Facet Fracture Dislocation Research Articles

A rare case of lumbar facet fracture-dislocation and review of the literature.

Lumbar facet fracture-dislocation is rare, often due to hyperflexion with rotational force. Abnormal scoliosis on radiography is a key sign, prompting further imaging. Facetectomy and laminectomy ensure safe reduction, while instrumented fusion is an effective surgical treatment. Traumatic lumbar facet dislocation is an uncommon condition, particularly when unilateral lumbar facet dislocation is accompanied by a contralateral facet fracture. The patient had a locked facet joint at the left L4-L5, a fracture of the right superior articular process of L5 and a comminuted fracture at the peritrochanteric region of the right femur following a fall. Emergent operation was conducted, starting with open reduction and fixation for the right proximal femur, followed by posterior open reduction and posterolateral fusion with instrumentation, without interbody fusion, for the lumbar spine injury. The patient exhibited positive outcomes throughout the follow-up. This article highlights the trauma mechanism of lumbar facet dislocation, emphasizing hyperflexion with rotational force. Abnormal local scoliosis is a distinctive imaging sign of facet joint dislocation. Facetectomy and laminectomy are recommended for safe reduction and instrumented fusion is considered a safe and effective surgical treatment for facet joint dislocation injuries.

Traumatic Cervical Facet Fractures and Dislocations.

Cervical facet injuries, though less common than other spinal injuries, represent a subset of subaxial cervical spine injuries and can present significant challenges in terms of diagnosis, management, and outcomes. A major concern with cervical facet fracture is identifying instability patterns that may necessitate surgical stabilization. Particularly in cases of cervical facet fracture dislocations, there remains controversy regarding requirements for closed reduction, timing, surgical approach, need for preoperative MRI, and method of fixation. This review article aims to provide a thorough understanding of the etiology, clinical presentation, diagnostic techniques, treatment options, and prognostic factors associated with cervical facet fractures.

Anterior-Alone Surgical Treatment for Subaxial Cervical Spine Facet Dislocation: A Systematic Review.

Study Design:Systematic review.Objective:Anterior-alone surgery has gained wider reception for subaxial cervical spine facets dislocation. Questions remain on its efficacy and safety as a stand-alone entity within the contexts of concurrent facet fractures, unilateral versus bilateral dislocations, anterior open reduction, and old dislocation.Methods:A systematic review was performed with search strategy using translatable MESH terms across MEDLINE, EMBASE, VHL Regional Portal, and CENTRAL databases on patients with subaxial cervical dislocation intervened via anterior-alone approach. Two reviewers independently screened for eligible studies. PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) flow chart was adhered to. Nine retrospective studies were included. Narrative synthesis was performed to determine primary outcomes on spinal fusion and revisions and secondary outcomes on new occurrence or deterioration of neurology and infection rate.Results:Nonunion was not encountered across all contexts. A total of 0.86% of unilateral facet dislocation (1 out of 116) with inadequate reduction due to facet fragments between the facet joints removed its malpositioned plate following fusion. No new neurological deficit was observed. Cases that underwent anterior open reduction did not encounter failure that require subsequent posterior reduction surgery. One study (N = 52) on old dislocation incorporated partial corpectomy in their approach and limited anterior-alone approach to cases with persistent instability.Conclusions:This systematic review supports the efficacy and success of anterior reduction, fusion, and instrumentation for cervical facet fracture dislocation. It is safe from a neurological standpoint. Revision rate due to concurrent facet fracture is low. Certain patients may require posteriorly based surgery or in specific cases combined anterior and posterior procedures.

Traumatic bilateral L4-5 facet fracture dislocation: a case presentation with mechanism of injury

BackgroundTraumatic bilateral locked facet joints at L4–5 level are a rare entity. A careful review only revealed four case reports. This case presented with an unusual mechanism of injury.Case presentationWe present a case of a 40-year-old male who suffered bilateral L4–5 traumatic facet fracture dislocation following a fall injury. The dislocation was associated with fractures of bilateral L4 inferior articular processes, left L4 pedicle, L4 spinous process and postero-inferior body of L4. He presented with cauda-equina syndrome and underwent emergency decompression, reduction and instrumented fusion.ConclusionThe biomechanics of the lumbar spine may differ with each individual. L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury.

