01Approach to the Critical Patient/attcp60

Immediate priorities

›Airway and cervical spine threats

›High cervical injury (C3-C5) threatening diaphragmatic function

›Phrenic nerve involvement risk

›Rapid respiratory failure possible

›Immediate intubation if respiratory distress

›Apnea or hypoventilation on presentation

›Bag-mask ventilation with inline cervical stabilization

›RSI with manual in-line stabilization preferred

›Airway obstruction from anterior hematoma

›Rare but surgical emergency

›Surgical airway if oral intubation fails

›Neurogenic shock recognition

›Hypotension with bradycardia in cervical SCI

›Loss of sympathetic tone below injury level

›MAP target >= 85 mmHg in acute SCI

›Norepinephrine or phenylephrine first-line vasopressor

›Differentiate from hemorrhagic shock

›Neurogenic: hypotension + bradycardia + warm periphery

›Hemorrhagic: hypotension + tachycardia + cool extremities

›IV access and fluid resuscitation

›2 large-bore IVs

›Avoid excessive fluid in pure neurogenic shock

Stabilization and monitoring

›Spinal motion restriction

›Hard cervical collar and backboard until imaging complete

›Log-roll precautions for all transfers

›Remove backboard as soon as feasible to prevent pressure injury

02History/hx60

Mechanism and onset

›High-energy trauma mechanisms

›Motor vehicle collision (MVC)

›Flexion-distraction dominant vector

›Frontal impact vs rollover

›Fall from height

›Ground level falls in elderly with ankylosing spondylitis

›Head-first fall

›Diving injury

›Shallow water impact

›Hyperflexion mechanism

›Contact sports collision

›Spearing or head-first tackle

Neurological symptoms

›Motor deficits

›Upper extremity weakness

›Grip strength

›Shoulder and elbow function

›Lower extremity weakness

›Ability to move legs immediately after injury

›Ambulatory status pre-hospital

›Complete loss of motor function below injury level

›ASIA A: complete SCI

›Prognostic significance

›Sensory symptoms

›Numbness or tingling in upper/lower extremities

›Dermatome distribution helps localize level

›Bowel or bladder dysfunction

03Physical Exam/exam70

Primary survey findings

›ATLS priorities with spinal motion restriction

›Airway patency with inline cervical stabilization

›Phonation and speech quality

›Stridor or gurgling

›Breathing pattern

›Diaphragmatic breathing (high cervical injury pattern)

›Paradoxical thoracic movement

›Circulation

›Blood pressure: hypotension with bradycardia (neurogenic shock)

›Peripheral perfusion: warm in neurogenic, cool in hemorrhagic

›Disability: GCS and brief neuro exam

›Pupil reactivity

›Movement of all four extremities on command

Neurological examination

›ASIA/AIS motor assessment

›Key muscle groups C5-T1

›C5: elbow flexion (biceps)

›C6: wrist extension

›C7: elbow extension (triceps)

›C8: long finger flexors

›T1: small finger abductor

›Key muscle groups L2-S1

›L2: hip flexion

›L3: knee extension

›L4: ankle dorsiflexion

›L5: great toe extension

›S1: ankle plantar flexion

04Differential Diagnosis/ddx54

Unstable cervical spine injuries

›Bilateral facet dislocation

›ICD-10 S13.1XXA

›Displacement of cervical vertebra, initial encounter

›>= 50% vertebral body translation

›Highly unstable, high SCI rate

›Unilateral facet dislocation

›ICD-10 S13.1XXA

›< 25% translation typical

›Rotational instability

›Burst fracture

›ICD-10 S12 series

›Axial loading mechanism

›Anterior column failure with retropulsion

›Distinguishing: CT shows comminuted vertebral body, no facet incongruence

Facet fracture variants

›Facet fracture without dislocation

›ICD-10 S12 series

›Lower-energy mechanism

›May be stable if minimal displacement

›CT differentiates: fracture line through facet without locked joint

›Teardrop fracture

›Hyperflexion with axial load

›Anterior vertebral body fragment

›Highly unstable

›Associated with anterior cord syndrome

Other cervical fractures

›Hangman fracture (C2 pars)

