Cervical Posttraumatic Unilateral Locked Facets: Clinical, Radiologic, and Surgical Remarks on a Series of 33 Patients

The surgical treatment of subaxial acute cervical spine facet dislocations in adults: a systematic review and meta-analysis

Adult cervical spine traumatic facet joint dislocations occur when excessive traumatic forces displace the vertebrae's facets, leading to loss of joint congruence. Reduction requires either cranial traction or open surgical procedures. This study aims to appraise the effects of different surgical techniques in the treatment of subaxial cervical spine acute traumatic facet blocks in adults. This study was based on a systematic literature review and meta-analysis, registered in Prospero (CRD42021279249). The PICO question was composed of adults with acute cervical spine traumatic facet dislocations submitted to anterior or posterior surgical approaches, associated or not with cranial traction for reduction. Each surgical technique was compared to the other. The primary clinical outcomes included neurological improvement or worsening and surgical success/failure rates. The anterior approach without cranial traction was efficient in reducing facet displacements. Skull traction was an efficient and immediate method to achieve spine dislocation reductions. Differences were not present among techniques regarding neurological improvement. There were no surgical failures in patients operated on via the posterior approach. The need to decompress and stabilize the cervical spine can be achieved by anterior or posterior surgical approaches, and there is no clear answer as to which initial approach is superior to the other.

Subaxial cervical articular process subluxation and dislocation: Cervical locked facet injuries in dogs

OBJECTIVE

To describe neurologic signs, diagnostic imaging findings, potential treatments, and outcomes in dogs with subaxial cervical articular process subluxation and dislocation, or a "locked facet."

STUDY DESIGN

Retrospective case series.

ANIMALS

Ten client-owned dogs.

METHODS

Dogs with a diagnosis of cervical locked facets were identified through medical records and imaging reports searches. Data on presenting signs, diagnostic findings, treatment, and outcome were recorded.

RESULTS

All cases were small or toy-breed dogs with preceding trauma. Four dogs were tetraplegic with intact pain perception, five were nonambulatory tetraparetic, and one was ambulatory tetraparetic, with half of the tetraparetic dogs having worse motor function in the thoracic limbs. The only sites affected were C5/6 (n = 6) and C6/7 (n = 4). All dogs had unilateral dorsal displacement of the cranial articular process of the caudal vertebra relative to the caudal articular process of the cranial vertebra at the luxation site. Five dogs were treated surgically, three by external coaptation, one by restriction, and one was euthanized the day after diagnosis. All dogs with outcome data (n = 8) became ambulatory. Nonambulatory dogs returned to ambulation in a median of 4 weeks (IQR 1-12; range 1-28).

CONCLUSION

In these dogs, locked facet injuries affected the caudal cervical vertebrae in small breeds and could be identified on imaging through the presence of dorsal displacement of a cranial articular process. Our small cohort had a functional recovery regardless of treatment.

CLINICAL SIGNIICANCE

Locked facet injuries should be a differential for small or toy-breed dogs with a cervical myelopathy secondary to trauma.

Imaging of facet joint diseases

Facet joints are the important articular pillars of the spine. Several pathologies can occur in and around the facet joint, including extra ossicles, traumatic dislocation, osteoarthritis, synovial cyst, axial spondyloarthritis, rheumatoid arthritis, calcium pyrophosphate deposition disease, septic arthritis, and malignant and benign neoplasms. Imaging is the mainstay to detect and characterize these diseases. In this review, we discuss the anatomy and function of facet joints, imaging techniques, and the imaging findings of several facet joint diseases. This information may be helpful to radiologists to make the correct diagnosis and optimize the management of patients with facet joint diseases.

Management of Unilateral Cervical Facet Joint Dislocation in Neurologically Intact Patients: Results of an Ao Spine latin American Survey

BACKGROUND

The treatment of unilateral CFD in patients without neurologic deficits remains controversial, especially in the choice of the best surgical approach. Our objective is to determine the way spine surgeons from Latin America manage this condition.

METHODS

A survey regarding management and surgical strategies was conducted by the AO Spine Latin American Trauma Study Group considering the treatment of unilateral CFD.

RESULTS

All AO Spine Latin American Trauma Study Group members were sent a link to the survey, among whom 285 replied, with 197 respondents answering all the questions. Nonsurgical management was considered by 25% of the surgeons. The majority stated that magnetic resonance imaging is necessary (65%) to treat this type of patient. A posterior approach was preferred by 44%, an anterior approach by 29%, and a combined approach by 25%, while 2.2% did not answer. Traction was not used by the majority of respondents (62%). In the setting of an anterior disk herniation, the majority of surgeons preferred to employ an anterior (45%) or combined (44%) approach versus an isolated posterior approach (only 0.5%). Comparing early versus late cervical trauma, fewer surgeons adopted an isolated anterior approach with the latter (29% vs. 15%).

