Delayed presentation of cervical facet dislocations

To review treatment outcomes of 19 patients with delayed presentation of cervical facet dislocations.

Records of 17 men and 2 women aged 21 to 63 (mean, 39) years who presented with unilateral (n=14) or bilateral (n=5) cervical facet dislocation after a delay of 7 to 21 (mean, 14) days were reviewed. The most common level of dislocation was C5-C6 (n=9), followed by C4-C5 (n=6), C3- C4 (n=2), and C6-C7 (n=2). The neurological status was graded according to the Frankel classification. One patient (with bilateral facet dislocation) had complete quadriplegia (grade A), 11 had incomplete spinal cord injury (grades C and D), and 7 had nerve root injury. Closed reduction using continuous skull traction for 2 days was attempted. In patients achieving closed reduction, only anterior discectomy and fusion was performed. Those who failed closed reduction underwent posterior partial/complete facetectomy and fixation. If there was traumatic disk prolapse, anterior decompression and fusion was then performed.

The mean follow-up was 46 (range, 12- 108) months. 10 of 14 patients with unilateral facet dislocation were reduced with traction and then underwent anterior discectomy and fusion. The remaining 4 patients who failed closed reduction underwent posterior facetectomy and fixation; 3 of them had traumatic disk prolapse and thus also underwent anterior discectomy and fusion with cage and plate. Four of the 5 patients with bilateral facet dislocations failed closed reduction and underwent posterior facetectomy and lateral mass fixation, as well as anterior surgery. The remaining patient achieved reduction after traction and hence underwent only anterior discectomy and fusion. All patients achieved pain relief and sufficient neck movement for normal activities. All 7 patients with nerve root injury improved completely; 9 of the 11 patients with incomplete spinal cord injury improved by one Frankel grade, and the remaining 2 by 2 grades. The patient with complete quadriplegia showed no improvement.

Preoperative traction is a safe and effective initial treatment for neglected cervical facet dislocation, as it reduces the need for extensive (anterior and posterior) surgery. If closed reduction is successful, anterior discectomy and fusion is the surgery of choice. If not, posterior facetectomy and fusion followed by anterior surgery is preferred.