05Laboratory Tests/lt49

Initial trauma labs

›Complete blood count

›Baseline hemoglobin

›Low hemoglobin associated with vertebral artery injury

›Anemia management pre-operatively

›Platelet count

›Surgical threshold planning

›Trauma-induced coagulopathy screening

›Metabolic panel

›Sodium, potassium, creatinine

›Baseline renal function for contrast administration

›Electrolyte disturbances in SCI (SIADH risk)

›Glucose

›Stress hyperglycemia common

›Target normoglycemia in SCI patients

›Coagulation studies

›PT/INR and aPTT

›Reversal needed if on anticoagulants before surgery

›Epidural hematoma risk stratification

›Type and screen

›Crossmatch if surgical intervention anticipated

›Major blood loss possible in anterior approach

Organ perfusion and shock labs

›Lactate

›Elevated >= 2 mmol/l indicates occult hemorrhagic component

›Pure neurogenic shock: normal or mildly elevated lactate

›Repeat at 2-4 hours if elevated

›Lactate clearance guides resuscitation

06Diagnostic Tests/dt124

Scoring Systems

›SLIC (Subaxial Injury Classification and Severity Score)

›Morphology score

›Rotation/translation (facet dislocation): 4 points

›Distraction: 3 points

›Compression: 1-2 points

›Disco-ligamentous complex (DLC) score

›Intact: 0 points

›Indeterminate: 1 point

›Disrupted: 2 points

›Neurological status score

›Intact: 0 points

›Root injury: 1 point

›Complete SCI: 2 points

›Incomplete SCI: 3 points

›Treatment algorithm

›SLIC <= 3: non-operative management

›SLIC = 4: operative or non-operative based on clinical context

›SLIC >= 5: operative management recommended

›Facet dislocations typically score >= 6

›ASIA Impairment Scale (AIS)

›Grade A: complete SCI, no motor/sensory below level

›61% of facet dislocation patients

›Poor neurological recovery prognosis

›Grade B: incomplete, sensory only below level

›Sacral sparing present

›Better prognosis than ASIA A

›Grade C: incomplete, motor function below level, < half grade 3+

›Grade D: incomplete, majority motor grade 3 or better

›Grade E: normal motor and sensory function

›AO Spine Subaxial Classification

›Type A: compression morphology

›Type B: distraction morphology

›Type C: translational/rotational morphology (facet dislocations)

›Type C injuries typically require operative management

›NEXUS and Canadian C-Spine Rule

›For initial decision to image in alert, low-risk patients

›NEXUS: 5 criteria, all must be absent to forgo imaging

›CCR: higher sensitivity for clinically significant injuries

›High-energy mechanism with neurological symptoms: imaging mandatory

MRI

›MRI cervical spine indications

›Pre-reduction MRI

›Mandatory in obtunded or uncooperative patients before closed reduction

›Controversial in alert patients: some advocate proceeding without MRI

›ACR Appropriateness Criteria 2024: usually appropriate pre-reduction

›Post-reduction MRI (all patients)

›Disc herniation assessment: ~54% incidence at injury level

›Spinal cord signal: edema vs hemorrhage predicts outcome

›Ligamentous integrity: DLC disruption assessment

›Epidural hematoma detection

›MRI findings and significance

›Cord hemorrhage (hypointense T2)

›Poor neurological prognosis

›Length of cord signal predicts outcome

›Cord edema (hyperintense T2)

›Better prognosis than hemorrhage

›May improve with decompression

›DLC disruption

›Supraspinous/interspinous ligament disruption

›Ligamentum flavum tear

›Traumatic disc herniation

›Anterior approach preferred when significant herniation

›Prevents worsening during reduction

›MRI protocol

›T2 sagittal: cord signal and DLC

›STIR: ligamentous injury more sensitive

›T1 and GRE for hemorrhage detection

›Axial sequences for root compression assessment

CT

›CT cervical spine without contrast

›First-line imaging for suspected cervical spine injury

›Sensitivity ~98% for clinically significant injuries

›Largely replaced plain radiography (X-ray sensitivity only 36%)