CONCLUSIONS

Wide variations exist in the management of unilateral CFD by Latin American surgeons, with early injuries generally treated using either an anterior or posterior approach and treated early but after an MRI, while a combined approach is used more commonly with late injuries. Either an anterior or combined approach is used when disk herniation is present.

Anterior reduction and fusion for acute unilateral cervical facet dislocation without severe spinal cord injuries

PURPOSE

This study aimed to evaluate safety and effectiveness of simple anterior reduction and fusion for acute lower cervical unilateral facet dislocation without severe spinal cord injuries.

MATERIALS AND METHODS

One hundred and two patients with unilateral cervical facet dislocations without severe spinal cord injuries who were surgically treated by the only anterior approach were analyzed. The treatment effects were evaluated based on the Visual Analogue Scale (VAS) scores, the Cobb angle of kyphosis, the Neck Disability Index (NDI) and Odom's criteria. Neurological recovery of patients was assessed by the Frankel grading.

RESULTS

The mean duration of follow-up was 12.4 ± 4.2 years (range, 10 to 17 years). VAS scores, Kyphosis angle and NDI scores were significantly changed from preoperative values of 7.4 ± 0.8, 11.3° ± 6.8° and 29.3 ± 5.1 to last follow-up values of 1.3 ± 0.8, -6.1° ± 7.5° and 8.8 ± 3.6 (P = 0.000). Of patients, 92 (90.2%) had good to excellent outcomes, 9 (8.8%) had satisfactory outcomes, and 1 (1.0%) had poor outcomes. Patients have obtained satisfactory neurological recovery. Three patients needed additional posterior reduction.

CONCLUSION

The anterior reduction and fusion is effective and safe for acute unilateral cervical facet dislocation, and can achieve good long-term clinical effects.

C2-3 Fracture Dislocation and Bilateral Vertebral Artery Occlusion Without Neurological Injury: A Case Report

A 27-year-old female involved a motor vehicle collision as the restrained driver presented to the ER with agonal breathing and a Glasgow Coma Scale (GCS) of 3. Radiographic imaging demonstrated C2-3 craniocaudal dislocation, bilateral C2 comminuted pedicle fractures extending through the transverse foramina, complete bilateral vertebral artery occlusion, and negative signs of stroke with MRI. After halo immobilization, surgical stabilization, and medical treatment the patient was discharged and at her six-month follow up she was without neurological deficit.

Multicentre comparative study of Z-shape elevating-pulling reduction and skull traction reduction for treatment of lower cervical locked facets

PURPOSE

The aim of this study was to assess the clinical efficacy and safety of Z-shape elevating-pulling reduction as compared to that of conventional skull traction in the treatment of lower cervical locked facet.

METHODS

Patients with cervical locked facet (n = 63) were retrospectively enrolled from four medical centers and divided into two groups according to the pre-operative reduction method used: Z-shape elevating-pulling reduction (Z-shape elevating group; n = 20) or traditional skull traction reduction (skull traction group; n = 43).

RESULTS

The success rates, efficacy of reduction, and safety were compared between the two groups. The success rates were significantly better in the Z-shape elevating group than in the skull traction group: 87.5% (7/8) vs. 35.3% (6/17) for unilateral locked facet reduction (P = 0.03) and 100% (12/12) vs. 69.2% (18/26) for bilateral locked facet reduction (P = 0.04). There was no obvious change in American Spinal Injury Association (ASIA) grade after the reduction in either group. Combined surgery was necessary in 5% in the Z-shape elevating group vs. 27.9% in the skull traction group. Imaging showed that the segment angle and horizontal displacement were significantly improved after surgery in both groups, with no significant difference between the groups. Follow-up with radiography showed good recovery of the cervical spine sequence; all internal fixation sites were stable, with no loosening, prolapse, or breakage of internal fixators.

CONCLUSIONS

Halo vest-assisted Z-shape elevating-pulling reduction appears to be a simple, safe, and effective technique for pre-operative reduction of lower cervical locked facets.

New reduction technique for the treatment of unilateral locked facet joints of the lower cervical spine : A retrospective analysis of 12 cases

BACKGROUND

Closed reduction of bilateral locked facet joints of the lower cervical spine is possible, but reduction of unilateral locked facet joints of the lower cervical spine (ULFJLCS) is challenging. We explored a new, simple, safe, and effective closed reduction method for the treatment of ULFJLCS.

METHODS

A retrospective analysis was done on 12 consecutive cases with traumatic ULFJLCS that underwent closed reduction by Z‑shape elevating-pulling reduction through a halo-vest. After reduction, only anterior cervical decompression and internal fixation were performed. The success of reduction and nerve function was assessed, and follow-up data analyzed.

