Keywords
cervical facet dislocation - neglected cervical injury - autofusion - nonsurgical
management - delayed presentation
Introduction
Bilateral facet dislocation in the subaxial spine is a flexion distraction injury
that usually culminates in weakness of the limbs and respiratory distress.[1] In acute injuries, closed or open reduction and spinal fixation are routinely advocated
treatments.[2] But in in third-world countries, neglected spinal injuries are not uncommon owing
to the lack of facilities, delayed diagnosis, and poor socioeconomic status.[3] Patients presenting after 3 to 8 weeks of injury are considered delayed or neglected
facet dislocation.[4] Previous studies have advocated surgical management in view of developing neurological
deficits and progressive deformity over time.[5]
[6]
[7] Although spontaneous fusion is documented in spondylolisthesis in the lumbar spine,
there are not many studies suggesting the same in the cervical spine. We present our
experience of eight cases of neglected cervical facet dislocation with no neurological
deficit and managed conservatively with careful observation.
Materials and Methods
We registered patients with cervical facet dislocation from June 2021 to May 2022
who presented to us after more than 3 weeks of initial trauma. Informed consent was
obtained from all the participants. All radiological investigations done and treatments
received were reviewed. A thorough clinical examination was carried out on all patients.
On presentation, all patients had dynamic cervical radiographs, computed tomography
(CT) scans, and magnetic resonance imaging (MRI) to rule out cervical instability
and cord compression. CT scan was assessed for cervical fusion. All the patients had
residual axial cervical pain at presentation. After a thorough clinical and radiological
assessment, all the patients were put on anti-inflammatory medications and physiotherapy.
Patients were counseled regarding the need for surgical management based on their
worsening deformity or neurology. All the patients were followed up for 6 months after
their initial presentation to us for worsening symptoms or progression of deformity.
Discussion
Cervical facet dislocation is a very disastrous injury, often resulting in quadriplegia.
A delayed presentation of cervical facet dislocation is not uncommon, especially if
it is not associated with a neurological deficit. Bohlman noted that one-third of
cervical spine injuries are not recognized initially. Lack of infrastructure and skilled
spine surgeons contributes to this burden further.[8] Poor health infrastructure, lack of proper radiology, and low suspicion are the
most important factors for the missed cervical facet dislocation injuries.[9]
[10] Closed reduction with surgical stabilization is the established treatment protocol
for acute injuries. Early decompression and fixation offer the best chance of neurological
recovery and rehabilitation.[11]
[12] The management of cervical facet dislocations presenting more than 3 weeks after
the initial trauma is uncertain and complicated. Surgical management is further complicated
by the choice and sequence of approaches.[13]
[14]
[15]
[16]
[17] Here we have reviewed published literature on both surgical ([Table 1]) and nonsurgical ([Table 2]) management of neglected cervical facet dislocations.
Table 1
Published studies on surgical management of neglected cervical facet dislocation
|
Study
|
N
|
Delay in diagnosis
|
Preoperative neurological deficit
|
Approach
|
Outcome
|
|
Bartels and Donk[14]
|
3
|
3 mo
|
Present
|
Posterior-anterior-posterior release and fusion
Anterior-posterior-anterior release and fusion
|
Neurological improvement
|
|
Hassan[16]
|
|
3.5 mo
|
Absent
|
Posterior + anterior release and fusion
|
Neurological improvement + bony fusion
|
|
Payer and Tessitore[10]
|
1
|
2.5 mo
|
Absent
|
Anterior-posterior-anterior
|
Bony fusion
|
|
Rajasekaran et al[6]
|
1
|
2 mo
|
Present
|
Closed traction + posterior fixation
|
Neurological improvement + bony fusion
|
|
Goni et al[7]
|
6
|
8.5 wk
|
Absent
|
Closed traction + posterior + anterior fixation
|
Neurological deterioration in one patient
|
|
Basu et al[5]
|
19
|
21 d
|
Present
|
Preoperative traction + anterior/posterior fusion
|
Neurological recovery
|
|
Srivastava et al[24]
|
1
|
14 mo
|
Absent
|
Posterior-anterior-posterior release and fusion
|
Bony fusion
|
|
Farooque et al[15]
|
2
|
4 mo
|
Absent
|
Anterior-posterior-anterior
|
–
|
|
Prabhat et al[12]
|
15
|
63 d
|
Present
|
Closed reduction + ACDF/posterior anterior
|
Neurological recovery
|
Table 2
Studies with nonoperative management and their outcome in neglected cervical facet
dislocation
|
Study
|
N
|
Delay in diagnosis
|
Management
|
Outcome
|
|
Shah et al[21]
|
2
|
> 2 y
|
Physiotherapy
|
Bony fusion; no neurological worsening
|
|
Bodman and Chin[22]
|
1
|
1 y
|
Oral medications
|
Bony fusion; no neurological worsening
|
|
Sulla and Mach[23]
|
1
|
4 wk
|
Oral medications
|
Bony fusion; no neurological worsening
|
Many published studies emphasized surgical intervention in neglected facet dislocations
due to the imminent risk of deformity progression and development of neurological
deficit. Although the choice of approach and use of initial closed reduction are debatable,
most of the authors have stressed the need for both anterior and posterior approaches
for alignment and stabilization.[18] The extensive combined approach increases the duration of the surgery, blood loss,
length of hospital stay, and risk of neurological injury. A high rate of dysphagia
has been seen in the combined anterior and posterior approaches.[19]
A halt in progression is seen in the natural history of lumbar spondylolysis and spondylolisthesis,
thus ruling out the need for surgery in many cases.[20] Fibrosis and bony fusion around facet joints, vertebral bodies, and uncovertebral
joints have also been found in neglected cervical facet dislocations.[17] Shah et al reported two cases with delayed presentation of cervical facet dislocation
and observed autostabilization without any progression of deformity.[21] Bodman and Chin and Sulla and Mach made similar observations.[22]
[23] They concluded that once healed, these injuries are stable without surgical intervention.
In this study, we managed eight patients who presented late after cervical facet dislocation
with careful observation, anti-inflammatory medication, and physiotherapy. Although
we informed the patient that surgery would be necessary if their neurology got worse
or the deformity progressed, we never saw any of these in any of our patients. At
the last follow-up, bony fusion was visible in three patients.
Conclusion
Although surgical intervention is strongly indicated in delayed cervical facet dislocations,
keeping in view the risks of instability and late progression of the deformity, a
trial of conservative management with closed observation can be given in carefully
selected patients with intact neurology. Many of these patients develop autofusion
and stabilization over the course of time, with no further increase in kyphosis.