›ACR Appropriateness Criteria 2024: CT is usually appropriate

›Classic CT findings in facet dislocation

›Reverse hamburger bun sign on axial images

›Dislocated facet sits posterior to inferior facet

›Normal joint = hamburger bun; reversed = dislocation

›Headphones sign

›Uncovertebral joint malalignment on axial images

›Empty facet sign

›Facet joint appears vacated on axial cut

›Translation measurement

›Unilateral dislocation: typically < 25% vertebral body width

›Bilateral dislocation: typically >= 50% vertebral body width

›Translation > 6.7 mm predicts vertebral artery injury

›Fracture identification

›Associated lateral mass or pedicle fractures

›Comminution pattern affects surgical planning

›CT angiography (CTA) of the neck

›Indications: all cervical facet dislocations

›Vertebral artery injury occurs in ~13% of facet dislocations

›OR 3.8-4.4 for blunt cerebrovascular injury (BCVI)

›OR 8.04 for VAI in ankylosing spondylitis/DISH

›Biffl grading of VAI

›Grade I: intimal irregularity or dissection < 25% stenosis

›Grade II: dissection or intramural hematoma >= 25% stenosis

›Grade III: pseudoaneurysm

›Grade IV: occlusion

›Grade V: transection

›Treatment implications

›Grade I-II: antithrombotic therapy (aspirin or heparin)

›Grade III-V: interventional radiology consultation

Ultrasound

›Limited primary role in facet dislocation

›Not a first-line imaging modality for bony spine injury

›CT is reference standard

›MRI for soft tissue and cord assessment

›FAST exam in polytrauma

›Free abdominal fluid assessment

›Pericardial effusion screen

›Hemothorax or pneumothorax identification

›POCUS vascular assessment

›Carotid and vertebral artery Doppler

›Screening if CTA unavailable

›Operator-dependent limitation

›CTA preferred for definitive VAI assessment

›IVC collapsibility for fluid status

›Neurogenic shock assessment

›Guides vasopressor vs fluid decision

›Soft tissue ultrasound

›Anterior cervical hematoma detection

›Post-surgical airway threat screening

›Expanding hematoma may compress airway

›DVT surveillance in SCI patients

›Iliac and femoral vein compression ultrasound

›High DVT risk: 50-100% without prophylaxis

07Disposition/dispo52

Admission criteria

›All true facet dislocations require admission

›No safe outpatient management of acute dislocation

›Unstable injury by definition

›SCI risk with further displacement

›Transfer to spine-capable center if not available

›Emergent transfer for bilateral dislocation with SCI

›Stabilize airway and hemodynamics before transfer

Level of care selection

›ICU indications

›Bilateral facet dislocation

›Highly unstable, high SCI rate

›Neurological deterioration risk

›Any acute SCI

›Cardiorespiratory monitoring

›MAP target >= 85 mmHg for 5-7 days

›Neurogenic shock requiring vasopressors

›Hemodynamic instability

›Titration of norepinephrine or phenylephrine

›High cervical injury (C3-C5)

›Respiratory failure risk

›Ventilatory support readiness

›Polytrauma

›Multisystem injury requiring ICU monitoring

›Step-down or floor admission

›Unilateral facet fracture-dislocation without SCI

›Spine surgeon to determine level of care

›Serial neurological checks

08Treatment/t131

Immediate resuscitation

›Hemodynamic support in neurogenic shock

›IV fluid resuscitation

›Cautious crystalloid to avoid fluid overload

›1-2 L isotonic saline or lactated Ringer's initial bolus

›Vasopressor therapy

›Norepinephrine: 0.01-3 mcg/kg/min IV infusion

›First-line for neurogenic shock

›Titrate to MAP >= 85 mmHg

›Phenylephrine: 0.1-0.5 mcg/kg/min IV infusion

›Alternative to norepinephrine

›Avoids further bradycardia

›Dopamine: 5-20 mcg/kg/min IV

›Alternative when bradycardia is prominent

›Chronotropic and vasopressor effects

›Atropine for refractory bradycardia

›0.5-1 mg IV push; may repeat to 3 mg total

›Temporary transcutaneous pacing if refractory

Closed reduction (skull traction)

