Cervical Spine Injury, ABOS Oral Boards Preparation

This is a 35-year-old male construction worker who fell approximately 15 feet from scaffolding, landing on his head and shoulder. He was immobilized in a cervical collar at the scene. On arrival, he was awake, alert, and oriented. He reported severe neck pain and bilateral upper extremity tingling. No lower extremity symptoms. Normal bowel and bladder function.

On neurologic exam, he had bilateral hand weakness, grip strength was 3 out of 5 bilaterally and intrinsic hand function was diminished. Deltoid and biceps strength was 5 out of 5. Lower extremities were 5 out of 5 throughout. Sensation was intact except for diminished light touch in the C7 and C8 distributions bilaterally. Hoffman sign was positive bilaterally, and deep tendon reflexes were 3+ in the upper extremities, both long tract signs indicating cord involvement. Babinski was absent. Rectal tone was normal. This is an incomplete spinal cord injury, I classified him as ASIA D.

CT of the cervical spine showed bilateral C6 facet fracture-dislocations with anterolisthesis of C5 on C6 and spinal canal narrowing. No vertebral body burst component. I obtained an MRI after the CT, this showed a C5-C6 disc herniation compressing the cord with intramedullary signal change at C6, and disruption of the posterior ligamentous complex. The MRI was critical because a large disc herniation could worsen with closed reduction.

This patient had an incomplete spinal cord injury with a reducible bilateral facet dislocation. Given that he was awake and could be monitored, I proceeded with emergent closed reduction using Gardner-Wells tong traction. Realignment was achieved at 45 pounds. His grip strength improved to 4 out of 5 immediately after reduction, a reassuring sign.

I then proceeded to definitive stabilization in the same operative session. I performed an anterior cervical discectomy and fusion at C5-C6 with structural allograft and an anterior plate, followed by posterior lateral mass fixation from C5 to C7. Given the bilateral facet fracture-dislocations with posterior ligamentous complex disruption, I performed combined anterior-posterior stabilization.

Post-operatively, he was placed in a rigid cervical orthosis. At two weeks, his wound was healing well and grip strength was 4+ out of 5. At six weeks, he had further neurologic recovery with near-normal hand function. At three months, X-rays showed early fusion. At six months, he had near-normal strength throughout, mild residual numbness in the C7 distribution, and a solid fusion on CT. He returned to work in a modified capacity at nine months.

The patient was satisfied with his neurologic recovery, though I counseled him that some residual deficits may be permanent. In retrospect, I would have applied traction sooner, we spent time coordinating the MRI before reduction, which was the right protocol, but I would have pushed for faster MRI turnaround to minimize the time the cord was compressed. Every hour matters with an incomplete cord injury, and optimizing that workflow is something I have since improved in our department. I monitored him closely for late myelopathic changes and adjacent segment degeneration, and at one year his neurologic exam was stable.