Closed reduction

Numbers

80% of patients will have their cervical fracture dislocation injuries reduced with a closed

permanent neurological complication: 1%

transient neurological complication: 2-4%

Aim

To reduce fracture-dislocations

Maintain normal alignment and/or immobilise the cervical spine to prevent further spinal cord injury

Reduction and indirect decompresses the spinal cord and roots

Ligamentotaxis may facilitate bone healing

Indications

Trauma

Unilateral or bilateral facet dislocations

Weights ranging from 10 to 120 pounds are frequently required to obtain a reduction of misaligned spinal elements following a dislocation.
10pounds per level

Displaced odontoid fractures, traumatic spondylolisthesis of the axis, rotatory atlantoaxial subluxation, basilar invagination, and cranial settling.

Lower serial traction weights (5–30 lbs)

Nontraumatic cervical spine conditions with deformity

Tumours
Infections
Rheumatoid arthritis
Late post traumatic kyphotic deformity or instability

Contraindications

Extension distraction injuries.

Atlantooccipital dislocation

Traction may worsen deficit.
If immobilisation with tongs/ halo is desired, use no more than ≈ 4 lbs

Types IIA or III hangman’s fracture

Skull defect/fracture at anticipated pin site:

May necessitate alternate pin site

Use with caution in paediatric age group (do not use if age ≤3 yrs)

Very elderly patients

Demineralized skull:

Some elderly patients
Osteogenesis imperfecta

In patients who are not alert and cannot participate in their neurologic examination,

Patients with an additional rostral injury

Patients with movement disorders:

constant motion may cause pin erosion through the skull

patient becomes hemodynamically unstable.

Clinical evaluation

Examination patient neurology

Radiological

X-ray

If a focal rotational deformity, indicative of a unilateral facet joint dislocation, is found on the lateral radiograph, it is useful to discern which facet is dislocated prior to traction application.

Examining head rotation, or radiographically.

On the anteroposterior plain X-ray, the more cephalad spinous process is rotated toward the side of the dislocated facet joint.

However, if there is fracture of the posterior elements, the spinous process direction might be deceptive. In this case, oblique X-rays should be obtained without moving the neck.

Good quality X-rays (including a Swimmer’s view, if needed) are necessary to visualize the lower cervical spine to the level of the superior end plate of T1.

On x-ray or CT if the vertebral body has more than 50percent is bilateral subluxation if less than 50percent is unilateral subluxation

Bow tie sign when the facet is dislocated

A 5-degree caudal tube tilt may help to separate the shoulders and reduce superimposition of surrounding anatomy. This view may be used when C6-C7 cannot be visualised on the lateral cervical view.

Check for disc displacement and degree of PLC injury
Studies have not shown pre traction MRI can reduce risk of injury
The controversy is whether there is need to obtain prereduction MRI to determine if there is a disk herniation.

For pre reduction MRI

To confirm the presence or absence of a herniated disk to prevent further spinal cord damage during the reduction.

Against pre reduction MRI

As long as the patient is awake and alert, closed skeletal traction reduction can be performed safely.

Some physicians recommend prompt reduction without MRI in awake patients with a cervical fracture or dislocation and a significant neurologic deficit < ASIA C

MRI is performed in these patients after reduction to facilitate surgical planning.

In those cases of bilateral or unilateral facet injury and nonsignificant neurologic deficit (>ASIA D) some physicians recommend to perform an MRI even if the patient is alert.

Devices

Head-halters

Pros

Non invasive
Easily applied

Cons

Can only be tolerated for a short period before making it unsuitable for reduction of fracture deformities and dislocations.

Cranial tongs

Gardner-Wells tongs are the most common tongs in use.
Crutchfield tongs require predrilling holes in the skull.
Most used for reduction of cervical spine fracture and fracture dislocations because they allow the application of large traction forces to the skull and cervical spine.
Most commonly used tongs for patients with cervical spine injuries.

Halo rings

Four-pin fixation perpendicularly applied directly to the skull
Low holding power against longitudinal traction.
If, after the acute stabilization, the later use of halo-vest immobilization is anticipated,

Difficulties Encountered

Worsening of a neurologic deficit

Stop closed reduction
Immediate MRI is performed
Surgical treatment is undertaken.

Moreover, disk herniations in cervical spine dislocations before and after reduction are very common.

The presence of an intervertebral disk herniation seen on MRI following a cervical spine dislocation has been implicated as the cause of neurologic worsening in some patients.
However, no sustained neurologic worsening has been reported in an alert, awake, and cooperative patient while undergoing a closed traction reduction.