›Gardner-Wells tong traction

›Patient selection

›Alert, cooperative, neurologically intact or incomplete SCI

›Consider pre-reduction MRI in obtunded patients

›Traction technique

›Initial weight: 2-5 kg (5-10 lb)

›Add 2-5 kg per level sequentially

›Maximum 18-27 kg typical range

›Fluoroscopic or serial radiographic monitoring

›Reassess neurological exam between weight additions

›Stop if neurological deterioration occurs

›Success rate 55-71%

›Higher for bilateral than unilateral dislocations

›Post-reduction

›MRI after successful closed reduction

›Disc herniation and ligamentous assessment

›Definitive surgical stabilization typically follows

Surgical management

›Anterior approach (ACDF with plating)

›Anterior cervical discectomy and fusion

›96% satisfactory realignment in large series

›Direct disc decompression possible

›Preferred when significant disc herniation present

›Indication

›Failed closed reduction

›Pre-reduction MRI shows disc herniation

›Anterior instability pattern

›Post-operative monitoring

›Anterior hematoma risk

›Airway compression can occur within hours

›Keep intubation equipment at bedside 24 hours

›Dysphagia: common complication

›Soft diet initially

›Swallow evaluation if persistent

›Posterior approach (lateral mass or pedicle screw fixation)

›Single-stage posterior open reduction and fixation

›Direct facet manipulation under visualization

›No surgical failures reported in series

›Pedicle screw fixation: strong biomechanical construct

›Indications

›Posterior ligamentous complex disruption dominant

›Surgeon preference and experience

›Lateral mass screws: C3-C6

›Magerl or Roy-Camille technique

›3.5 mm screws typical

›Pedicle screws: C7-T1

›Greater pullout strength

›Higher vertebral artery risk at C3-C6

›Combined anterior-posterior approach

›Indications

›Irreducible or chronic dislocation

›Complex injury pattern

›Failed single-approach fixation

›Higher operative morbidity

›Reserved for complex cases

›Staged vs single-session based on patient stability

Non-operative management

›Selected stable injuries only

›Minimally displaced unilateral facet fractures without SCI

›True dislocations rarely managed non-operatively

›Spine surgeon decision

›Rigid cervical orthosis

›Hard collar 8-12 weeks

›Miami J or Philadelphia collar

›Dynamic flexion-extension radiographs at 6 weeks

›Confirm stability

›Assess healing

›Conservative reoperation rate

›Late kyphotic deformity and radiculopathy in ~18% of conservatively managed cases

›Reoperation risk

›Close imaging follow-up mandatory

Neuroprotection and SCI management

›MAP augmentation

›Target MAP >= 85 mmHg for 5-7 days post-SCI

›Class IIb recommendation (ACS Best Practices 2022)

›Spinal cord perfusion pressure maintenance

›Avoid hypotension: secondary cord injury risk

›Methylprednisolone

›No longer routinely recommended

›Marginal neurological benefit; significant complications

›Pneumonia, sepsis, GI bleeding risk

›Shared decision-making if within 8 hours of injury

›If administered: 30 mg/kg IV bolus over 15 min

›Then 5.4 mg/kg/hour for 23 hours (injury < 3 hours)

›If 3-8 hours post-injury: 48-hour infusion

›DVT prophylaxis in SCI

›Mechanical prophylaxis immediately

›Intermittent pneumatic compression devices

›Compression stockings

›Pharmacologic prophylaxis within 24-72 hours of injury

›Enoxaparin 40 mg SC daily

›Hold 12-24 hours perioperatively

›DVT risk 50-100% without prophylaxis in SCI

›PE leading cause of death after acute SCI

Pain management

›Acute pain

›Multimodal approach preferred

›Acetaminophen 975 mg PO/IV every 6 hours

›NSAIDs (short-term): ibuprofen 400-600 mg PO every 6-8 hours

›Avoid long-term: may impair bone healing

›Caution with renal impairment

›Opioids for severe pain

›Morphine 0.1 mg/kg IV titrated

›Limit to <= 3 days when feasible

›Patient-controlled analgesia for post-operative period

›Muscle relaxants for spasm

›Cyclobenzaprine 5-10 mg PO TID (short-term)

