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Letters to Editor Delayed presentation of post‑traumatic bilateral cervical facet dislocation: A series of 4 cases
approach. In one patient [Figure 1] initial discectomy was done at C5‑C6 level followed by posterior facetectomy and fusion. Finally polyetheretherketone (PEEK) cage placement and plating was done via anterior approach.
Sir, Post‑traumatic bilateral cervical facet dislocation of cervical spine results from hyperflexion injury and is considered as an unstable injury. Early management of these cases is required to prevent the impending neurological deficit. However in patients with delayed presentation there is progressive deformity and fusion which increases the surgical dilemma. We present our experience of four cases. Between January 2013 and January 2014 four patients with cervical spine injuries were admitted with post‑traumatic bilateral cervical facet dislocation. Medical records and operative procedure of all patients were reviewed. Cervical x‑rays and computed tomography (CT) scans were done in the follow up period to evaluate correction of alignment [Figures 1‑4] The neurological outcome was assessed using American spinal injury association (ASIA) scoring system [Table 1]. All patients except one were operated via posterior‑anterior‑posterior
a
b
Delayed diagnosis of bilateral facet dislocation has been described as patients presenting more than three weeks.[1] to eight weeks.[2] after injury. Closed reduction by means of traction is successful only in 20% of patients presenting more than 72 hours after injury than in patients who present themselves earlier. [3] There are few cases in literature addressing the surgical dilemma posed by such cases [Table 2].[4‑7] Reduction in facet joint dislocations with accompanying intervertebral disc herniations should be performed Table 1: ASIA impairment scale (AIS) A=Complete. No sensory or motor function is preserved in the sacral segments S4‑S5 B=Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4‑S5 C=Motor Incomplete. Motor function is preserved below the neurological level, and more than half of key muscle functions below the single neurological level of injury have a muscle grade less than 3 (Grades 0‑2) D=Motor Incomplete. Motor function is preserved below the neurological level, and at least half of key muscle functions below the level of injury have a muscle grade >3 E=Normal AIS - Asia impairment scale
c
Figure 1: Imaging of case 1 with preoperative CT of the cervical spine (a) Grade II listhesis at C5-C6 level and preoperative MRI of the cervical spine (b) Listhesis at C5-C6 with disc prolapse at the same level. The postoperative cervical spine radiographs (c) Of the same patient showing good alignment with anterior plate and lateral mass fixation at C5-C6
540
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
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a
c
b
Figure 2: Imaging of case 2 with preoperative CT of the cervical spine (a) Grade IV listhesis at C4-C5 (a) and bony fusion at the facet joints (b). Post-operative radiographs showing (c) good alignment with plate at C4-C5 and C3-C6 lateral mass fixation
a
b
c
Figure 3: Imaging of case 3 with preoperative CT of the cervical spine (a) C4-C5 listhesis with bony fusion between C4-C5 vertebral body and preoperative MRI of the cervical spine (b) C4-C5 listhesis with cord compression. Post-operative cervical radiographs of the same patient showing (c) good alignment with plate at C4-C5 with iliac crest bone graft and lateral mass fixation at the same levels
after the herniated intervertebral discs have been removed through an anterior approach to prevent the exacerbation of neurologic symptoms.[8] If satisfactory results are achieved with a reduction after the removal of the herniated discs through an anterior approach, then an anterior fixation and fusion can be performed. However, in our experience, majority of cases have fibrous fusion of facets which may not be visible radiologically. This is the main cause of unsuccessful reduction and we recommend that all patients should be approached posteriorly first except when associated with extruded disc. Also, Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
after partial facetectomy facets joints become mobile, forceful reduction at this stage should not be attempted as anterior compression might lead to neurological deterioration of the patient. In the second stage, gentle traction with anterior cervical discectomy and fusion (ACDF) may help in reduction of the residual listhesis. Traction is helpful intra‑operatively as it reduces the listhesis and opens up the disc space for surgery. In conclusion, posterior‑anterior‑posterior approach may be appropriate for patients with delayed presentation of bilateral dislocation of facets except when complicated by extruded disc when an 541
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Letters to Editor
a
b
c
Figure 4: Imaging of case 4 with preoperative CT of the cervical spine showing (a) grade III listhesis at C5-C6 and pre-operative MRI (b) Grade III listhesis at C5-C6 with cord compression. (c) Postoperative CT of cervical spine showing persistence of grade I listhesis after posterior surgery. Final post-operative radiographs showing good alignment
Table 2: Case series on bilateral facet dislocation
Author
Number of Treatment patients protocol
MG Hasan[4]
12
Bartels[2]
3
Payer[7] Liu[6]
1 9
Jain[5]
4
Traction for 1 week ‑ if reduced - carry out ACDF (2 patients). If not reduced ‑ posterior facetectomy and posterior fixation. If alignment not achieved then traction continued for another 1 week followed by ACDF (9 patients) Anterior approach (discectomy) first ‑ if reduction not achieved ‑ complete facetectomy In case reduction achieved ACDF done followed by posterior fixation Anterior‑posterior‑anterior approach Posterior first by facetectomy and spinous process wiring ‑ ACDF carried out anteriorly Posterior followed by anterior approach
ACDF - Anterior cervical discectomy and fusion
anterior‑posterior‑anterior approach may be more suitable.
