The role of pre-reduction MRI in the management of complex cervical spine fracture-dislocations: an ongoing controversy?

Abstract

Background: Cervical spine fracture-dislocations in neurologically intact patients represent a surgical challenge due to the risk of inflicting iatrogenic spinal cord compression by closed reduction maneuvers. The use of MRI for early advanced imaging in these injuries remains controversially debated.

Case presentation: A 54-year old man sustained a fall over the handlebars of his racing bicycle. The helmeted patient sustained a fall on his head which resulted in a hyperflexion injury of the neck. He was neurologically intact on presentation. Initial CT imaging revealed a complex multisegmental cervical spine injury with a left-sided C6/C7 perched facet, a right sided C7/T1 fracture-dislocation, and a right-sided C6 and C7 traumatic laminotomy. The initial management consisted of temporary external Halo fixator application without closed reduction maneuver, to mitigate the risk of a delayed spinal cord injury. Subsequent advanced imaging by MRI revealed an acute traumatic C7/T1 disc herniation, with the intervertebral disc completely extruded into the spinal canal. Definitive surgical management was then accomplished by employing a three-stage anterior-posterior-anterior spinal decompression, realignment, fixation and fusion C4-T2 in one operative session. The patient recovered well and retained full neurological function. He resumed bicycle street racing within 10 months of the injury following successful spinal reconstruction.

Conclusions: The diagnostic evaluation of cervical fracture-dislocations should include advanced imaging by MRI in order to fully understand the injury pattern prior to proceeding with spinal reduction maneuvers which may impose the imminent threat of a devastating iatrogenic injury to the spinal cord. The presented staged management by initial Halo fixation without attempts for spinal reduction, followed by a surgical decompression and multilevel fusion, appears to represent a feasible and safe strategy for patients at risk of a delayed neurological injury.

Keywords: Cervical spine trauma; Fracture-dislocation; Intervertebral disc herniation; Patient safety; Perched facet; Spinal cord injury; Timing of surgery.

Fig. 1

Initial diagnostic workup of the cervical spine injury with CT (panels a-f) and MRI (panels G,H). The sagittal views in panels a-d demonstrate the fracture dislocation with the left sided perched facet (panel c, and arrow in panel b) and the right sided facet fracture-dislocation (panel d). The posterior traumatic laminotomy is shown in axial CT images of C6 (panel e) and C7 (panel f). Panels g and h are sagittal STIR-weighed MRI images of the cervical spine, demonstrating the extruded C7/T1 disc within the spinal canal (panel h is a magnification of panel g

Fig. 2

Lateral radiograph of the cervical spine after posterior C4-T1 fusion and anterior C7 corpectomy and fusion

Fig. 3

The patient and his wife giving a “thumbs up” in the surgical intensive care unit on postoperative day 1 after spinal fusion and Halo removal

Fig. 4

The patient depicted on his first street bicycle race at 10 months post injury, with an accompanying letter of gratitude