Analysis of Surgical Treatment and Factor Related to Closed Reduction Failure for Patients with Traumatically Locked Facets of the Subaxial Cervical Spine

PURPOSE: Cervical dislocations with locked facets account for more than 50% of all cervical injuries. Thus, investigating a suitable management of cervical locked facets is important. This study examined factors of close reduction failure in traumatically locked facets of the subaxial cervical spine patients to determine suitable surgical management. METHODS: We retrospectively analyzed of the case histories of 28 patients with unilateral/bilateral cervical locked facets from Nov. 2004 to Dec. 2010. Based on MRI evaluation of disc status at the injury level, we found unilateral dislocations in 9 cases, and bilateral dislocations in 19 cases, The patients were investigated for neurologic recovery, closed reduction rate, factors of the close reduction barrier, fusion rate and period, spinal alignment, and complications. RESULTS: The closed reduction failed in 23(82%) patients. Disc herniation was an obstacle to closed reduction (p=0.015) and was more frequent in cases involving a unilateral dislocation (p=0.041). The pedicle or facet fracture was another factor, although some patients showed aggravation of neurologic symptoms, most patients had improved by the last follow up. The kyphotic angle were statistically significant (p=0.043). Sixs patient underwent anterior decompression/fusion, and 15 patients underwent circumferential fusion, and 7 patients underwent posterior fusion. All patients were fused at 3 months after surgery. The complications were 1 case of CSF leakage and 1 case of esphageal fistula, 1 case of infection. CONCLUSION: We recommend closed reduction be performed as soon as possible after injury to maximize the potential for neurological recovery. Patients fot whom closed reduction of the cervical locked facets have a higher incidence of anatomic obstacles to reduction, including facet fractures and disc herniation. Immediate direct open anterior reduction or circumferential fixation/fusion of locked cervical facets is recommended as a treatment of choice for traumatic locked cervical facet patients after closed reduction failure.

Bilateral Locked Facets at Lower Lumbar Spine Without Facet Fracture: A Case Report

Bilateral locked facets at L4-5 without facet fracture is a rarely known disease. We present a case of a 37-year-old male patient diagnosed as traumatic L4-5 bilateral facets dislocation without facet fracture. We carried out open reduction, epidural hematoma removal, posterior interbody fusion. After surgery, we attained rapid improvement of the neurologic deficits and competent stabilization.

Management of Unilateral Facet Dislocation of the Cervical Spine

OBJECTIVE: Unilateral facet dislocation of the cervical spine occurs by flexion and rotation injuries and cannot be easily reduced by axial traction. We analyzed 14 consecutive patients with unilateral facet dislocation of the cervical spine to increase knowledge about anatomical reduction of locked facet and factors for successful reduction. METHODS: Fourteen patients (10 men and 4 women) with unilateral facet dislocation of the cervical spine were retrospectively analyzed. Plain X-ray, computerized tomography scan, and magnetic resonance imaging were performed. All patients underwent manual reduction and surgery with anterior interbody fusion and plate fixation. The manual reduction was performed by neck flexion and rotation to the opposite side of dislocation, followed by rotation and flexion of the head toward the side of dislocation and extension with relaxation of traction. Mean follow-up period was 17 months. The level of spine, amount of subluxation, combined facet fracture, and time from injury to initial reduction were analyzed using the data obtained from medical records. RESULTS: Thirteen (93%) patients were reduced successfully. Immediate reduction was achieved in 7 patients but failed in 7 patients. Seven patients underwent delayed closed reduction under general anesthesia, and successful reduction was achieved in 6 patients. Only one patient with bone chips between articular facets failed to achieve anatomical reduction. CONCLUSION: In order to reduce the locked facet more easily and safely, we recommend manipulative traction with anterior interbody fusion and plate fixation under general anesthesia after being aware of spinal cord injury with magnetic resonance imaging.

Posterior-anterior approach in treatment of irreducible traumatic spondylolisthesis of lower cervical vertebrae combined with facet dislocation / 中国矫形外科杂志

[Objective]To introduce the clinical experiences and efficiency in surgical treatment of irreducible traumatic spondylolisthesis of lower cervical vertebrae combined with facet dislocation with decompression,reduction and internal fixation through anteroposterior approaches.[Methods]A total of 34 cases of irreducible traumatic spondylolisthesis of lower cervical vertebrae combined with facet dislocation(25 males and 9 females,with age range of 21-61 years)treated from October 2005 to February 2009 were analyzed.Twenty-one cases showed double joints interlocking and 13 cases single facet joint interlocking,which was indentified by the three dimensional CT scan.All cases were treated with decompression,reduction and internal fixation through anteroposterior approach.Among them,13 cases were done through one stage anterior delompression,posterior unlock,fusion and stabilization as well as anterior fusion and stabilization in turn,21 cases were done through one stage posterior unlock,fusion and stabilization as well as anterior decompression,fusion and stabilization in turn.The Frankel grade scores was used as the judging criteria for the recovery of the spinal cord.[Results]All patients were followed up from 7 to 35 months,and the mean follow-up time was 16 months.Lateral mass screw and pedicle screw insertion were successful in all cases.After operation,the joint interlocking and dislocation were all released and reduced.There were no death,infection,interfixation failure or neurological function deterioration.Solid fusion were obtained in all cases in the follow-up.Incomplete spinal cord lesions had some recovery of nervous function postoperatively.Besides,one grade was improved in 23 cases by Frankel grade scores and 2 grades in 8 case.There were no improvements in 3 cases.[Conclusion]Decompression,reduction and internal fixation through anteroposterior approaches is an appropriate treatment method for the irreducible traumatic spondylolisthesis of lower cervical vertebrae combined with facet disclocation,with the advantages of relatively safe operation and strong stability.Most complications can be prevented under correct control of anatomic features and adjacent structures of the cervical lateral mass and pedicle as well as careful operation.