›Avoid in elderly

›Neuropathic pain in SCI

›Gabapentin: first-line

›Start 300 mg PO TID; titrate to 1800-3600 mg/day in divided doses

›Renal dose adjustment

›Pregabalin: first-line alternative

›75 mg PO BID; titrate to 150-300 mg BID

›Renal dose adjustment

›Amitriptyline: second-line

›10-25 mg PO at night; titrate to 50-75 mg

›ECG monitoring for QT prolongation

09Special Populations/sp97

Pregnancy

›Pregnancy and cervical facet dislocation

›Mechanism and epidemiology

›Young females (reproductive age): MVC and falls

›Ligamentous laxity of pregnancy does not directly increase facet dislocation risk

›Fetal wellbeing monitoring mandatory after trauma

›Imaging approach

›CT cervical spine without contrast: perform when clinically indicated

›Fetal radiation exposure from cervical CT is minimal

›Benefit exceeds risk in significant mechanism

›MRI preferred over repeated CT when possible

›No ionizing radiation

›Gadolinium contrast: avoid in first trimester

›Surgical management

›Operative management proceeds for unstable injuries

›Maternal outcome priority

›Obstetric team involvement mandatory

›Anesthesia considerations

›Supine hypotension: left lateral tilt during transport and procedures

›Aspiration risk increased: RSI for all general anesthesia

›Vasopressor selection in neurogenic shock

›Phenylephrine and norepinephrine: acceptable

›Maintain uteroplacental perfusion

›Post-operative care

›Continuous fetal monitoring if viable gestation

›DVT prophylaxis: LMWH preferred

›Warfarin avoided: teratogenic

›Spinal cord injury in pregnancy

›Autonomic dysreflexia risk in labor

›C-section often preferred delivery method in high SCI

Geriatric

›Older adults and facet dislocation

›Epidemiology and mechanism

›Low-energy falls increasingly common

›Ankylosing spondylitis and DISH dramatically increase fracture risk

›Ground-level falls can cause complete SCI in rigid spine

›Over-representation of comorbidities

›Osteoporosis affects fixation strategy

›Anticoagulant use increases epidural hematoma risk

›Atypical presentation

›Pre-existing myelopathy may mask acute neurological change

›Baseline exam critical for comparison

›Confusion and delirium may be primary symptoms

›Do not attribute to dementia without imaging

›Afebrile presentation common despite injury severity

›Surgical considerations

›Higher peri-operative morbidity

›Cardiac and pulmonary comorbidities

›Frailty assessment guides surgical risk-benefit

›Osteoporotic fixation challenges

›Longer constructs may be needed

›Cement augmentation occasionally used

›Ankylosing spondylitis surgery

›Long posterior construct typically required

›High re-operation rate with short constructs

›Non-operative management considerations

›Rigid collar may be poorly tolerated

›Skin breakdown risk

›Dysphagia risk

›Goals-of-care discussion early in complete SCI in elderly

›Informed consent for operative risk

›Medication adjustments

›Renal dosing for gabapentin and pregabalin

›Opioid caution: delirium, fall risk

›Avoid muscle relaxants (anticholinergic risk)

›DVT prophylaxis: monitor renal function with LMWH

Pediatrics

›Children and adolescents with facet dislocation

›Epidemiology

›Rare in young children (< 8 years): pseudosubluxation at C2-C3 mimics injury

›Normal physiologic subluxation up to 4 mm at C2-C3

›Swischuk line to distinguish normal from injury

›True traumatic facet dislocation increases in adolescents

›Mechanism: MVC, contact sports, diving

›SCIWORA (Spinal Cord Injury Without Radiological Abnormality) more common in children