249. Traumatic subaxial cervical facet joint dislocation: predictors of spinal cord injury and surgical failure

BACKGROUND CONTEXT Approximately two thirds of cervical spine injuries affect the subaxial cervical spine, with fractures occurring most often at C6 and C7 and dislocations at C5-C6 and C6-C7. In the spectrum of these injuries, facet joint dislocation represents a severe injury, frequently associated with spinal cord injury (SCI). PURPOSE The purpose of this study was to analyze a cohort of surgically treated subaxial cervical spine dislocations and to identify factors associated with higher risk of SCI and predictors of surgical failure. METHODS All patients operated in a single institution during a 10-year period (2007-2016) for traumatic single-level cervical facet joint dislocation were retrospectively reviewed. Age, gender, injury characteristics (dislocation or subluxation, uni- or bilateral, level of injury and presence of associated facet fracture), mechanism of trauma, presence of SCI (determined by the American Spinal Injury Association Impairment Scale [ASIA]), surgical data and follow-up records were reviewed. All patients had a minimum follow-up of 2 years. RESULTS A total of 71 patients, 53 men and 18 women, with mean age of 57 ± 18 years (18-90) were identified. Motor-vehicle accidents were the most frequent trauma mechanism, followed by fall from height. Young adults were mostly represented among motor-vehicle accidents, whereas falls contributed to a majority of facet joint dislocations sustained by the elderly. The C6-C7 level was the most affected (37/71 cases). Forty-seven patients had unilateral and 24 bilateral dislocation, with 47 of these cases (66%) having associated facet fractures. Spinal cord injury was present in 37% of the cases. Rigid columns (p = 0.009) and bilateral dislocations (p = 0.004) were associated with the presence of spinal cord injury. Patients with bilateral dislocation were 4.7 times more likely to have a spinal cord injury (OR: 4.7, 95% CI = 1.6-13.8). The closed reduction with cranial traction was attempted in 51 cases, with a success rate of 86%. 59 cases were submitted to isolated anterior cervical arthrodesis and 7 to anterior cervical corpectomy. Five were submitted to combined anterior and posterior fixation (360°). There were 3 failures after the previous isolated fixation, which required revision surgery with 360 ° fusion. All cases of failure occurred after an isolated anterior fusion in the C7-T1 transition (p CONCLUSIONS Patients with rigid spines or with bilateral facet dislocations are at higher risk for SCI. After successful reduction, anterior discectomy and fusion, as a single procedure, offers an excellent surgical option in the management of many cervical facet fracture dislocations, has showed in this analysis. Failure occurred always at the C7-T1 level, suggesting that here; a 360 degree fusion may be needed. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Rapid incremental closed traction reduction of cervical facet fracture dislocation: the Stoke Mandeville experience.

Retrospective case series study. To determine the success rate and neurological outcomes of rapid incremental closed traction reduction (RICTR) of cervical dislocations with spinal cord compression in the National Spinal Injuries Centre (NSIC), between June 2006 and December 2011. Tertiary spinal injuries centre, Stoke Mandeville Hospital, UK. A list of cervical trauma patients who were admitted to NSIC between January 2006 and December 2011 was retrieved from the hospital's electronic records, consultant and admission logbooks. Patients, admitted within 7 days of cervical facet dislocation and spinal cord injury (SCI), were included. Retrospective data collection and analysis was done using a data collection form and an Excel spreadsheet. Seventeen patients have met the eligibility criteria of the study. One patient was excluded because he only had nerve root symptoms. The procedure was successful in 44% of the cases. Eighty-six percent of patients in the successful RICTR group improved in their discharge motor index score (MIS), whereas 43% improved in their post-reduction MIS. Overall, 81% of the cohort had improvements in their discharge MIS. Our RICTR success rate was low compared to the reported average success rate in the literature, likely due to delays in admission. Neurological outcomes were favourable in the majority of patients at discharge. In our opinion, early admission and RICTR attempts could have improved the results and therefore we would recommend that RICTR procedures are done for suitable patients in the Emergency Departments of Major Trauma Centres (MTC).