RESULTS

All patients using our new reduction technique underwent successful closed reduction; the shortest time of reduction was 40 min and the longest 110 (mean, 65) min. No aggravation of neurological damage was observed, nor were other complications. All patients were followed-up from 28 to 72 (mean, 44) months after surgery. The improvement in Frankel's score (on average) was two levels in most patients.

CONCLUSION

These data demonstrate that our new reduction technique is a simple, safe, and effective treatment for ULFJLCS.

Traumatic subaxial cervical facet subluxation and dislocation: epidemiology, radiographic analyses, and risk factors for spinal cord injury

BACKGROUND CONTEXT

Distractive flexion injuries (DFIs) of the subaxial cervical spine are major contributors to spinal cord injury (SCI). Prompt assessment and early intervention of DFIs associated with SCI are crucial to optimize patient outcome; however, neurologic examination of patients with subaxial cervical injury is often difficult, as patients commonly present with reduced levels of consciousness. Therefore, it is important to establish potential associations between injury epidemiology and radiographic features, and neurologic involvement.

PURPOSE

The aims of this study were to describe the epidemiology and radiographic features of DFIs presenting to a major Australian tertiary hospital and to identify those factors predictive of SCI. The agreement and repeatability of radiographic measures of DFI severity were also investigated.

STUDY DESIGN/SETTING

This is a combined retrospective case-control and reliability-agreement study.

PATIENT SAMPLE

Two hundred twenty-six patients (median age 40 years [interquartile range = 34]; 72.1% male) who presented with a DFI of the subaxial cervical spine between 2003 and 2013 were reviewed.

OUTCOME MEASURES

The epidemiology and radiographic features of DFI, and risk factors for SCI were identified. Inter- and intraobserver agreement of radiographic measurements was evaluated.

METHODS

Medical records, radiographs, and computed tomography and magnetic resonance imaging scans were examined, and the presence of SCI was evaluated. Radiographic images were analyzed by two consultant spinal surgeons, and the degree of vertebral translation, facet apposition, spinal canal occlusion, and spinal cord compression were documented. Multivariable logistic regression models identified epidemiology and radiographic features predictive of SCI. Intraclass correlation coefficients (ICCs) examined inter- and intraobserver agreement of radiographic measurements.

RESULTS

The majority of patients (56.2%) sustained a unilateral (51.2%) or a bilateral facet (48.8%) dislocation. The C6-C7 vertebral level was most commonly involved (38.5%). Younger adults were over-represented among motor-vehicle accidents, whereas falls contributed to a majority of DFIs sustained by older adults. Greater vertebral translation, together with lower facet apposition, distinguished facet dislocation from subluxation. Dislocation, bilateral facet injury, reduced Glasgow Coma Scale, spinal canal occlusion, and spinal cord compression were predictive of neurologic deficit. Radiographic measurements demonstrated at least a "moderate" agreement (ICC>0.4), with most demonstrating an "almost perfect" reproducibility.

CONCLUSIONS

This large-scale cohort investigation of DFIs in the cervical spine describes radiographic features that distinguish facet dislocation from subluxation, and associates highly reproducible anatomical and clinical indices to the occurrence of concomitant SCI.

Anterior pedicle spreader reduction for unilateral cervical facet dislocation

OBJECTIVE

The anterior only surgical procedure including discectomy, open reduction and fusion is used as a recommended approach in the treatment of unilateral cervical facet dislocations, but is difficult to achieve satisfactory anterior open reduction by vertebra distractor to spread the facet joints, especially for delayed management of unilateral cervical facet dislocation (7-21days). The goal of this study was to report an anterior pedicle spreader technique to distract directly the facet joint for anterior reduction and the results of 4 patients with successful application and describe safety.

METHODS

Four patients with unilateral cervical facet dislocation who failed to open anterior reduction by vertebra spreader procedure were surgically treated by the anterior pedicle spreader reduction. In these 4 patients (3 males and 1 female), the distribution of spine level was from C4/5 to C6/7; the neurological status was comprised 2 patients with ASIA E, 1 with D and 1 with A; the surgical management was ranged from 7 to 18days. After discectomy, if failed to open anterior reduction procedure, the anterior pedicle spreader was inserted along the pedicle axis with the fluoroscope-assisted view imaging. The spreader was distracted directly to the facet joint and pushed in a caudad direction to achieve posterior translation of the upper segment.

RESULTS

Postoperatively, all patients had obtained successful reduction and satisfactory anatomic sagittal alignment. There was no complication owing to the use of this technique. The ASIA A showed no neurological improvement; the patient with ASIA D was improved neurologically to ASIA E; no ASIA E patients showed neurological deterioration.

CONCLUSIONS

Anterior pedicle spreader reduction represents an efficacious but technically challenging option for the delayed treatment of unilateral cervical facet dislocation.