Medical Journal
Management of the neglected and healed bilateral cervical facet dislocation
- Abhishek Srivastava
- Reuben Chee Cheong Soh
- Gerard Wen Wei Ee
- Seang Beng Tan
- Benjamin Phak Boon Tow
Received: 20 February 2014 / Revised: 8 April 2014 / Accepted: 14 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Key finding
Neglected and healed bilateral cervical facet dislocations are rare and complex, often requiring a staged surgical approach. This case highlights the importance of early diagnosis, as delayed management may result in circumferential bony fusion. A posterior–anterior–posterior (P–A–P) approach proved effective in restoring alignment and stability, with excellent long-term outcomes and no neurological compromise.Introduction
There is limited literature on the management of neglected healed (fused) bilateral cervical facet dislocation. The authors report a case of a middle-aged male who developed a bilateral facet dislocation but only sought treatment 14 months post-injury when he experienced pain and deformity in the cervical spine.
Case report: A 42-year-old male was pushed into a 1.2-meter pool by accident and hit his head on the bottom. He immediately felt a sharp pain in his neck but was able to get out of the pool by himself and was found to have no neurological deficit at the emergency department. Standard trauma radiographs were performed and a grade 1 anterolisthesis of C4 on C5 was observed without any facet subluxation or dislocation.
An emergent Magnetic Resonance Imaging (MRI) of the cervical spine confirmed the X-ray results and additionally demonstrated injury to the posterior ligament complex and a broad-based posterior disc bulge. Computed Tomography (CT) scans revealed no facet dislocation or fractures. Unfortunately, the patient failed to attend his follow-up visits and at 14 months post-injury, presented again with pain, deformity, and impairment of horizontal gaze.
Computed tomography and MRI demonstrated a fused (bony) bilateral facet dislocation at C4/5. A cervical spine reconstruction consisting of a posterior–anterior–posterior approach was performed to address both the deformity and the pain. At 32-month follow-up, the patient remains well with no neurological symptoms, minimal neck pain, and successful fusion.
Conclusion: Current literature does not offer a clear solution to the management of healed neglected bilateral cervical facet dislocation. The presence of circumferential bony fusion around the deformity necessitates a posterior and anterior release and subsequent stabilization to address this complex problem.
The authors also highlight the importance of the order of the reconstructive approach and the need to recognize cervical spine instability despite normal CT scans in order to prevent late deformity.
Keywords
- Neglected healed bilateral facet dislocation
- Cervical spine
- Cervical trauma
Fig.1 Imaging at initial injury showing mild subluxation on flexion view of X-ray. No fracture and malalignment was seen in CT scan; however,
MRI shows disc injury at C4–5 along with posterior soft tissue edema suggestive of posterior ligamentous complex injury
Case presentation:
A 42-year-old Chinese male, with no significant past medical history, fell into a swimming pool of 1.2 meters in depth after being pushed accidentally in November 2009. His head struck the bottom of the pool and the patient felt an acute sharp pain in his neck but did not suffer any neurological deficit. He was subsequently able to get out of the pool by himself and presented to our emergency department (ED).
At the ED, a detailed neurological examination showed no abnormalities, and his standard trauma X-rays revealed a mild Grade 1 anterolisthesis of C4–C5 vertebrae. He was admitted to the hospital for a magnetic resonance imaging (MRI) scan, which showed mild Grade 1 anterolisthesis of C4–C5 with injury to the posterior ligament complex and a moderate broad posterior disc bulge without cord compression. Posterior muscular and ligament complex oedema was seen, with no oedema or injury observed in the cord. A subsequent CT scan was performed, which showed no subluxation or fracture in the cervical spine.
The patient was thus managed with an Aspen collar and discharged home with advice to be seen again in one month. At the first month, radiographs did not demonstrate further listhesis and the patient indicated that his pain was improving.
This prompted the spine team to continue pursuing a conservative management approach with an Aspen collar, with a plan to review again at three months post-injury.