On the relative importance of bending and compression in cervical spine bilateral facet dislocation

BackgroundCervical bilateral facet dislocations are among the most devastating spine injuries in terms of likelihood of severe neurological sequelae. More than half of patients with tetraparesis had sustained some form of bilateral facet fracture dislocation. They can occur at any level of the sub-axial cervical spine, but predominate between C5 and C7. The mechanism of these injuries has long been thought to be forceful flexion of the chin towards the chest. This “hyperflexion” hypothesis comports well with intuition and it has become dogma in the clinical literature. However, biomechanical studies of the human cervical spine have had little success in producing this clinically common and devastating injury in a flexion mode of loading. MethodsThe purpose of this manuscript is to review the clinical and engineering literature on the biomechanics of bilateral facet dislocations and to describe the mechanical reasons for the causal role of compression, and the limited role of head flexion, in producing bilateral facet dislocations. FindingsBilateral facet dislocations have only been produced in experiments where compression is the primary loading mode. To date, no biomechanical study has produced bilateral facet dislocations in a whole spine by bending. Yet the notion that it is primarily a hyper-flexion injury persists in the clinical literature. InterpretationCompression and compressive buckling are the primary causes of bilateral facet dislocations. It is important to stop using the hyper-flexion nomenclature to describe this class of cervical spines injuries because it may have a detrimental effect on designs for injury prevention.

Traumatic Cervical Unilateral and Bilateral Facet Dislocations Treated With Anterior Cervical Discectomy and Fusion Has a Low Failure Rate.

Study Design:Retrospective radiographic and chart review.Objective:To define the rate and associated risk factors of treatment failure of anterior cervical fusion for treatment of cervical facet dislocations.Methods:Between 2004 and 2014, a retrospective review at a single level 1 trauma center identified 38 patients with unilateral or bilateral dislocated facet(s) treated with anterior cervical discectomy and fusion (ACDF). Two patients were eliminated due to less than 30-day follow-up. Demographic data, initial neurological exams, surgical data, radiographic findings, and follow-up records were reviewed.Results:Of the 36 patients with facet dislocations treated with ACDF using a fixed locking plate, 16 were unilateral and 20 were bilateral. The mean age was 35 years (range 13-58). Mean follow-up was 323 days (range 30-1998). There were 3 treatment failures (8%). Three of 7 (43%) endplate fractures failed (P < .01), and 1/28 (4%) facet fractures failed (P = .13). The mean time to failure was 4 weeks (1-7 weeks). One treatment failure had a facet fracture, and all 3 failures had an associated endplate fracture.Conclusion:Treatment failure occurred in 3 out of 36 (8%) patients with facet fracture dislocations treated with anterior cervical discectomy, fusion, and plating. Rates of failure are lower than has been previously reported. Endplate fractures of the inferior level in jumped facets appears to be a major risk factor of biomechanical failure. However, a facet fracture may not be a risk factor for failure. In the absence of an endplate fracture, ACDF is a reasonable treatment option in patients with single-level cervical facet dislocation.

Two Adjacent Levels Dislocation of the Cervical Spine Managed via an Anterior Only Approach : A Case Report

We report the rare case of a 52-year-old man who presented an incomplete tetraplegia after a hang gliding accident. Computed tomography revealed a complete bilateral facet fracture-dislocation at the C4C5 level, with a unilateral facet fracture-dislocation on the left side at the C3C4 level; there was also a sagittal fracture of the fifth cervical vertebra extending through the middle of its body with a second fracture through the posterior arch. The patient was taken urgently to the operating room and closed reduction maneuvers were performed under general anesthesia, followed by an anterior prevascular approach for C3 to C5 fusion with two iliac crest grafts and a plate. Patient’s muscle strength was 3/5 on all four limbs on discharge and between 4/5 and 5/5 at one year. He stopped self-catheterization nine months after the accident. At two years follow-up, X-rays and CT scan showed a stable construct with satisfactory fusion. This is the first paper, in the literature, to describe double level contiguous cervical dislocation with a sagittal split fracture, and managed via an anterior only approach.