anciennes du rachis cervical inferieure. In: Rachis cervical inferieure. 6mes journees d’Orthopedie de la Pitie, Masson, Paris 1988. p. 139‑46. 2. Bartels RH, Donk R. Delayed management of traumatic bilateral cervical facet dislocation: Surgical strategy. Report of three cases. J Neurosurg 2002;97:362‑5. 3. Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine (Phila Pa 1976) 1982;7:1‑27. 4. Hassan M. Treatment of old dislocations of the lower cervical spine. Int Orthop 2002;26:263‑7. 5. Jain AK, Dhammi IK, Singh AP, Mishra P. Neglected traumatic dislocation of the subaxial cervical spine. J Bone Joint Surg Br 2010;92:246‑9. 6. Liu P, Zhao J, Liu F, Liu M, Fan W. A novel operative approach for the treatment of old distractive flexion injuries of subaxial cervical spine. Spine (Phila Pa 1976) 2008;33:1459‑64. 7. Payer M, Tessitore E. Delayed surgical management of a traumatic bilateral cervical facet dislocation by an anterior‑posterior‑anterior approach. J Clin Neurosci 2007;14:782‑6. 8. Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case report. J Bone Joint Surg Am 1991;73:1555‑60. Access this article online Quick Response Code:
Akash Mishra, Deepak Agrawal, P. K. Singh Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India E‑mail: [email protected]
References 1.
542
Roy‑Camille R, Edward B, Zeller R, Lapresle P. Les lesions traumatiques
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144454
Received: 13-07-2014 Review completed: 21-08-2014 Accepted: 03-10-2014
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Letters to Editor Delayed presentation of post‑traumatic bilateral cervical facet dislocation: A series of 4 cases
approach. In one patient [Figure 1] initial discectomy was done at C5‑C6 level followed by posterior facetectomy and fusion. Finally polyetheretherketone (PEEK) cage placement and plating was done via anterior approach.
Sir, Post‑traumatic bilateral cervical facet dislocation of cervical spine results from hyperflexion injury and is considered as an unstable injury. Early management of these cases is required to prevent the impending neurological deficit. However in patients with delayed presentation there is progressive deformity and fusion which increases the surgical dilemma. We present our experience of four cases. Between January 2013 and January 2014 four patients with cervical spine injuries were admitted with post‑traumatic bilateral cervical facet dislocation. Medical records and operative procedure of all patients were reviewed. Cervical x‑rays and computed tomography (CT) scans were done in the follow up period to evaluate correction of alignment [Figures 1‑4] The neurological outcome was assessed using American spinal injury association (ASIA) scoring system [Table 1]. All patients except one were operated via posterior‑anterior‑posterior
a
b
Delayed diagnosis of bilateral facet dislocation has been described as patients presenting more than three weeks.[1] to eight weeks.[2] after injury. Closed reduction by means of traction is successful only in 20% of patients presenting more than 72 hours after injury than in patients who present themselves earlier. [3] There are few cases in literature addressing the surgical dilemma posed by such cases [Table 2].[4‑7] Reduction in facet joint dislocations with accompanying intervertebral disc herniations should be performed Table 1: ASIA impairment scale (AIS) A=Complete. No sensory or motor function is preserved in the sacral segments S4‑S5 B=Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4‑S5 C=Motor Incomplete. Motor function is preserved below the neurological level, and more than half of key muscle functions below the single neurological level of injury have a muscle grade less than 3 (Grades 0‑2) D=Motor Incomplete. Motor function is preserved below the neurological level, and at least half of key muscle functions below the level of injury have a muscle grade >3 E=Normal AIS - Asia impairment scale
c
Figure 1: Imaging of case 1 with preoperative CT of the cervical spine (a) Grade II listhesis at C5-C6 level and preoperative MRI of the cervical spine (b) Listhesis at C5-C6 with disc prolapse at the same level. The postoperative cervical spine radiographs (c) Of the same patient showing good alignment with anterior plate and lateral mass fixation at C5-C6
540
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Letters to Editor
a
c
b
Figure 2: Imaging of case 2 with preoperative CT of the cervical spine (a) Grade IV listhesis at C4-C5 (a) and bony fusion at the facet joints (b). Post-operative radiographs showing (c) good alignment with plate at C4-C5 and C3-C6 lateral mass fixation
