Delayed management of traumatic bilateral cervical facet dislocation: surgical strategy

Abstract

<jats:p content-type="fine-print">✓ Postinjury cervical spine instability typically requires surgical treatment in the acute or semiacute stage. The authors, however, report on three patients with older (&gt; 8 weeks) untreated bilateral cervical facet dislocation. In two patients they attempted a classic anterior-posterior-anterior approach but failed. The misalignment in the second stage of the procedure could not be corrected, and they had to add a fourth, posterior, stage. To avoid the fourth stage, thereby reducing operating time and risk of neurological damage while turning the patient, they propose the following sequence: 1) a posterior approach to perform a complete facetectomy bilaterally with no attempt to reduce the dislocation; 2) an anterior microscopic discectomy with reduction of the dislocation and anterior fixation; and 3) posterior fixation. This sequence of procedures was successfully performed in the third patient. Based on this experience, they suggest that in cases of nonacute bilateral cervical facet dislocations the operating sequence should be posterior-anterior-posterior.</jats:p>

Surgical treatment of traumatic cervical facet dislocation: anterior, posterior or combined approaches?

“…Although good surgical outcomes can be obtained with all techniques, there are specific situations in which one may preferentially be used instead of the other. Although based on expert opinion and poor evidence studies, some authors recommended that the best approach is chosen based on the site of spinal cord compression, the presence of additional bone fracture (in the vertebral body or in the posterior bone elements) and the surgeon(s) preference/expertise 1,4,5,6,7 . When a posterior cervical approach is planned, a preoperative MRI is recommended to evaluate a relevant disc herniation and anterior cord compression.…”

“…The combined approach provides the strongest fixation, significantly limiting motion 5,7 . A combined fixation for cervical dislocation increases the fusion rate, although without the additional advantage for neurological recovery (Level of Evidence: III) 28 .…”

“…Posterior approaches are less likely to restore cervical lordosis than anterior approaches and absence of a normal cervical alignment may have a negative influence in the long term outcome (Level of Evidence: III) 15,22 . Posterior approaches based on rigid fixation techniques with lateral mass screws or pedicular screws are a good alternative for treating distractive and rotation injuries using reduction maneuvers that can be applied directly to realign the spine 5,6,7,27 . Additionally, patients with posterior bone compression associated with facet dislocation, such as a lamina fragment into the canal, can be managed successfully using a posterior approach.…”

“…Although the benefits of preoperative traction and reduction compared to open reduction need further studies, this treatment modality may provide early decompression of the neural tissue and also facilitate surgery, especially in centers where spine surgeons are not available full time. A cervical spine MRI may be obtained prior to the procedure to rule out a cervical disc herniation, but traction can be safely performed in awake patients with close clinical monitoring of the neurological status even without a cervical MRI (Level of Evidence: III) 4,5 . Typically, the initial weight is 2.5 kg/per injury level and can be performed in neutral, flexion or extension position, according to injury characteristics 1,21 .…”

Delayed presentation of post-traumatic bilateral cervical facet dislocation: A series of 4 cases

“…[1] to eight weeks. [2] after injury. Closed reduction by means of traction is successful only in 20% of patients presenting more than 72 hours after injury than in patients who present themselves earlier.…”