Negative pressure pulmonary edema associated with anterior cervical spine surgery.

We report a very rare case of negative pressure pulmonary edema (NPPE) that occurred immediately after anterior cervical discectomy and fusion (ACDF). The patient was a 25-year-old man who sustained a facet fracture-dislocation of C5 during a traffic accident. After ACDF, he developed NPPE and needed mechanical ventilation. Fortunately, he recovered fully within 24 hours. NPPE is a rare postoperative complication that may occur after cervical spine surgery. The aims of this report are to present information regarding the diagnosis and emergent treatment of NPPE, and to review the previous literature regarding this serious complication.

Treatment of Irreducible Bilateral Cervical Facet Fracture-Dislocation with a Prolapsed Disc Using a Prefixed Polyetheretherketone Cage and Plate System

When anterior reduction fail in the surgical treatment of cervical bilateral facet fracture-dislocation with concomitant disc extrusion, it is necessary to perform a reduction using a posterior approach and then a third anterior procedure is often necessary to accomplish the anterior reconstruction. This presents difficulties for both patients and surgeons because of the need for frequent position changes (supine-prone-supine). The purpose of this study is to illustrate a modified surgical technique, which is anterior reduction and fixation with a prefixed polyetheretherketone (PEEK) cage to a buttress plate for the treatment of irreducible bilateral cervical facet fracture-dislocation with a prolapsed disc is an enhancing technique for the stability of the interbody graft than a buttress plate alone because the PEEK cage has more fixation power and reduces both the number of position changes and the length of the operation.

Lésions étagées contiguës du rachis cervical inférieur lors d’un traumatisme en flexion de diagnostic retardé : à propos d’un cas

The authors report a case of bilateral C4-C5 facet fracture dislocation associated with a severe sprain underlying C5-C6, which had occurred during an traffic accident. The diagnosis of severe sprain was raised on the 55th day. The injury mechanism is studied. Contiguous multilevel injuries of the lower cervical spine should be suspected in case of high-energy trauma. MRI can provide an exhaustif diagnosis of possible multilevel injuries. After fixation of the obvious lesion, intraoperative dynamic fluoroscopy must be performed to demonstrate any instability in another area.

Traumatic Subluxation Associated With Absent Cervical Pedicle

Case description. To describe a case of traumatic subluxation in association with a congenitally absent cervical pedicle, and review the pertinent medical literature. The congenital absence of a cervical pedicle is a relatively uncommon developmental anomaly that is frequently mistaken for a unilateral facet fracture-dislocation in the context of acute trauma. Because there is little evidence of recovery after surgery, and the symptoms are usually not disabling, surgery is not recommended for most cases. A 62-year-old man presented with severe neck and right shoulder pain after falling. Plain radiographs and computed tomography of the cervical spine showed the typical features of a congenitally absent pedicle at C6 with anterolisthesis of C6 on C7. We performed anterior interbody fusion at C6-C7 because of persistent neck pain and progressive instability. Complete restoration of the C6-C7 subluxation was achieved with resolution of the presenting symptoms. At 18 months follow-up, flexion and extension dynamic radiographs demonstrated good alignment with solid fusion at C6-C7. Although conservative treatment is the primary treatment for this clinical entity, surgery is an alternative option for those patients who fail to achieve recovery after conservative treatment or exhibit instability.