Therapeutic options to treate subaxial cervical fracture-dislocation with locked-facet / 中国矫形外科杂志

[Objective]To evaluate a simple,safty and effective therapeutic option to treate subaxial cervical fracture-dislocation with locked-facet.[Method]With the patients being awake and supervized under X-ray fluoroscopy,the authors used the early and continued closed skull traction-reduction to treate 16 cases of traumatic subaxial cervical fracture-dislocation with locked-facet.Before the beginning of the treatment,all the patients were taken for X-ray plain films and MRI/CT examinations as well as American Spinal Injury Association(ASIA) neurological function grade.The dynamic ASIA neurological function scale and X-ray fluoroscopy examnations were asked during the skull traction–reduction procedures.The average interval from the traumatic events to begin to skull traction–reduction was 31 hours(6-52 hours).The authors would continue the skull traction to maintain the anatomy position as soon as they succeeded in reducing the dislocation with locked-facet,forthmore they would take the anterior operation or combinations with anterior and posterior operations during the best condition.[Result]The MRI scans showed that there were 8 disc hernations and 5 disc disruptions at the dislocation levels before traction–reduction procedures.The ASIA scale were 7 grade C,5 grade D and 4 grade E,respectively.All the 16 cases succeeded in reduction as well as no neurological deterioration occurred.The postreduction MRI scans showed that 2 disc herations had converted to nearly normal disc position and another 4 disc hernations remained unchanged.Accordingly,2 disc disruption remained unchanged and another case had converted to disc hernation.The average traction weight was 19 kg(10~32 kg) and average traction time was 53 minutes(30~135 minutes).[Conclusion]Under the intensive dynamic ASIA neurological function grade and X-Ray fluoroscopy examnations,with the patients being awake and co-operation,the early and continued closed skull traction-reduction and then performing elective anterior or anterior-posterior surgery depending on the patient's overall and local status to treate subaxial cervical fracture-dislocation with locked-facet is safe and effective.

Anterior Reduction and Stabilization of Unilateral Locked Facet of Cervical Spine

OBJECTIVE: We present an evaluation of the safety and effectiveness of anterior reduction and stabilization of unilateral locked facet of the cervical spine. METHODS: Nine patients with unilateral locked facet of the cervical spine were treated with anterior decompression, reduction and stabilization from January 1997 through December 2000. There were six male and three female patients who ranged in age from 22 to 59 years (average 37.4 years). The level of facet dislocation was C4-5 in one, C5-6 in four, and C6-7 in four patients. One patient presented with complete spinal cord injury, two patients with incomplete spinal cord injury, four patients with radioculopathy, and two patients were neurologically intact. All patients underwent plain radiogram, computed tomogram scan, and magnetic resonance imaging. All patients underwent surgery for anterior open reduction, decompression and stabilization using bone graft and anterior cervical plate fixation systems. The mean follow-up periods was 11.9 months. RESULTS: All patients showed good decompression, reduction and stabilization without postoperative complications. Two patients showed vertebral artery thrombosis at facet locked side, but no cerebral ischemic symptoms. Follow-up neurological status was unchanged in two patients and improved in 7 patients. No patient experienced neurological deterioration or complications after this procedure. All patients showed good bony fusion without instability at follow-up period. CONCLUSION: Our results show that anterior decompression, reduction and stabilization procedure are safe and effective method in unilateral locked facet of the cervical spine without significant complications.

Clinical Analysis of the Result of Halo Immobilization Versus Surgical Fusion in the Management of Traumatic Cerical Spine Injury

In the mamagement of cervical spine injuries, it is difficult to determine when to use halo immobilization alone, surgical fusion alone or a combination of the two. To investigate the appropriate condition and relative effectiveness of the treatment of cervical spine injuries, a 3-year retrospective analysis was conducted. During this study the authors reviewed the medical records and X-rays of 46 patients with cervical spine injuries treated with either halo immobilization or surgical fusion. Eighteen patients were treated with the initial surgical fusion, yielding a fusion failure rate of 22%. On the other hand, the remaining 28 patients were initially treated with the halo immobilization, yielding a fusion failure rate of 35%. The main fracture types in patients that require surgical fusion after failure with halo immobilization were hyperflexion anterior subluxation and locked facet injuries. From these findings, we concluded that halo immobilization of hyperflexion anterior subluxation injury and unilateral or bilateral locked facet results in relatively high failure rates and therefore treatment by initial surgical fusion should be the method of choice. Close monitoring is mandatory following halo vest with any type of fracture and level.