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

Background. Following a 2015 ruling, the South African (SA) Constitutional Court obligates closed reduction of cervical facet dislocations sustained through low-energy injury mechanisms, within 4 hours of injury. Closed traction reduction of cervical facet dislocations requires specific equipment and expertise, which have limited availability in SA. Objectives. To review the time delays, delaying factors and success rate of closed reductions of cervical facet dislocations in a tertiary-level orthopaedic department and training facility, and to consider the feasibility of such a reduction within 4 hours after injury. Methods. The clinical records and imaging screens of patients presenting with cervical facet dislocations to an academic training hospital between November 2008 and March 2016 were retrospectively reviewed, with specific attention to demographic information, mechanism of injury, time delays from injury to treatment and factors resulting in delay, as well as the success rate in closed cervical reduction. Results. Ninety-one patients with cervical dislocation presented during the study period, of whom 69 were included for further review. The mean age at presentation was 37.6 (range 18 - 65) years. Successful reduction was achieved in 71% (n=49) of cases, with a median delay time from injury to reduction of 26 (interquartile range (IQR) 19.50 - 31.75) hours. Only 1 patient of 69 patients received successful reduction within 6 hours after injury. Neurological improvement was noticed in 5 of 53 patients with neurological deficit - after successful reduction. Two patients improved with two American Spinal Injury Association (ASIA) grades (from A to C), and 2 improved with one ASIA grade (from A to B and D to E). Conclusions. Successful reduction of a cervical facet dislocation within 4 hours presents a challenge to healthcare infrastructure globally. The relative scarcity of this type of injury (91 cases during 8 years in a tertiary referral hospital) prevents district-level clinicians from readily acquiring a level of experience to confidently perform closed reduction of these injuries, unless very specific training and support are provided towards this end.