ligamentous injuries or disruptions. It is very unstable and is usually associated with severe spinal cord trauma due to marked spinal canal narrowing and impingement on the spinal cord. Locking occurs w h e n the inferior portions of the Annals of Emergency Medicine
cephalad facets slide anterior to the superior portion of the facets of the next lower vertebra. The degree of distraction and severity of cord injury are not related. There may be little distraction and severe injury, or great distraction with little or no injury. Most facet dislocations remain in the dislocated state after the injury. A significant number cannot be reduced without operative intervention. Seldom can bilateral facet dislocations be easily reduced with traction alone. The addition of gentle flexion while under traction may have facilitated reduction of the facets in our case. This technique, however, m u s t be done with utmost care and careful monitoring of the patient's neurologic status. Our patient had a history and examination suggestive of hyperflexion injury (fall backwards striking head and neck, occipital contusion). We postulate that one of three scenarios could explain the development of bilateral locked facets. First, a spontaneous reduction may have occurred after the injury. Second, the facet dislocation was reduced when the patient was placed in the cervical collar by paramedics. The usual difficulty encountered with the reduction of this injury would suggest that spontaneous relocation in the field, with or without the paramedics' assistance, would be unlikely, The third, and perhaps m o s t reasonable explanation, involves a neardislocation injury with severe ligamentous damage. Subsequent positioning or repositioning, despite cervical collar i m m o b i l i z a t i o n , could have allowed luxation and facet locking. The subsequent difficulty encountered in external reduction argues against spontaneous reduction in the field. Several studies have documented the inadequacy of cross-table lateral views and limited cervical spine series [cross-table lateral view, standard anter o p o s t e r i o r view, and o p e n - m o u t h view) in diagnosing significant cervical spine injuries. 16q8 Our case supports these findings. Our patient had what appeared to be spinal cord injury despite normal radiographs, and due to complications of language barrier and intoxication, 1392/117
BILATERAL FACET DISLOCATION Salomone & Steele
c o u l d n o t c o o p e r a t e for a m o r e detailed e x a m i n a t i o n initially. W h e n an u n s t a b l e i n j u r y is suspected, f l e x i o n a n d e x t e n s i o n r a d i o g r a p h s m a y be helpful. T h e s e e x a m i n a t i o n s m u s t be done w i t h the assistance of a k n o w l edgeable physician, preferably one w h o is a c t u a l l y m a n i p u l a t i n g t h e spine. S o m e suggest that these v i e w s s h o u l d be o b t a i n e d w i t h t h e aid of an i m a g e intensifier and direct visualiz a t i o n of t h e spine. ~3 U t m o s t c a r e should be used and c o n s t a n t m o n i t o r ing of the patient's n e u r o l o g i c status performed. Computed tomography scanning m a y be useful in ruling out fractures and intrusions into the spinal canal. 19 Emergency myelography might have proved helpful if any extradural c o m pression had b e e n apparent. However, e m e r g e n c y m y e l o g r a p h y m a y be unhelpful and p o t e n t i a l l y harmful. 12 Collars alone allow significant m o t i o n of t h e l o w e r c e r v i c a l spine.2O, 21 T h e P h i l a d e l p h i a ® c o l l a r a l l o w s app r o x i m a t e l y 30% of n o r m a l flexionextension, and a p p r o x i m a t e l y 40% of n o r m a l rotation. 21 T h i s collar i m m o bilizes the upper cervical spine better t h a n it does the lower. It is conceivable t h a t a p a t i e n t w i t h severe ligam e n t o u s d a m a g e and instability could have sufficient motion even in the c o l l a r to a l l o w for l u x a t i o n . T h i s w o u l d s e e m to be particularly true of injuries to the lower cervical spine. O u r c a s e i l l u s t r a t e s t h e n e e d for m a i n t a i n i n g a high i n d e x of suspicion in t h e h i g h - r i s k p a t i e n t d e s p i t e adverse conditions. T h e " u n c o o p e r a t i v e " i n t o x i c a t e d p a t i e n t m a y indeed be unable rather t h a n unwilling. O u r case e m p h a s i z e s the n e e d for c o n s t a n t ree v a l u a t i o n a n d u t m o s t c a r e in h a n dling patients w i t h spinal injuries and
s u s p e c t e d s p i n a l c o r d t r a u m a . Adequate i m m o b i l i z a t i o n u n t i l definitive f i n d i n g s are i d e n t i f i e d m u s t be t h e role. In cases w i t h a h i g h probability of injury, adequate i m m o b i l i z a t i o n requires m o r e t h a n a s i m p l e rigid collar.
