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Cervical Facet Dislocation

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Other Names

  • Cervical Facet Fracture
  • Bilateral Facet Dislocation
  • Unilateral Facet Dislocation
  • Cervical Flexion Distraction Injuries

Background

  • This page covers dislocations and fractures of the cervical facets
    • This can be unilateral or bilateral
    • May also be termed flexion-distraction injuries of the cervical spine

Epidemiology

  • Facet fractures
    • Facet fractures represent 6.7% of all types of cervical spine fracture[1]
    • Most commonly occur at C6, C7[2]
  • Facet dislocations
    • Most commonly occur at C5-C6, C6-C7[3]

Pathophysiology

  • Flexion-distraction injuries can be described as anterior displacement of the vertebral body due to tensile or shearing forces and failure of the posterior elements typically coupled with either facet fractures or dislocations
  • Facet dislocation can be defined as anterior displacement of one cervical body over another
    • Subluxed: most mild form with partial uncovering of facet joint
    • Perched: moderate form, facet joint inferiorly sits perched on ipsilateral superior articular process
    • Locked: jumping from inferior process over suiperior articular process and locked in position
  • Unilateral facet dislocation can be considered stable, bilateral is unstable

Etiology

  • Fractures
    • Mechanism is typically hyperextension with lateral sidebending or rotation
  • Dislocation
    • Excessive flexion-distraction from a seatbelt injury
    • Flexion-rotation

Pathoanatomy

  • Cervical Vertebrae
    • The facets are the articular surface between spinal vertebral levels
  • Involves complex vertebral ligament injuries including
    • Anterior Longitudinal Ligament (ALL)
    • Posterior Longitudinal Ligament (ALL)
    • Ligamentum Flavum
    • Apophyseal joint ligaments
    • Annulus fibrosus
    • Interspinous ligaments
  • Injury to Intervertebral Disc

Associated Injuries

  • Spinal Cord Injury
  • Nerve Root Injury
  • Acute disc herniation

Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • General: Physical Exam Neck
  • History
    • Will endorse history of significant trauma
  • Physical Exam
    • If unilateral dislocation, may have weakness in C6 or C7 (most commonly)
    • If bilateral, likely spinal cord injury with significant defecits

Evaluation

Radiographs

  • Standard cervical spine films
  • May be obtained in the setting of trauma , inferior to CT
  • Potential findings
    • Subluxation of vertebral bodies on lateral view
    • Up to 25% on unilateral, 50% on bilateral
    • Loss of disc height
  • May need flexion-extension films to exclude instability

CT

  • Gold standard for cervical spine injuries in the setting of trauma
  • Better evaluates
    • Bony antomy
    • Facet fracture
    • Malalignment or subtle subluxation
    • Associated fractures

MRI

  • May be useful to better evaluate cervical spine
  • Controversial in the acute/ emergent setting and stabilization or reduction may be done first
  • MRI after stabilization is indicated to better evaluate soft tissue structures

Classification

  • N/A

Management

Prognosis

  • These injuries are potentially devastating, associated with a high degree of morbidity and mortality
  • Duration of cord compression correlates with severity of resulting functional deficits[4]
  • Goals of treatment
    • Reduce canal stenosis
    • Establish stable cervical segment
    • Relieve cord compression
    • Improve neurological outcome

Facet Fracture

Nonoperative

  • Decision to operate is controversial and large studies guiding best practices are lacking
  • In one study, the nonoperative approach was successful 59% of the time[5]

Operative

  • Displaced fractures require surgical reduction
  • Operative treatment yielded the greatest likelihood of successful anatomical reduction (90.8%)
    • Nonoperative techniques were only successful 43% of the time
  • Maintenance of reduction with open reduction and stabilization was successful 94.9% of the time
  • Technique
    • Can be anterior, posterior or combination of both

Facet Dislocation

Nonoperative

  • Unilateral facet dislocation remains controversial
    • Some spine surgeons believe nonoperative management will result in minor morbidities including neck pain and arm discomfort
    • No clear guidelines for nonsurgical vs surgical treatment
    • Beatson et al: spontaneously resolution of radicular symptoms in unilateral facet dislocations that were not reduced[6]
    • Haid et al: similar outcomes in patients treated with and without reduction[7]
    • Rorabeck et al: higher incidence of late pain in patients treated without reduction[8]
  • Consider immobilization in Cervical Collar, Halo Vest

Operative

  • Bilateral facet dislocation is a surgical emergency
    • Nonoperative treatment with halo immobilization or external orthoses has been associated with a high rate of radiographic failure
  • Closed reduction[9]
    • Described in literature and considered controversial
    • Yu et al: 88% success for unilateral, 15.4% for bilateral with skull traction[10]
    • Transient injury to cervical spine 2-4%, permanent injury 1%[11]
  • Open reduction and internal fixation
    • After reduction is achieved, operative fixation and arthrodesis is required due to severe instability
  • Indications for surgical management of unilateral facet dislocation remain controversial

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • N/A

Complications

  • Spinal Cord Injury
  • Hardware failure rates range from 13-54% depending on the injury pattern and surgical approach[12][13]
  • Deformity
  • Chronic neck pain
  • Kyphosis

See Also


References


  1. Hadley MN, Fitzpatrick BC, Sonntag VK, Browner CM: Facet fracture-dislocation injuries of the cervical spine. Neurosurgery 30:661–666, 1992
  2. Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman J, Mower W. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17–21
  3. Miao, De-Chao, et al. "Management of Severe Lower Cervical Facet Dislocation without Vertebral Body Fracture Using Skull Traction and an Anterior Approach." Medical science monitor: international medical journal of experimental and clinical research 24 (2018): 1295.
  4. Delamarter R, Sherman J, Carr JB: Pathophysiology of spinal cord injury. J Bone Joint Surg Am 77:1042-1049, 1991
  5. Kepler, Christopher K., et al. "Treatment of isolated cervical facet fractures: a systematic review." Journal of Neurosurgery: Spine 24.2 (2016): 347-354.
  6. Beatson T: Fractures and dislocations of the cervical spine. J Bone Joint Surg Br 45:21-35, 1963
  7. Haid R, Kopitnik T, Nugent R: Unilateral facet dislocation: changing concepts in management, in AANS Annual meeting. Park Ridge, IL, AANS, 1988, p 120
  8. Anderson P, Henley MB, Grady MS, et al: Posterior cervical arthrodesis with AO reconstruction plates and bone graft. Spine 16:S72-S79, 1991
  9. Cloward RB. Reduction of traumatic dislocation of the cervical spine with locked facets. Technical note. J Neurosurg. 1973;38:527–31.
  10. Yu JS, Yue JJ, Wei F, et al. Treatment of cervical dislocation with locked facets. Chin Med J (Engl) 2007;120:216–18
  11. Lee JY, Nassr A, Eck JC, Vaccaro AR. Controversies in the treatment of cervical spine dislocations. Spine J. 2009;9:418–23
  12. Henriques T, Olerud C, Bergman A, Jonsson HJ. Distractive flexion injuries of the subaxial cervical spine treated with anterior plate alone. J Spinal Disord Tech. 2004;17:1–7
  13. Johnson M, Fisher C, Boyd M, Pitzen T, Oxland T, Dvorak M. The radiographic failure of single segment anterior cervical plate fixation in traumatic cervical flexion distraction injuries. Spine (Phila Pa 1976). 2004;29:2815–2820.
Created by:
John Kiel on 4 July 2019 09:23:43
Authors:
Last edited:
17 November 2020 15:53:00