Operative management of bilateral facet dislocation

Abstract

Fifty-two patients with acute traumatic bilateral locked facets were treated at one trauma center during a 3 1/2-year period (July, 1987, to December, 1990). The patients presented with complete motor quadriplegia (34 cases), incomplete myelopathy (13 cases), or intact long-tract function (five cases). The injuries occurred at C2-3 (one patient, with intact function), C4-5 (12 patients), C5-6 (16 patients), C6-7 (19 patients), and C7-T1 (four patients). Immediate traction (with increasing weight and serial x-ray studies) and/or induction of general anesthesia and muscle relaxation reduced the dislocation in 40 patients, but 12 needed prompt operative reduction as their injuries failed to reduce within 4 hours. Stabilization was indicated for all patients, but three did not undergo surgery: two elderly patients with complete injuries (one refused surgery and one died), and one patient with multiple injuries (fusion was achieved by halo-vest immobilization for 3 months). Of the 49 patients treated operatively, 23 (44.2%) underwent surgery on the day of injury and 26 on a delayed basis (mean 8.7 days postinjury). Surgical treatment included fusion of the posterior facet to a spinous process (44 cases), an anterior Caspar plate technique (three cases), and both procedures (two cases). Of these 49 patients, three (6.1%) with complete injuries died due to an adult respiratory distress syndrome. Improvement of cord function, judged by functional grade change, was observed at discharge in 15 patients (31.9%) and in 15 (71.4%) of the 21 patients with a 1-year follow-up period. Of the 34 patients with complete myelopathy on admission, three are ambulatory after 1 year, and 13 others have gained function in at least one nerve root. It is concluded that prompt reduction (nonoperative or surgical) and internal stabilization facilitate recovery even in neurologically compromised patients, and that early operative intervention is a wiser option than conservative management. This report also documents a higher incidence of this injury without deficit (five of the 52 cases) than reported in other series.

Cervical facet joint kinematics during bilateral facet dislocation

“…Standard guidelines for cervical stabilization following reduction do not exist. The use of numerous treatment modalities such as halo vest immobilization, anterior plating, posterior fusion with plates or wires, or a combination of anterior and posterior fusion, indicates that the optimal treatment regimen has yet to be established [5,12,20,25,31]. These controversies may be due to poor understanding of the high-speed facet motions during dislocation that cause the wide range of ligamentous injury severity observed clinically.…”

“…The spinal cord injury rate is between 55 and 89%, with greater than 90% of patients presenting neurological symptoms [5,12,17,20,31]. Controversy exists regarding the specific ligaments injured [29].…”

“…Despite the high injury severity, no clear treatment guidelines exist and the timing of closed reduction remains debatable. Some favor rapid reduction in an attempt to minimize cord injury [11,31], while others believe the risk of disc herniation causing further cord compression upon reduction mandates pre-reduction imaging using MRI [6,10]. Standard guidelines for cervical stabilization following reduction do not exist.…”

“…Bilateral facet dislocation (BFD) is a devastating consequence of cervical spine trauma [31], occurring most often during motor vehicle collisions, diving accidents, and falls [2,5,20]. The spinal cord injury rate is between 55 and 89%, with greater than 90% of patients presenting neurological symptoms [5,12,17,20,31].…”

Manipulation for cervical spinal dislocation under general anaesthesia: serial review for 4 years

“…Previous studies showed that prompt reduction of dislocation is of paramount importance for patients with signi®cant neurological involvement. 1,5,9 Others, on the other hand, have suggested that patients with incomplete neurological damage can still make signi®cant neurological recovery even when dislocations have been left unreduced. 13 The timing of reduction in patients with minimal neurological de®cits is less critical, though there have been reports of progressive paralysis after bilateral facet dislocation; most occurred outside spinal injury units.…”