›Imaging considerations

›Proportionally larger head increases cervical flexion in supine position

›Padding under shoulders in young children for neutral alignment

›Significant cartilaginous component: CT may underestimate injury

›MRI essential in pediatric cervical trauma with neurological deficit

›Radiation sensitivity: minimize CT exposure

›MRI-first approach when available for neurological injury

›Treatment approach

›Skull traction

›Gardner-Wells tongs: not suitable for young children

›Halo ring traction preferred in older children and adolescents

›Surgical technique modifications

›Smaller instrumentation

›Pediatric implant systems

›Neurological recovery

›Children have better neurological recovery than adults

›Greater cord plasticity

›Early rehabilitation critical

›Pharmacologic considerations

›Gabapentin: 5-15 mg/kg/day PO in divided doses for neuropathic pain

›Titrate based on response and tolerability

›Opioids: weight-based dosing

›Morphine 0.05-0.1 mg/kg IV PRN

›DVT prophylaxis: enoxaparin 0.5 mg/kg SC BID

›Anti-Xa monitoring

10Background/b97

Epidemiology

›Incidence and distribution

›Facet dislocation accounts for ~10% of all subaxial cervical spine fractures

›Most common levels: C5-C6 and C6-C7

›Most mobile segment of subaxial cervical spine

›Sex distribution

›Male sex: ~70% of cases

›Higher exposure to high-energy mechanisms

›Age distribution

›Young adults: MVC-predominant mechanism

›Older adults: falls increasingly prevalent

›Bimodal distribution in high-resource settings

›SCI burden and outcomes

›Bilateral dislocation: 61% SCI rate

›76% complete SCI in thoracolumbar bilateral facet dislocations

›Cervical bilateral dislocations: similar high SCI rate

›Unilateral dislocation: 42% SCI, 40% radiculopathy

›Less severe than bilateral

›Neurological recovery

›Incomplete SCI (ASIA B-D): frequent improvement with decompression

›Complete SCI (ASIA A): poor prognosis for recovery

›Late kyphotic deformity and radiculopathy: ~18% reoperation rate

›Vertebral artery injury prevalence

›~13% of cervical facet dislocations

›OR 3.8-4.4 for blunt cerebrovascular injury

›Stroke risk: primary concern driving CTA screening

›Translation > 6.7 mm predicts VAI

›Greater displacement: higher VAI probability

›Ankylosing spondylitis: OR 8.04 for VAI

Pathophysiology

›Mechanism of injury

›Flexion-distraction

›Posterior element tension failure

›Capsular ligament rupture

›Interspinous and supraspinous ligament disruption

›Inferior facet rides over superior facet of level below

›Unilateral: rotational component locks one facet

›Bilateral: equal bilateral displacement, no rotation

›Rotational component in unilateral dislocation

›One facet jumps forward and locks

›Facet sits anterior to next inferior facet (locked facet)

›Torticollis: head rotated away from dislocated side

›Axial loading combined with flexion

›May produce associated disc herniation

›54% incidence of traumatic disc herniation at injury level

›Spinal cord injury mechanism

›Canal diameter reduction

›Pre-existing cervical stenosis: near-perfect predictor of severe SCI

›Dynamic stenosis worsens during flexion

›Translation magnitude

›Greater displacement: more cord compression

›Bilateral > 50% translation: canal obliteration

›Cord injury types

›Contusion and edema: T2 hyperintensity, better prognosis

›Hemorrhage: T2 hypointensity, poor prognosis

›Central cord syndrome: common with pre-existing stenosis

›Anterior cord syndrome: vascular injury pattern

›Vertebral artery injury mechanism

›Stretching and torsion of vertebral artery in transverse foramen

›Intimal tear and dissection

›Thrombus formation

›Translation > 6.7 mm: excessive artery deformation

›Biffl grading reflects severity

›Stroke risk from embolism or low-flow occlusion

›Delayed ischemic events up to weeks post-injury

Therapeutic Considerations

›Reduction vs stabilization decision

›Early reduction rationale

›Canal decompression improves cord perfusion

›Neurological recovery possible with decompression

›Time to reduction: each hour of cord compression matters

›Pre-reduction MRI debate

›Disc herniation worsened by traction: rare but reported

›Alert patients: most experts proceed without MRI

›Obtunded patients: MRI before reduction standard of care

›Surgical approach choice

›Anterior: better for disc herniation, direct decompression

›Posterior: better for posterior ligamentous disruption

›Neither approach superior for neurological outcomes

›Combined: reserved for complex or failed single-approach cases

›Neuroprotection evidence base

›MAP augmentation

›Rationale: maintain spinal cord perfusion pressure

›Target >= 85 mmHg for 5-7 days

›Class IIb recommendation (ACS 2022)