Posterior Reduction/Fusion Followed by Anterior Decompression/Fusion of Unreduced Bilateral Facet Fracture-Dislocation in the Lower Cervical Trauma

We evaluate the results of posterior reduction/fusion followed by anterior fusion in 17 unreduced bilateral cervical facet fracture-dislocations with neurologic deficit. The patients were investigated for neurologic recovery [American Spinal Injury Association (ASIA) motor and sensory scale], fusion rate and period, complications, operating time, and canal-to-body ratio at the region of injury. At the last follow-up, the ASIA motor and sensory scores demonstrated a statistically significant increase. No patient showed aggravation of neurologic symptoms. Canal-to-body ratio was 0.60±0.33 preoperatively and 0.92±0.06 postoperatively, which is a statistically significant increase. Posterior reduction/fusion followed by anterior decompression/fusion in unreduced cervical bilateral facet dislocation should be familiar to spine surgeons. It is not complex and is a relatively nondangerous treatment.

Single Level Arthrodesis as Treatment for Midcervical Fracture Subluxation

Although many different techniques exist for fusion of midcervical facet fracture dislocations, limiting arthrodesis to a single level could have a theoretical advantage: fewer fused segments could lessen long-term negative effects of fusion on adjacent segments. Therefore, we prospectively treated 22 consecutive patients with midcervical fracture dislocation without vertebral body fracture with single level arthrodesis even if anterior/posterior surgery were required. Twelve patients with unilateral facet subluxation underwent anterior cervical discectomy, distraction reduction with Caspar posts (AESCULAP, Tuttlingen, Germany) with allograft fusion and anterior cervical plating. Ten patients with any component of bilateral facet subluxation underwent anterior cervical discectomy, distraction reduction with Caspar posts, allograft fusion and plating followed by posterior lateral mass plating. No patients demonstrated worsening of nerve root or spinal cord function postoperatively. Interbody stability occurred in all cases. Only complications were 4 cases of pneumonia, 1 case of wound leakage, and 1 case of superficial wound infection. Good reduction was achieved for both unilateral and bilateral facet fractures. Single level interbody arthrodesis is safe and effective strategy with both unilateral and bilateral facet fractures. Single level arthrodesis may also offer long-term benefit compared with multilevel fusions.

Reduction of traumatic dislocations and facet fracture-dislocations in the lower cervical spine

Traumatic facet dislocations and facet-fracture dislocations in the lower cervical spine (C2/C3 to C7/T1) are frequently associated with devastating neurological symptoms. A good outcome can only be achieved if the operator has wide and sound knowledge of reduction techniques and the best possible strategy is devised for the subsequent treatment of these severe lesions. Between 1973 and 1997 a total of 117 of our patients met at least one of the following inclusion criteria: unilateral locked facet dislocation (48%), bilateral locked facet dislocations (23%), unilateral "perched" facet subluxation (14%), bilateral perched facet subluxation (12%), uni- or bilateral dislocation/perched subluxation with facet fractures (3%). Most of the lesions were located at the levels of C5/C6 and C6/7 (n=46 for each). Associated neurological deficits were present initially in 65% of patients: 35% had complete or incomplete spinal cord injuries (tetraplegia), 2% were paraplegic, and 28% had cervical radiculopathies. Closed reduction (e.g. with the aid of a halo ring) should be carried out as soon as possible after lower cervical spine dislocation or facet-fracture dislocation, as both the success rate of reduction and the potential for recovery from neurological deficits are clearly higher when reduction is achieved within the first 4 h after the initial injury.

The Radiographic Failure of Single Segment Anterior Cervical Plate Fixation in Traumatic Cervical Flexion Distraction Injuries

