Management of Unilateral Locked Facet of the Cervical Spine

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Abstract

ABSTRACT

TWENTY-FOUR PATIENTS WITH unilateral cervical locked facets were treated between 1986 and 1990. The primary mechanisms of injury were vehicular accidents (58%) and altercations (38%). The level of unilateral facet dislocation was C5-C6 (41%), C6-C7 (25%), C3-C4 (17%), and C4-C5 (17%). Seventeen (70%) came to the hospital with radiculopathy, five (20%) were normal, and two (10%) had spinal cord injuries. Plain films showed subluxation but no fracture. All patients had a cervical computed tomographic scan. Fracture in addition to facet locking was seen in 12 (50%) of 24 scans: 5 with facet fracture, 4 with facet/laminar fractures, 2 with facet/laminar/body fractures, and 1 foramen transversarium fracture. On the basis of CT findings, closed reduction was thought to be contraindicated in two cases. Five patients (22%) underwent successful closed reductions. Two of the patients with closed reductions were placed in a halo but again had subluxation. Thus, 24 patients underwent surgery for open reduction, posterior spinous process wire fixation, and facet wiring to struts of the iliac crest for bony fusion. The initial surgery was successful in 23 (96%) of 24 patients. One patient experienced subluxation and underwent further surgery for anterior cervical fusion/plating. Two wound infections were treated, and there were no deaths or neurological worsening. At 1 year, all deficits had improved. Of 16 radiculopathies, 3 (19%) had persistent 4/5 weakness, and the rest were normal, including 2 delayed-diagnosis patients who both showed improvement from 2/5 to 5/5 strength within 1 week of surgery. Two spinal cord injuries were a central cord injury with persistent bilateral intrinsic hand muscle weakness and a Brown-Séquard injury, initially 1/5, that improved to 4/5 strength. Persistent neck pain was seen in 4 (17%) of 24 cases. A cervical computed tomographic scan provided information that aided in the diagnosis and management. Our experience, along with a review of the literature, strongly suggests that reduction and internal fixation/bony fusion is most successful for this injury.

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