Procedure

See Paediatric traction

Pt supine and later in a reverse Trendelenburg position.

Allows the patient’s body weight to counteract the pull of traction weights.
Spinal bed

Application of cranial fixation device

Halo

Shave hair at posterior pins sites

Skin prep

Choosing ring

Complete circle rings
Open circle rings

Ring size: choose an appropriately sized ring that leaves a ≈ 1–2cm gap between the scalp and the ring all the way around

Head positioning

Folded towels behind head

Use as many towel as possible to keep head above bed in a comfortable position.
Slowly remove one by one until head is almost in a neutral position that is comfortable for the patient.

If patient is in spasm use analgesia and diazepam to relax muscle

Paddle AKA “spoon” to support the head beyond the edge of the bed,

Ring position:

At or just below the widest portion of the skull (the “equator”), but the front should be ≈ 1cm above the orbital rim and the back should be ≈ 1cm above the pinna.

Anterior pins:

above the lateral two–thirds of the orbit
to avoid

Supraorbital and supratrochlear nerves,
Penetrating the relatively thin anterior wall of the frontal sinus

Posterior pins:

just behind the ears
Just above mastoid

In paediatrics, additional pins may be placed to further distribute the load on the thinner skull

Use back of the needle cover to mark incision and local injection point

Mark away from medial supraorbital notch

Infiltrate local anaesthetic.

Incise skin at the posterior two mastoid points with scalpel

Prevents pins from driving in surface contaminants
Prior to penetrating the forehead skin for anterior pins, have the patient close their eyes and hold them closed as the pins are advanced (this avoids “pinning the eyes open”)

Hand screw in the pins across from each other to finger tight

Use the 8nm Torqued screw driver to screw in the pins

2–5 in-lb for paeds

Funny video for patients

Gardner-Wells tongs

The position of the placement of the cranial tongs is crucial

Skin prepped

Local down to the skull periosteum.

The pins are applied below the equator of the skull, about 1cm superior to the pinna of the outer ear.

Pins are placed in the temporal ridge (above the temporalis muscle), 2–3 fingerbreadths (3–4cm) above pinna.

Tong placement

Neutral:

Place directly above external acoustic meatus for neutral position traction;

Posterior to the neutral axis

2–3cm posterior for flexion (e.g. for locked facets);
Used in unilateral or bilateral facet dislocation.
Traction in this setting results in a flexion moment to the spine and ‘‘unlocks’’ the dislocated facet(s).

Anterior tong placement will

2–3cm anterior for extension.
Result in an extension moment on the spine
A more difficult time reducing the facet(s), requiring additional traction weight to obtain a reduction.

One pin has a central spring-loaded force-indicator.

The pins are tightened by hand until the indicator on the spring-loaded side protrudes about 1mm and retightened 24 hours after their application, until the indicator along the protruding stem is again flush with the flat surface of the pin.

They should not be retightened after this.

Direction of traction:

Unilateral or bilateral facet dislocations, the traction should be applied to gently flex the neck.

It is not unusual to apply a 30- to 45 degree flexion moment to begin the process of realigning the spine.
Displaced odontoid fracture

Bivector traction (both a longitudinal and flexion vector force)

Basilar invagination

Due to rheumatoid arthritis,
longitudinal low-weight traction (10–20 lbs)

Extension-type injuries

require particular care because they are extremely unstable, and even a small degree of weight may result in excessive interspace distraction.
Gentle graded flexion vector
Patients may be reduced in a halo vest with manual halo ring flexion.

Weight:

For stabilisation of injury and to compensate for ligamentous instability

5 lbs for the upper C-spine
10 lbs for lower C-spine

Facetal dislocation

Start with 10 lb and add 5 lb per level = a C5-C6 injury should have 35 lb of traction weight.
More weight is required to reduce a unilateral facet dislocation than a bilateral dislocation.

Reduction weights of > 75 pounds are fairly common in reduction of a unilateral facet dislocation and fairly uncommon in reduction of a bilateral dislocation.

If progressive weight is applied, but reduction is not possible, and there is no change in position of the dislocated vertebrae, a decision must be made whether to pursue further closed reduction.

Additional time under traction is often helpful to allow muscular relaxation and may allow reduction to occur.
Furthermore, intravenous small doses of diazepam may help to reach this goal.

Axial traction alone is not enough to reduce a dislocated facet joint(s).

A flexion vector is necessary to help unlock of facet joints, usually in the range of 30 to 40 degrees.

