15-year-old Male Football Player with Severe Neck Pain After Spear Tackle
The patient is a 15-year-old male football player who presents with severe neck pain after a spear tackle.
On examination, the patient shows 4/5 left deltoid weakness, but besides that, he is neurologically intact. He’s awake and alert.
Figure 1: Sagittal CT scan showing C4-C5 facet dislocation
Figure 2: Sagittal reconstructed CT scan showing left unilateral facet dislocation
Figure 3: Sagittal reconstructed CT scan of the right side showing some subluxation at C4-C5 without dislocation
Figure 4: Axial view at C4-C5 demonstrating rotational malalignment
Figure 5: CT scan showing soft tissues: note what may be bone and/or disc behind the posterior-inferior border of C4
Figure 6: Axial MRI of C4-C5 demonstrating disc material posteriorly
Figure 7: Sagittal MRI showing disc material and ligament posteriorly
C4-C5 unilateral facet fracture dislocation with herniation/disc material in canal with C5 radicular findings
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The patient was taken to the OR in the morning for ACDF and reduction. This was followed by PCF.
Figure 8: Immediately after anterior reduction, decompression, and fixation. Note slight splaying of spinous processes.
Figure 9: Immediate post-operative images after posterior fixation
The patient had an excellent outcome with resolution of his C5 radiculopathy. He has returned to playing football.
I think this is an excellent case because of the risks involved in not treating this in the proper fashion. Handled incorrectly, there will be serious consequences for the patient, so the surgeon needs to know the algorithm of how to get this patient properly treated. Once the decision is made, the treatment itself is fairly straightforwardit's the process of carefully thinking through the treatment decision that's the take-away from this case.
Dr. Albert handled this case correctly and demonstrates the importance of getting an MRI on a patient like this. The current recommendation is to get an MRI before reducing so that you know what you're dealing with. This is especially true if the patient is incoherent and can't talk to you, but it even applies if the patient is neurologically intact, as this patient was.
While I agree with how Dr. Albert treated the case, I would have done this case semi-emergent. I wouldn't have waited to treat in the morning. In a young, healthy adult like this patient, there is no benefit in waiting; he has no other medical issues or injuries from this trauma, and he has an unstable spine.
Based on the MRI, I would not reduce this patient in the ER. I would put the patient in traction in the OR and check his alignment using an x-ray.
I would then do an ACDF, followed by posterior stabilization, just as Dr. Albert did. However, as mentioned before, I wouldn't wait and instead would treat immediately.
I appreciate Dr. Girasole's comments. In general, we would not hesitate to reduce a patient like this awake in the emergency room with Gardner-Wells tong traction (sometimes employing high weights).
What is also different about this case is the findings on the CT (obtained immediately) suggestive of bone/disc in the canal. This combined with the MRI (obtained to clarify) forced us to urgent surgery within the next 12 hours. If a traction reduction were to be performed, the critical issue is to have the patient awake and alert (functioning as the best neurologic real-time monitoring).