SUMMARY A c a s e of d e l a y e d p r e s e n t a t i o n of cervical facet dislocation was presented and pitfalls in the diagnosis of unstable cervical spine injuries reviewed. T h e i n a d e q u a c y of l i m i t e d c e r v i c a l spine radiographs for d e t e c t i n g unstable injuries was reiterated. A m o r e extensive radiological e x a m i n a t i o n m a y be indicated to rule out occult injury in certain cases.
7. Baker RP, Grubb RL: Complete fracture-dislocation of cervical spine without permanent neurological sequelae. J Neurosurg 1983;58: 760-762. 8. Rogers WA: Fractures and dislocations of the cervical spine. J Bone Joint Surg 1957;39A: 311-376. 9. Norton WL: Fractures and dislocations of the cervical spine. J Bone Joint Surg I962;44A: 115-139. 10. Beatson TR: Fractures and dislocations of the cervical spine. J Bone Joint Suxg 1963;45B: 21-35. 11. Holdsworth F: Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg 1970;52A:1534-1551. 12. Jacobs B: Cervical fractures and dislocations (C3-7). Clin Orthop 1975;109:18-32. 13. Babcock JL: Cervical spine injuries. Arch Surg 1976;111:646-651.
The authors thank James J Hamilton, MD, Professor and Chairman, Department of Orthopaedic Surgery; and Dipak Shah, MD, Assistant Professor, Department of Radiology, Truman Medical Center, for their comments and suggestions.
REFERENCES 1. Taylor AR, Blackwood W: Paraplegia in hyperextension injuries with normal radiographic appearances. J Bone Joint Surg t948;30B: 245-248. 2. Taylor AR: The mechanism of injury to the spinal cord in the neck without damage to the vertebral column. J Bone Joint Surg 1951;33B: 543-547. 3. Scher AT: Cervical spinal cord injury without evidence of fracture or dislocation. South Aft Med J 1976;50:962-965. 4. Pang D, Wilberger JE: Spinal cord injury without radiographic abnormalities in children. Neurosurg 1982;57:114-129. 5. Bovill EG, Eberle CF, Day L, et al: Dislocation of the cervical spine without spinal cord injury. JAMA 1971;218:1288-1290. 6. Pitman MI, Pitman CA, Greenberg IM: Complete dislocation of the cervical spine without neurological deficit. A case report. J Bone Joint
Annals of Emergency Medicine
I4. Bohlman HH: Acute fractures and dislocations of the cervical spine. J Bone Joint Surg 1979;61A:1119-1142. 15. O'Brien PJ, Schweigel JF, Thompson WJ: Dislocations of the lower cervical spine. [ Trauma 1982;22:710-714. 16. Shaffer MA, Doris PE: Limitation of the cross table lateral view in detecting cervical spine injuries: A retrospective review. A n n Emerg Med 1981;I0:508-513. 17. Streitwieser DR, Knopp R, Wales LR, et al: Accuracy of standard radiographic views in detecting cervical spine fractures. Ann Emerg Med I983; 12:538-542. 18. Blahd WH, Iserson KV, Bjelland JC: Efficacy of the posttraumatic cross table lateral view of the cervical spine. J Emerg Med 1985;2:243-249. 19. Mace 8E: Emergency evaluation of cervical spine injuries: CT versus plain radiographs. Ann Emerg Med 1985;14:973-975. 20. McCabe JB, Nolan DJ: Comparison of the effectiveness of different cervical immobilization collars. Ann Emerg Med 1986;15:50-53. 21. Johnson RM, Hart DL, Simmons, EF, et al: Cervical orthoses: A study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg 1977;59A: 332-339.
16:12 December 1987