For unknown reasons, the patient did not return to the clinic as scheduled and instead returned after 14 months with complaints of neck pain and radiating pain to the shoulder and jaw. He also had difficulty maintaining horizontal gaze. X-ray showed a dislocated C4–C5 facet with fusion and anterolisthesis of more than 50%, with no movement on dynamic views.
The MRI demonstrated kinking of the spinal cord at that level. Computed tomography scan showed bilateral cervical facet fusion with an anterior bone bar between the C4–C5 vertebrae. The patient was offered operative management with the aim of decompressing the cervical spine and restoring sagittal alignment. He was initially reluctant for surgery but returned one month later (15 months post-injury) to undergo the procedure.
Fig. 2 Patient at second presentation 14 months after being lost to follow-up. Note fusion of facet and anterior vertebral body in dislocated position. No movement is seen at C4–C5 on dynamic lateral X-rays views. Magnetic resonance imaging shows kyphosis and indentation of cord by internal salient at the level of deformity
Diagnostic imaging section: Historical review of missed and healed facet dislocation
While there is some consensus on the management of facet fracture dislocation, there are few papers in the literature discussing missed cervical facet dislocations. Thompson and Hohl first described the condition in 1978 with their case report of healed anterior cervical dislocation. The patient, however, did not require any surgery following a full examination and investigation. Subsequent studies report series of neglected facet dislocations, but these demonstrate delayed presentations rather than healed lesions, and these often are still amenable to skeletal traction, manipulation, and subsequent surgery.
Hassan et al., in their series of 10 patients with an average delay of 3.5 months in diagnosis, treated all of them with an initial one week of skull traction. If the dislocation was reduced, it was followed by anterior discectomy and fusion (ACDF). However, if reduction did not occur, a partial facetectomy was done with reduction followed by posterior fixation. If facetectomy was not successful in achieving reduction, another week of skull traction was applied, which would be concluded with an ACDF procedure. As a result, a majority of patients in his group had to undergo a five-stage procedure if partial facetectomy was unable to achieve complete reduction. Their rationale for skull traction was to distract the interposed and contracted fibrotic soft tissue to assist with subsequent reduction.
Liu et al. and Jain et al. each had a group of four patients. They advocated two-stage posterior–anterior procedures. Both recommended procedures consisting of a posterior soft tissue and fibrosis release from the dislocated facet joint with bilateral facetectomy and reduction under image intensifier. Reduction was supplemented by posterior wiring, following which the patient was turned supine and ACDF was performed after complete reduction. In both groups, no pre-operative anterior fusion was reported.
Madhavan et al. reported a series of cervical spine injuries which included three cases of bilateral facet subluxations identified as secondary lesions that went unidentified before a late review. Two were managed by revision of previous posterior construct only to include the affected levels, and one case was managed conservatively. No additional anterior surgery was done in these cases.
A two-stage anterior–posterior procedure, as described by Allred and Sledge for treatment of irreducible dislocation of the cervical spine with a prolapsed disc using a buttress-junctional plate held stabilized to the superior vertebral body, has been shown to give good results in a small subset of patients.
The technique does not offer rigid anterior stabilization and relies on posterior interspinous wiring to prevent recurrence of anterior dislocation. In addition, placement of the graft may be a challenge, as the posterior facet may not be sufficiently distracted. Further distraction adds more tension to an already taut spinal cord, which may result in neurological sequelae.
Most recently, Jiang et al. presented his series of 14 facet dislocations of varying time to presentation: 28–395 days. However, it was noted that none of his bilateral facet dislocations had more than 7 months of delayed presentation, and thus it is surmised that there would be an unlikely problem of a healed facet dislocation. His series focuses on the cervical canal versus vertebral body diameter, and he concludes that in severe stenosis, successful reduction will require a two-stage procedure.
