Unilateral Facet Dislocation

Unilateral facet dislocations usually result from flexion and rotation of the cervical spine. They are considered stage 2 distractive flexion injuries (see earlier section on classification of cervical spine fractures). The most common site of dislocation is at C5-6. Patients may present with an isolated nerve root injury or an incomplete neurological deficit. The injury may be purely ligamentous or may involve a facet fracture in addition to the dislocation. Unilateral facet dislocations may be difficult to reduce in skeletal traction. Closed reduction may be attempted to unlock the dislocated facet joint; however, this is successful in less than 50% of patients, and we do not routinely use manipulation of the cervical spine. Rorabeck et al. reviewed 26 patients with unilateral facet dislocations and found that 12 had isolated dislocations, and 14 had fractures of the facets or vertebral bodies; closed reduction was possible in only six patients. Of the other 20 patients, 10 fractures were left unreduced, and 10 had open reduction. The patients who underwent open reduction and fusion had better results than the patients whose fractures were left unreduced. In our experience, open reduction and internal fixation of unilateral facet dislocations have provided consistently good results. If a unilateral facet dislocation can be reduced in skull traction, halo vest immobilization can be used for 3 months, with the possibility that stability would be obtained by spontaneous fusion. If skull traction does not reduce the dislocation, however, we prefer to proceed with open reduction and posterior cervical fusion with either triple wiring or oblique facet wiring for additional rotational control. Postoperative treatment consists of immobilization in a rigid cervical orthosis for 6 to 8 weeks. Often patients present with chronic pain, limitation of rotation, and radiculopathy caused by a unilateral jump facet that was either missed initially or was allowed to heal unreduced. For these patients with nerve root impingement and chronic pain, we recommend foraminotomy with decompression of the involved nerve root and posterior cervical fusion over the involved segment. Reduction with traction may be attempted, but this usually is impossible. Bilateral facet dislocations are flexion-rotation injuries and are considered stage 3 distractive flexion lesions. These injuries produce approximately 50% anterior subluxation of one vertebral body on the vertebra below. Usually both facet capsules, the posterior longitudinal ligament, and the posterior anulus fibrosus and disc are disrupted. These injuries are more frequently associated with neurological deficits than are unilateral facet dislocations. These dislocations are more easily reduced with closed traction methods than are unilateral dislocations, but because they are so unstable, redislocation is frequent when they are treated with prolonged skeletal traction or even in a halo vest. Some bilateral facet dislocations heal with spontaneous anterior interbody fusions, but this is unpredictable, and we prefer open reduction and internal fixation with an interspinous process wiring technique, such as the Bohlman triple-wire technique, or oblique wiring from the inferior facet of the upper level to the spinous process of the lower level. Posterior cervical plating also provides stable fixation and is advantageous when laminar and spinous processes are deficient. Studies by Arena et al. have shown the association of disc herniation with unilateral and bilateral facet dislocations. Disc herniations occurred in six of 68 patients (8.8%) in their series; myelography, postmyelography CT, or MRI

identified most of the disc herniations. Vaccaro et al. reported an increased incidence of disc herniation after awake closed traction reduction for cervical spine dislocation. Two of the 11 patients had disc herniations noted on MRI before reduction; however, after reduction, five patients were noted to have disc herniations, although none had increased neurological deficit. Although the process of closed traction reduction seems to increase the incidence of intervertebral disc herniations, the relationship of these findings to the neurological safety of this procedure is unclear. One radiographic indication of disc herniation is marked narrowing of intervertebral disc space on the plain lateral view. Failure to recognize a herniated disc associated with unilateral or bilateral facet injuries may result in increased neurological deficit when realignment of the spine with skull traction is attempted. Arena et al. recommended anterior discectomy for removal of extruded disc material before posterior interspinous wiring and fusion.