Patient: 23-year-old male Presentation: Motor vehicle accident (restrained driver, rear-ended), conscious and coherent, severe neck pain and midline tenderness, no neurological deficits Relevant history: No previous neck problems, no medical conditions, no anticoagulation Examination findings:
| Test | Result | Normal Range | Interpretation |
|---|---|---|---|
| N/A | - | - | Bloods not primary investigation for isolated cervical trauma |
Image 1: CT Cervical Spine - Sagittal and Axial
Radiological features:
Image 2: MRI Cervical Spine (if obtained)
MRI findings:
What is your initial assessment and management of this patient?
Describe the imaging findings and classify this injury. What classification systems are relevant?
What additional imaging would you obtain and why? What is the role of MRI?
How would you manage this unilateral facet dislocation? Describe reduction options.
Closed reduction is successful. What are your surgical options for stabilisation?
What are the potential complications and what is the expected outcome for this patient?
This pattern suggests Cervical Spine Trauma (Unilateral Facet Dislocation):
Comparison - Unilateral vs Bilateral Facet Dislocation:
| Feature | Unilateral | Bilateral |
|---|---|---|
| Mechanism | Flexion-rotation | Hyperflexion |
| Subluxation | <50% | >50% (usually complete) |
| Stability | Unstable | Very unstable |
| Neurology | Often intact, root possible | Higher cord injury risk |
| Reduction | Often successful closed | More difficult |
| Approach | ACDF often sufficient | Often 360° |
Q: "What is the role of steroids in acute SCI?"
| Agent | Recommendation |
|---|---|
| Methylprednisolone (NASCIS II/III protocol) | Not routinely recommended |
| Evidence | NASCIS studies had methodological flaws |
| Current practice | Not standard of care in most centres |
| Risks | Infection, GI bleed, hyperglycaemia |
| Exception | Some centres still use within 8 hours of injury |
Conclusion: Most spine surgeons do not administer high-dose steroids. Individual centres may vary.
Q: "When would you obtain MRI before attempted reduction?"
| Situation | Recommendation |
|---|---|
| Awake, examinable patient | Can attempt closed reduction without MRI |
| Obtunded/intubated patient | MRI first to rule out disc herniation (controversial) |
| Neurological deficit present | MRI to assess cord, plan decompression |
| Failed closed reduction | MRI before open surgery |
The controversy centres on the theoretical risk of disc herniation compressing the cord during reduction. Evidence suggests closed reduction in awake patients is safe because neurological change prompts immediate cessation.
Q: "What are the indications for emergency surgery in cervical spine trauma?"
| Indication | Rationale |
|---|---|
| Incomplete SCI with cord compression | Decompress to maximise recovery |
| Progressive neurological deficit | Stop ongoing injury |
| Unreducible dislocation | Open reduction needed |
| Bilateral locked facets with SCI | Urgent reduction required |
Neurologically intact patients with stable injuries can be managed semi-electively (within 24-48 hours).