Nonoperative Management of Isolated, Unilateral Cervical Facet Fractures

Abstract

Introduction There is a continued amount of controversy in the optimal treatment of unilateral cervical facet fractures. Historical data and previous studies have shown that nondisplaced unilateral facet fractures treated nonoperatively may have a potentially unacceptable high rate of displacement leading to failure (range, 20–80%). The goal of this study was to analyze the success rate of cervical facet fractures treated nonoperatively in either a hard collar or Halo immobilization; while secondarily identifying risk factors for failure of nonoperative treatment that lead to delayed surgical intervention. Study Design Retrospective review of 65 patients diagnosed with isolated, unilateral cervical facet fractures without dislocation, or spinal cord injury that were treated either a hard collar ( n = 58) or halo vest ( n = 7). Outcomes were analyzed with end points radiographic healing, clearance of collar in clinic, or failure of nonoperative management as measured by subluxation, new onset of neurologic deficits, or debilitating pain leading to delayed surgical intervention. The nonoperative failure group was further radiographically analyzed for risk factors of failure. Patient Sample A total of 65 patients at a single Level I trauma center over the time period of 2005 to 2012 were included. Five spine surgeons at one institution participated in the care of these patients. Methods Retrospective review of injury computed tomography and plain films of patients diagnosed with unilateral cervical facet fractures were evaluated and included based on presence of an isolated or primary facet fracture pattern, absence of facet dislocation or perch, and documented clinical follow-up. Results Of the 65 facet fractures treated nonoperatively, 7 patients failed (10.8%), as measured by subluxation, persistent or increased radiculopathy, and/or continued pain requiring operative intervention. There were 58 facets (89%) successfully treated nonoperatively in this study as deemed by clearance of collar and radiographic stability at the time of final follow-up. In the failure group, 85% of these patients had an absolute fracture height of greater than 0.9 mm and greater than 60% of the intact lateral mass; with the one outlier less than 0.9 mm having a previous ACDF. Summary Several published articles in the available literature on unilateral cervical facet fractures support operative intervention with relatively few advocating nonoperative treatment. At this time, our study has found a significantly lower observed failure rate in the nonoperative group when compared with historical data. Conclusion To our knowledge, this is the single largest collection of nonoperatively treated cervical facet fractures in published literature. On the basis of this data, nondisplaced cervical facet fractures in the neurologically intact patient warrant a trial period of nonoperative management. Although continued investigation of risk factors for failure of nonoperatively treated fractures is needed, patients should be educated about the potential risks and complications of each treatment modality. Consistent with previous work by Spector et al, all the nonoperative failures demonstrated fracture height approaching 1 cm and at least 40% of the intact lateral mass. A larger prospective study would be beneficial to correlate exact radiographic predisposition of facet fractures for failure with long-term patient outcomes.