As soon as cervical distraction has progressed to the point where the articular facets are perched,

a slight extension movement can be applied to the cervical spine by replacing the springs on the frame and/or placing a small roll between the shoulder blades to gain some cervical extension.
The traction weight is then reduced and X-rays are obtained.

Every time adding weights the following must be checked

X-ray to check for:

Excessive distraction at the level of the injury;

Check alignment and rule out overdistraction at any level and atlantooccipital dislocation
To avoid overdistraction, smaller weight increments (i.e., 5 pounds) should be used.

If overdistraction or a significant change in the neurologic exam occurs, the weights should be quickly removed.

BDI should be ≤ 12mm.

Position of the head, to ensure the vector of traction is correct;
To make sure that no occult instability exists, especially at the occipitocervical junction.

Neurologic examination

Weights are then added in 5- to 10-pound increments at 10- to 20-minute intervals to allow muscle relaxation and soft tissue creep.

Post-placement care

Pin tightening:

pins are re-torqued in 24 hours.
Some authors do one additional tightening the day after that.
Avoid further tightenings which can penetrate the skull

Pin care:

clean (e.g. half strength hydrogen peroxide), then apply povidone-iodine ointment.

Frequency:

In hospital: q shift.
At home following discharge: twice daily.

Alternatively, simple cleaning with soap and water twice daily is acceptable.

Definitive fixation

Application of halo vest

For vest placement (i.e., patients not remaining in traction) once the halo ring is placed (see above) it
needs to be attached to the vest by posts.
No clothing between vest and body
The mechanism varies between manufacturers. If possible, have the patient in a cotton T-shirt prior to placing the vest (this may require cutting the neck opening to accommodate the ring).
The vest should be snug, but too tight so as to restrict respirations. Shoulder straps should be contacting the shoulders (the vest will tend to ride up when the patient is sitting).
Most vests come with
a wrench that is taped to the vest for emergency removal e.g. for cardiopulmonary resuscitation.

ACDF
Posterior fixation
Or anterior and post together

Bailout, Rescue, and Salvage Procedures

Before any closed manipulative procedure is performed, the facets must be at a minimum perched.

If a reduction manoeuvre is performed without the facets in this distracted position, the reduction will often be unsuccessful and may potentially result in unnecessary spinal cord compression.

For manipulation of a unilateral facet dislocation, the physician grasps the tongs with both hands while standing above the head of the patient.

The physician applies compression on the located facet side and then turns the neck gradually toward the dislocated facet about 30 to 40 degrees past the midline. If any resistance is felt, the manipulation should be stopped.
A forced manipulation may result in neurologic deficit or a facet fracture.
Usually, with a successful reduction, a pop or click is heard or felt.
A lateral X-ray should then be obtained, and if adequate reduction is achieved, a small roll is placed under the shoulder to maintain slight cervical extension.
The traction weight is then reduced to about 10 to 20 pounds.

For a bilateral facet dislocation, the manipulation maneuverers somewhat different.

The spinous processes are carefully palpated, and a gap can usually be felt at the level of the dislocation.
The physician can apply slight anterior pressure just caudal to the gap, as slight distraction is applied to the tongs.
The head and the neck should be rotated toward one side slowly, about 30 to 40 degrees beyond the midline, then toward the midline, and finally 30 to 40 degrees beyond the midline in the opposite direction to aid in achieving reduction.
The head and neck are then gently extended.
If a closed reduction fails to reduce the dislocation, then an open reduction is performed after the appropriate imaging studies are obtained.

Pitfalls

Causes of failure of closed reduction of cervical spine dislocations and fracture dislocations include

Severe pain or spasm
Deterioration of neurologic function during reduction
Fracture fragments physically preventing reduction
Delay in the time to reduction with partial soft tissue and bony healing

When closed reduction is not successful, a MRI should be obtained and an open reduction and spinal stabilisation procedure is generally considered the treatment of choice.

Complications

Skull penetration by pins due to:

Pins torqued too tightly
Placed over thin bone

Temporal squamosa
Over frontal sinus

Poor bone quality

Elderly patients
Paediatric patients
Osteoporotic skull

Invasion of bone with tumour: e.g. multiple myeloma
Fracture at pin site

Reduction of cervical dislocations may be associated with neurologic deterioration which is usually due to retropulsed disc and requires immediate investigation with MRI or myelogram/CT

Overdistraction from excessive weight

especially with upper cervical spine injuries
may also endanger supporting tissues

Caution with C1–3 injury, especially with posterior element fracture (traction may pull fragments in towards canal)

Infection

Osteomyelitis in pin sites: risk is reduced with good pin care
Subdural empyema