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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 5 | Page : 540-542
Delayed presentation of post-traumatic bilateral cervical facet dislocation: A series of 4 cases
Akash Mishra, Deepak Agrawal, PK Singh
Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||13-Jul-2014|
|Date of Decision||21-Aug-2201|
|Date of Acceptance||03-Oct-2014|
|Date of Web Publication||12-Nov-2014|
Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mishra A, Agrawal D, Singh P K. Delayed presentation of post-traumatic bilateral cervical facet dislocation: A series of 4 cases. Neurol India 2014;62:540-2
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 [Figure 1],[Figure 2],[Figure 3] and [Figure 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 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.
|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|
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|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|
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|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|
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|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|
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Delayed diagnosis of bilateral facet dislocation has been described as patients presenting more than three weeks.  to eight weeks.  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.  There are few cases in literature addressing the surgical dilemma posed by such cases [Table 2]. ,,,
Reduction in facet joint dislocations with accompanying intervertebral disc herniations should be performed after the herniated intervertebral discs have been removed through an anterior approach to prevent the exacerbation of neurologic symptoms.  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, 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 anterior-posterior-anterior approach may be more suitable.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]