Rationale for treatment and evidence-based literature
Based on the evidence presented, it is concluded that missed facet dislocations will often require at least two stages of surgery. This can either be posterior–anterior or anterior–posterior, while the key focus of treatment lies in detethering the contracted tissues at the facet as well as along the anterior column.
Our patient, however, differs from these cases described in the literature due to the bony fusion located circumferentially around the missed bilateral facet dislocation. This results in the need to perform a combined anterior and posterior release in order to safely restore the anatomic parameters of this patient.
Bartels and Donk were unable to reduce the neglected dislocation (more than 2 months) by classical anterior–posterior–anterior procedure and had to add a fourth posterior procedure for sufficient reduction. They reflected on this and subsequently reported a third case where a posterior–anterior–posterior approach was performed with success in an 8-month-old neglected subaxial bilateral cervical facet dislocation.
Payer and Tessitore described good results with anterior–posterior–anterior approach for reduction in a 10-week-old dislocation, but the procedure shared similar problems of cage placement and stabilization as described with other anterior-first approaches. Thus, the posterior–anterior–posterior approach (P–A–P) was deemed the most predictable and rational.
Procedure:
The patient underwent the cervical spine procedure in three stages, beginning with posterior lateral mass screw insertion, decompression, and facetectomy, followed by anterior osteotomy and cervical discectomy, and concluding with final posterior alignment of the sagittal profile and fixation. This was carried out under neural monitoring using both free running EMG and SSEP (NIM Eclipse, Medtronic).
Stage 1: Posterior cervical spine release
The patient was positioned on a Jackson table after application of Mayfield clamps. A standard posterior midline exposure was performed to access the affected facet joints. Bony fusion was identified along both facets, as previously seen on CT, and resection and release were performed using a high-speed burr. Once a gap was created, gentle reduction attempts were made under image intensifier but were unsuccessful. Lateral mass screws were inserted bilaterally at C4 and C5, and the wound was temporarily closed. The cervical spine was stabilized using an Aspen collar before the patient was repositioned supine.
Stage 2: Anterior cervical spine release
A standard Smith–Robinson anterior approach was used, and the anterior bony bridge was osteotomised under fluoroscopic guidance. Caspar pins were used to distract the intervertebral space and assist with microscope-assisted discectomy. Distraction and discectomy were alternated stepwise until reduction was achieved. Throughout this stage, no neural monitoring signals were lost. A Polyetheretherketone (PEEK) cage filled with autologous bone was inserted into the C4/C5 intervertebral space, and an anterior cervical plate was applied to secure the cage and ensure rigid anterior fixation.
Stage 3: Posterior cervical fixation
The posterior wound was reopened, and the nerve roots were examined for impingement following anterior reduction. Appropriately sized rods were inserted, and set screws were tightened. The surgical site was thoroughly irrigated, and the wound was closed in layers over a suction drain. The total procedure lasted 340 minutes with a total blood loss of 650 ml. There was no loss of neural monitoring signals during the procedure, and the patient tolerated the operation well, remaining ASIA E postoperatively.
The patient was subsequently discharged on the fifth post operative day to his home. At the time of discharge he was ambulatory and performing activities of daily living independently. There were no radicular complaints.
Fig. 3 Immediate Post operatively X-ray showing complete reduction and alignment with single motion segment anterior posterior stabilization. The alignment was maintained at last follow-up (32 months post surgery) with complete fusion across C4–C5 without recurrence of kyphosis and with reasonable sagittal balance
Outcome and follow-up
The patient was kept on an Aspen collar for 3 weeks post operatively. The wounds healed well and he reported decreased neck pain and improved cervical spine posture.
At his last follow-up (nearly 3 years) the implants were stable with complete fusion across the operated level without loss of reduction or recurrence of listhesis and the cervical spine retained its sagittal alignment (Fig. 3).
Conflict of interest This study was funded entirely by the author’s institution of practice. There were no external grants or funding sources.
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