Abstract

FLEMING, MA; WESTGARTH-TAYLOR, Τ; CANDY, S  and  DUNN, R. How does pre-reduction MRI affect surgeons' behaviour when reducing distraction-flexion (dislocation) injuries of the cervical spine?. SA orthop. j. [online]. 2015, vol.14, n.4, pp.42-46. ISSN 2309-8309.  http://dx.doi.org/10.17159/2309-8309/2015/v14n4a5.

STUDY DESIGN: Retrospective review AIM: To identify factors affecting surgeons' management decisions regarding acute cervical distraction-flexion dislocation reduction and the consequences thereof. SUMMARY OF BACKGROUND DATA: There is clinical benefit when early (<24 hours) decompression in distraction-flexion dislocation (DF) injuries with cord injury is performed. The risk of secondary cord injury during awake closed reduction is low. The need for MRI scanning prior to reduction is controversial but it may identify patients with an uncontained herniated 'disc at risk' that may be drawn into the spinal canal during reduction, causing further cord injury. Surgeons' belief regarding the importance of pre-reduction MRI varies. Thus in many clinical scenarios, treatment algorithms are chosen individually by the surgeon on the merits of each case as well as limited access to MRI facilities in the remoter areas of this large country. METHODS: Analysis was performed on 110 consecutive patients with a mean age of 37.1 years with DF dislocation injuries of the cervical spine. Pre-reduction MRI scans were assessed by two independent, blinded teams to determine patients with a 'disc at risk'. This subgroup was then investigated as to the management decisions, neurological status and outcome. RESULTS: Nineteen patients (21%) were identified to have a perceived 'disc at risk'. Six of these patients underwent anterior surgery. Initial closed reduction was attempted in the other 13. None deteriorated neurologically. Presenting neurological status was found to have a large impact on surgeons' choice of reduction. Of the nine ASIA A patients, seven had initial closed reduction, while in the three ASIA E group only one had closed reduction. CONCLUSION: Patients with agreed MRI features of a perceived 'disc at risk' had no increased risk of secondary cord injury. The presence of these disc lesions only influenced our surgeons to choose open reduction in four cases (21%). Neurological status had a much greater effect on surgical decision-making in that those with neurological deficit (most to gain) were reduced closed and ASIA E (most to lose) tended to open reduction. Early reduction need not wait for MRI imaging and should be performed as soon as possible in cord-injured patients.

Keywords : cervical; MRI; distraction-flexion; unifacet; bifacet; surgeon behaviour.

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