›Methylprednisolone

›NASCIS II/III trials: marginal benefit, significant harms

›Not recommended as routine: practice varies by center

›Shared decision-making within 8 hours of injury

›Temperature management

›Fever increases metabolic demand in injured cord

›Maintain normothermia

›Vertebral artery injury management

›Antithrombotic therapy by Biffl grade

›Grade I-II: aspirin 81-325 mg daily or therapeutic heparin

›Grade III-V: endovascular intervention vs anticoagulation

›Duration: 6 weeks to 3 months minimum

›Repeat CTA at 6-8 weeks to assess healing

›Stroke prevention priority

›Risk highest in first 2 weeks post-injury

11Patient Discharge Instructions/pdi43

copy discharge instructions

›Facet dislocation discharge care

›Wear your cervical collar at all times as prescribed

›Remove only for skin care as directed by your surgeon

›Do not drive while wearing a collar

›Activity restrictions

›No lifting, bending, or twisting of the neck

›No contact sports or activities with fall risk until surgeon clearance

›No swimming or submersion of incision if post-operative

›Medications

›Take pain medications as prescribed

›Do not stop blood thinners without calling your surgeon

›Take stool softeners to prevent constipation from opioids

›Wound care if post-operative

›Keep incision dry for 48-72 hours

›Report any redness, swelling, or drainage from incision

›Warning signs requiring immediate return to the ER

›Neurological warning signs

›New or worsening weakness or numbness in arms or legs

›Loss of ability to move limbs you could move before

›Loss of bladder or bowel control

›Respiratory warning signs

›Difficulty breathing, shortness of breath

›Choking or difficulty swallowing (after anterior surgery)

›Vascular warning signs after anterior surgery

›Rapid swelling or fullness in the front of the neck

›Increasing difficulty breathing: may indicate hematoma

›Stroke warning signs (if vertebral artery injury diagnosed)

12References/r48

Guidelines and key sources

›Primary clinical guidelines

›American College of Surgeons (ACS) Best Practices Guidelines: Spine Injury (2022)

›Schroeder GD, Vaccaro AR, Welch WC, et al.

›MAP augmentation, CTA screening, SLIC classification

›ACR Appropriateness Criteria: Acute Spinal Trauma 2024 Update

›Hassankhani A, Freeman CW, Banks J, et al. JACR 2025

›Imaging algorithm recommendations

›Cochrane Review: Surgical Approaches for Cervical Spine Facet Dislocations

›Del Curto D, Tamaoki MJ, et al. Cochrane Database 2014

›Key epidemiology and outcome studies

›Quarrington RD, Jones CF, et al. Spine J 2018

›Epidemiology, radiographic analyses, SCI risk factors

›Glassman DM, Magnusson E, et al. Spine J 2019

›Impact of stenosis and translation on SCI outcomes

›Haq IZ, Fehlings MG, Vaccaro AR, et al. Eur Spine J 2025

›Bilateral cervical facet dislocation treatment algorithm

›Vertebral artery injury references

›Fokin AA, Wycech Knight J, et al. J Surg Res 2026

›Cervical facet dislocations and vertebral artery injury

›El-Hajj VG, Habashy KJ, et al. Neurosurgery 2025

›VAI incidence, risk factors, long-term outcomes

›Lebl DR, Bono CM, et al. Spine 2013

›Multivariate regression: VAI in blunt cervical trauma

›Tsuchiya R, Kamide T, et al. Acta Neurochir 2019

›Dislocation distance as VAI risk factor

›Imaging and classification references

›Daffner SD, Daffner RH. J Emerg Med 2002

Evidence & Review