Closed traction reduction of cervical spine facet dislocations: Compelled by law

Abstract

The urgency of closed reduction of acute low-velocity cervical facet dislocations has recently been highlighted by the Constitutional Court of South Africa (SA), following a permanent spinal cord injury that a young rugby player sustained during a club-level match. The court found that if emergency care of the complainant had resulted in rapid closed reduction of his cervical spine injury, he might not have suffered permanent neurological damage. [1] The findings of the court were based on research by Newton et al., [2] who specifically looked at the timing of reduction of low-velocity cervical facet dislocation sustained by rugby players. In their cohort, reduction of facet dislocation within 4 hours after injury was associated with improved neurological outcomes. By performing an early closed reduction of the cervical spine, pressure is relieved from the spinal cord, preventing secondary ischaemic trauma and thus improving the possibility of neurological recovery. [3-5] It is important to note that this cohort of patients sustained low-velocity injuries. These may include sports-related injuries, falls from a standing height and blunt object assault. The severity of spinal cord trauma, or the viscous response of spinal cord tissue, is a product of the severity of compression, duration of compression and rate at which compression is applied, [6] which can also be referred to as the velocity of trauma. When compression is applied at a lower velocity, the spinal cord is more likely to show recovery and can withstand higher loads of compression than when subjected to the same compressive load applied at a higher velocity. Animal studies demonstrated this threshold to be 3 m/s, which equates to a fall from a standing height. [7] The current dispensation in SA demands that injuries of this nature be treated in specialised orthopaedic or neurosurgical units, or by qualified surgeons, with limited, if any, attempts at a closed reduction prior to arrival at a dedicated unit or service. The question of feasibility of mandatory closed reduction of cervical facet dislocations within 4 hours is therefore raised. This study reviews the time delays, delaying factors and success rate of closed reductions of cervical facet dislocations in an orthopaedic department at a tertiary-level training hospital over a period of 8 years. Methods A retrospective review of case notes and imaging screens of patients >18 years of age with cervical facet-joint dislocations presenting to a tertiary-level academic hospital in Western Cape Province of SA was performed. The university-affiliated hospital has a capacity of 1 899 beds and provides advanced trauma and This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Adherence to a standard operating procedure for patients with acute cervical spine dislocations: review of a tertiary, referral, academic hospital in South Africa

“…8 A retrospective review of rugby players with cervical dislocations found a 63% difference in reported neurological improvement if closed reduction was performed within four hours of the injury -a larger quantified effect on patient recovery than surgical intervention. 9 All Western Cape hospitals strive to perform closed reduction of cervical dislocations within four hours of the injury, 10 partly to comply with a 2015 Constitutional Court ruling but also to adhere to best medical practice. 11 This is, however, particularly challenging as the mean transport time between sustaining a spinal injury and receiving medical care was previously found to be three hours, which leaves little room to comply with the four-hour ruling.…”

“…11 This is, however, particularly challenging as the mean transport time between sustaining a spinal injury and receiving medical care was previously found to be three hours, which leaves little room to comply with the four-hour ruling. 10 Therefore, a new management protocol was introduced in June 2016 -the 'early reduction protocol' -requiring all closed reductions to be performed within one hour of admission.…”