a
b
c
Figure 3: Imaging of case 3 with preoperative CT of the cervical spine (a) C4-C5 listhesis with bony fusion between C4-C5 vertebral body and preoperative MRI of the cervical spine (b) C4-C5 listhesis with cord compression. Post-operative cervical radiographs of the same patient showing (c) good alignment with plate at C4-C5 with iliac crest bone graft and lateral mass fixation at the same levels
after the herniated intervertebral discs have been removed through an anterior approach to prevent the exacerbation of neurologic symptoms.[8] If satisfactory results are achieved with a reduction after the removal of the herniated discs through an anterior approach, then an anterior fixation and fusion can be performed. However, in our experience, majority of cases have fibrous fusion of facets which may not be visible radiologically. This is the main cause of unsuccessful reduction and we recommend that all patients should be approached posteriorly first except when associated with extruded disc. Also, Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
after partial facetectomy facets joints become mobile, forceful reduction at this stage should not be attempted as anterior compression might lead to neurological deterioration of the patient. In the second stage, gentle traction with anterior cervical discectomy and fusion (ACDF) may help in reduction of the residual listhesis. Traction is helpful intra‑operatively as it reduces the listhesis and opens up the disc space for surgery. In conclusion, posterior‑anterior‑posterior approach may be appropriate for patients with delayed presentation of bilateral dislocation of facets except when complicated by extruded disc when an 541
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Letters to Editor
a
b
c
Figure 4: Imaging of case 4 with preoperative CT of the cervical spine showing (a) grade III listhesis at C5-C6 and pre-operative MRI (b) Grade III listhesis at C5-C6 with cord compression. (c) Postoperative CT of cervical spine showing persistence of grade I listhesis after posterior surgery. Final post-operative radiographs showing good alignment
Table 2: Case series on bilateral facet dislocation
Author
Number of Treatment patients protocol
MG Hasan[4]
12
Bartels[2]
3
Payer[7] Liu[6]
1 9
Jain[5]
4
Traction for 1 week ‑ if reduced - carry out ACDF (2 patients). If not reduced ‑ posterior facetectomy and posterior fixation. If alignment not achieved then traction continued for another 1 week followed by ACDF (9 patients) Anterior approach (discectomy) first ‑ if reduction not achieved ‑ complete facetectomy In case reduction achieved ACDF done followed by posterior fixation Anterior‑posterior‑anterior approach Posterior first by facetectomy and spinous process wiring ‑ ACDF carried out anteriorly Posterior followed by anterior approach
ACDF - Anterior cervical discectomy and fusion
anterior‑posterior‑anterior approach may be more suitable.
anciennes du rachis cervical inferieure. In: Rachis cervical inferieure. 6mes journees d’Orthopedie de la Pitie, Masson, Paris 1988. p. 139‑46. 2. Bartels RH, Donk R. Delayed management of traumatic bilateral cervical facet dislocation: Surgical strategy. Report of three cases. J Neurosurg 2002;97:362‑5. 3. Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine (Phila Pa 1976) 1982;7:1‑27. 4. Hassan M. Treatment of old dislocations of the lower cervical spine. Int Orthop 2002;26:263‑7. 5. Jain AK, Dhammi IK, Singh AP, Mishra P. Neglected traumatic dislocation of the subaxial cervical spine. J Bone Joint Surg Br 2010;92:246‑9. 6. Liu P, Zhao J, Liu F, Liu M, Fan W. A novel operative approach for the treatment of old distractive flexion injuries of subaxial cervical spine. Spine (Phila Pa 1976) 2008;33:1459‑64. 7. Payer M, Tessitore E. Delayed surgical management of a traumatic bilateral cervical facet dislocation by an anterior‑posterior‑anterior approach. J Clin Neurosci 2007;14:782‑6. 8. Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case report. J Bone Joint Surg Am 1991;73:1555‑60. Access this article online Quick Response Code:
Akash Mishra, Deepak Agrawal, P. K. Singh Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India E‑mail: [email protected]
References 1.
542
Roy‑Camille R, Edward B, Zeller R, Lapresle P. Les lesions traumatiques
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144454
Received: 13-07-2014 Review completed: 21-08-2014 Accepted: 03-10-2014
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
