Cervical Facet Dislocation

Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist
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Rx Musculoskeletal System (A - Z)

Cervical facet dislocation is the anterior displacement of one cervical vertebral body on another; two facet joints are located posterior to each cervical vertebral level. Cervical facet dislocation is the anterior displacement of one cervical vertebral body on another. The aim of this study was to evaluate the clinical efficacy of skull traction through an anterior cervical approach in the treatment of severe lower cervical facet dislocation without vertebral body fracture. The cervical facet refers to a joint within the cervical spine which lies in close proximity to nerves and blood vessels. Cervical facet pain can cause distress to the patient and difficulty moving the neck in different directions.

Facet dislocation refers to the anterior displacement of one vertebral body on another. Without a fracture, the only way anterior displacement can occur is by dislocation of the facets. Facet dislocation can occur to varying degrees: subluxed facets. perched facets. Bilateral facet dislocation occurs when a vertebra’s inferior facet dislocates anteriorly over the lower vertebra’s superior facet, locking in the intervertebral foramina, and creating a severely unstable fracture. 2,3. CT has a higher sensitivity for C-spine injury and is the preferred imaging modality.

Initial treatment of severe cervical fractures and dislocations may involve skeletal traction and closed reduction, with metal pins placed in the skull connected to a pulley, rope, and weights. Nonoperative treatments include brace (orthotic) treatment and medications.

Other Names

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

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: the mildest form with partial uncovering of facet joint
    • Perched: moderate form, facet joint inferiorly sits perched on ipsilateral superior articular process
    • Locked: jumping from the inferior process over the superior articular process and locked in position
  • Unilateral facet dislocation can be considered stable, bilateral is unstable

Causes

  • Fractures
    • The mechanism is typically hyperextension with lateral side bending or rotation
  • Dislocation
    • Excessive flexion-distraction from a seatbelt injury
    • Flexion-rotation
  • 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
  • Spinal Cord Injury
  • Nerve Root Injury
  • Acute disc herniation
  • Fractures
    • C1
      • Jefferson Fracture
    • C2
      • Odontoid Fracture
      • Hangman’s Fracture
    • C3-C7
      • Cervical Spinous Process Fracture
      • Cervical Teardrop Fracture
      • Cervical Compression Fracture
      • Transverse Process Fracture
  • Subluxations and Dislocations
    • Atlanto Occipital Dissociation
    • Cervical Facet Dislocation
    • Atlantoaxial Instability
  • Neuropathic
    • Cervical Cord Neuropraxia
    • Cervical Radiculopathy
    • Cervical Myelopathy
  • Muscle and Tendon
    • Cervical Whiplash
    • Myofascial Neck Pain
  • Pediatric/ Congenital
    • Klippel Feil Syndrome
    • Cervical Congenital Anomalies
    • Pseudosubluxation
  • Other Etiologies
    • Cervical Disc Disease
    • Cervical Spine Stenosis
    • Cervical Vascular Injuries
    • Spear Tackler’s Spine

Diagnosis

  • General: Physical Exam Neck
  • History
    • Will endorse a 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 deficits

Radiographs

  • Standard cervical spine films
  • It 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

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

MRI

  • It May be useful to better evaluate the 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

Treatment

Prognosis

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

Facet Fracture

Nonoperative

  • The 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 a 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

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