A radiographic review of 87 patients with either unilateral or bilateral facet dislocations or fracture/dislocations treated with anterior cervical discectomy, fusion, and plating. The primary objective of this study was to report the incidence of radiographic failure and factors that would predispose to this loss of alignment. The secondary objective was to report the rate of pseudarthrosis. Biomechanical and clinical data conflict regarding the appropriate approach and method of fixation of distractive flexion cervical injuries. Unilateral and bilateral facet fracture subluxations may be surgically stabilized by anterior cervical discectomy, fusion, and plating, posterior instrumentation, or both. There are no documented reports of the rate of radiographic failure of this procedure when limited to a single level injury from a distractive flexion mechanism. Inclusion criteria were all single-level unilateral and bilateral facet fracture dislocations or subluxations treated with a single-level anterior cervical discectomy, fusion, and plating. Retrospectively, 107 cases were identified (87 with complete radiographs) from January 1994 to December 2001. Radiographic failure was defined as a change in translation of greater than 4 mm and/or change in angulation of greater than 11 degrees between the immediate postoperative films and the most recent follow-up. Fusion was assessed radiographically. A 13% incidence of radiographic loss of alignment is reported in 87 unilateral and bilateral facet fracture subluxations stabilized with anterior cervical discectomy, fusion, and plating. Radiographic failure correlated with the presence of endplate compression fracture and facet fractures on injury radiographs. There was no correlation between radiographic failure and age, gender, surgeon, unilateral or bilateral injury, plate type, level of injury, degree of translation, or sagittal alignment at the time of injury. Loss of postoperative alignment occurred in 13% of facet fracture subluxations treated with anterior cervical discectomy, fusion, and plating. Concern regarding mechanical failure of flexion/distraction injuries should be high when they are associated with fractures of either the facets or of the endplate. Endplate fracture was associated with both mechanical failure and pseudarthrosis.

The management of traumatic cervical bilateral facet fracture-dislocations with unicortical anterior plates.

The goal of this study was to evaluate single-level anterior cervical discectomy and stabilization for bilateral facet fracture dislocations using bone graft and anterior titanium plates with unicortical screw fixation in the clinical setting. We conducted a retrospective review during a consecutive 6-year period of patients treated in a single institution for traumatic single-level cervical bilateral facet fracture-dislocation. All fracture-dislocations that could be aligned with traction were subsequently stabilized using an anterior cervical discectomy with bone graft and titanium unicortical locking plates. All patients were examined after operation for radiographic evidence of healing and neurologic outcome. Twenty-two patients (M:F ratio, 16:6; average age, 47.7 years) underwent an anterior cervical discectomy and stabilization with either an allograft (n = 12) or an autograft (n = 10) and a titanium unicortical locking plate. Most patients had sustained a spinal cord injury (87%) or a radicular injury (9%). The average follow-up was 32 months, with a minimum follow-up of 1 year (range, 13 to 77 months). There was one instrumentation-related failure, but all 22 patients ultimately had evidence of stability at the instrumented level on the final follow-up examination. Anterior fixation with unicortical cervical locking plates as a single procedure offers an excellent surgical alternative in the management of many cervical bilateral facet fracture dislocations in patients who can be reduced preoperatively.

Facet fracture-dislocation injuries of the cervical spine: Hadley MN, Fitzpatrick BC, Sonntag VKH, et al Neurosurg 30:661–666 May 1992

Facet fracture-dislocation injuries of the cervical spine: Hadley MN, Fitzpatrick BC, Sonntag VKH, et al Neurosurg 30:661–666 May 1992

Facet Fracture-Dislocation Injuries of the Cervical Spine

Sixty-eight patients with acute traumatic cervical facet fracture-dislocation injuries are presented. These patients represented 6.7% of all cervical spine fractures identified over a 12-year period. Thirty-one patients had unilateral facet injuries and 37 had bilateral facet injuries. Neurological morbidity was 90% and was most severe among bilateral facet injury patients (84% complete injuries). Spinal shock was identified in 13 patients and was a poor prognostic indicator for the subsequent recovery of associated neurological deficits. Closed reduction was attempted in 66 of 68 patients and was successful in 58% of the patients. Seven patients deteriorated. Open reduction-internal fixation was successful in 83% of 24 patients with a 4% morbidity. Seventy-eight percent of patients improved with rapid closed reduction, and 60% improved with open reduction-internal fixation; however, only 10 patients of the entire 68 made significant neurological recoveries. In these 10 patients, the timing of decompression-realignment appeared to be more important than the means of reduction.