Cervical Spine Injury — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 35-year-old right-hand-dominant male construction worker presents to the trauma bay after falling approximately 15 feet from scaffolding, landing on his head and shoulder. He was immobilized in a cervical collar at the scene. He is awake, alert, and oriented. He reports severe neck pain and bilateral upper extremity tingling. He has no lower extremity symptoms and reports normal bowel and bladder function. On exam, he has midline cervical tenderness at C5-C6. Neurologic exam reveals bilateral hand weakness — grip strength is 3/5 bilaterally and intrinsic hand function is diminished. Deltoid and biceps strength is 5/5 bilaterally. Lower extremity motor function is 5/5 throughout. Sensation is intact except for diminished light touch in the C7 and C8 distributions bilaterally. Hoffman sign is positive bilaterally. Deep tendon reflexes are 3+ in the upper extremities and 2+ in the lower extremities. Babinski is absent bilaterally. Rectal tone is normal.
CT of the cervical spine reveals a bilateral C6 facet fracture-dislocation with anterolisthesis of C5 on C6 and narrowing of the spinal canal at this level. There is no vertebral body burst component. MRI obtained after CT shows a C5-C6 disc herniation compressing the spinal cord with intramedullary signal change (cord edema) at the C6 level. There is disruption of the posterior ligamentous complex.
You performed emergent closed reduction with Gardner-Wells tong traction under continuous neurologic monitoring, achieving realignment after 45 pounds of traction. Neurologic exam improved following reduction — grip strength returned to 4/5 bilaterally. You then performed anterior cervical discectomy and fusion at C5-C6 with structural allograft and anterior cervical plate, followed by posterior cervical lateral mass fixation from C5 to C7 during the same operative session. Post-operatively, the patient was placed in a rigid cervical orthosis and remained neurologically improved.
What Examiners Look For
- Data gathering: Neurologic exam is paramount — document motor and sensory levels, presence of long tract signs, and ASIA classification before any intervention.
- Diagnosis: Describe the injury pattern — bilateral facet dislocation implies complete disruption of all three columns. What does MRI add to the CT findings?
- Treatment plan: Closed reduction under traction — when is it safe? When do you need an MRI before reduction, and when is it acceptable to reduce first?
- Technical skill: Describe the anterior-posterior combined approach. Why did you choose combined rather than anterior alone or posterior alone?
- Indications: What are the criteria for emergent versus urgent surgical intervention in cervical spine trauma with incomplete neurologic deficit?
- Complications: What if the neurologic exam worsens during traction? What is central cord syndrome and how does it differ from this presentation?
- Ethics: Discuss the time-sensitive nature of spinal cord decompression and how you communicate prognosis to the patient and family.
Common Pitfalls
- Performing closed reduction without being able to monitor the neurologic exam — awake, cooperative patient is essential for traction reduction.
- Not obtaining MRI before reduction when the patient has an unreliable exam — risk of disc herniation causing cord compression during reduction.
- Confusing a unilateral facet dislocation (rotational instability) with bilateral (translational instability) — the treatment is different.
- Not documenting a complete ASIA exam — this is the standardized assessment and examiners expect you to use it.
- Forgetting that posterior ligamentous complex disruption makes this an unstable injury requiring posterior fixation in addition to anterior reconstruction.
Key Classifications
Free — takes 3 minutes