The patient presents with a deteriorating neurologic exam in the presence of a bilateral C5-6 facet dislocation. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake.
An ASIA Impairment Scale of E is a normal exam. An ASIA Impairment Scale of D shows preserved motor function below the neurological level, but with more than half of key muscles below the neurological level showing weakness but with a muscle grade greater than 3. Therefore his exam is worsening. You know it is a bilateral facet dislocation as there is 50% subluxation of the vertebral bodies. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake. Because of his rapid decline in neurologic function you would not want to delay reduction by obtaining an MRI. All facet dislocations need to be stabilized surgically following reduction. Following closed reduction an MRI should be obtained to look for a cervical disc herniation, as the presence of one will determine the approach for stabilization.
The cited reference by Star et al is a case series (LOE4) of 53 patients who underwent closed reduction. They found that contrary to prior beliefs, adding weights of > 50 lbs and up to 100 lbs was safe and effective. In their series, 39 patients required greater than 50 lbs to obtain reductions and there was no associated complications with this additional weight.
Vaccaro et al performed prereduction and postreduction magnetic resonance imaging in eleven consecutive patients with cervical spine dislocations. They found the process of closed traction reduction appears to increase the incidence of intervertebral disc herniations. The relation of these findings, however, to the neurologic safety of awake closed traction reduction remain unclear.
Illustration A shows a simple algorithm to determine the ASIA Impairment Score (AIS).
The diagnosis was never conclusive to me, since there was no verified bilateral nerve compression, although it is possible that some of the cauda equina is affected by a large central herniation at L5/S1. Now, I feel that my later discovered cervical herniations are more probable as the source of most of my suffering, at least structurally. One intervertebral bulge, in particular, really displaces the spinal cord severely and this may explain the incredible diversity of symptoms I endure. I place far more credence in this theory than in the lumbar disc-enactment suspicions.