Delayed presentation of lower cervical facet dislocations: What to learn from past reports?

Abstract

Delayed presentation of lower cervical facet dislocations is uncommon, and there is no standardized way to approach these neglected injuries. The literature on neglected lower cervical facet dislocations is limited to case reports and few retrospective studies. This justifies the need for a comprehensive review of this condition. Our purpose was to elaborate a review on the epidemiology, clinical and radiological presentation, and treatment techniques and approach to these neglected injuries. Middle-aged adults from 30 to 50 represent 73.8% of reported cases, and most of them are males (72.0%). The most affected level is C5-C6 (43.0%). While most delays are due to missed injuries (52.1%) and ineffective non-operative treatment (36.2%), the other reason for delay is negligence in seeking medical care (11.7%). Patients present with variable degrees of neurological deficit, persistent neck pain, and neck stiffness. Reported approaches and techniques to reduce and stabilize these injuries are highly variable and depend on the surgeon's judgment, experience, and preference. Fibrotic tissues and bony fusion around the dislocated facet joint contribute to the reduction challenge, and 77.0% of closed reduction attempts fail. Anterior and posterior approaches to the cervical spine are used selectively or in combination for surgical release, reduction, and stabilization. Despite the lack of standardized treatment guidelines and different approaches, most of the authors reported improvement in pain, balance, and neurology post-surgery. Starting with the posterior surgical approach aims to achieve reduction compared to the anterior approach which largely aims at spinal decompression. Given the existing controversies, the need for quality prospective studies to determine the best treatment approach for lower cervical facet dislocations presenting with delay is evident.

Keywords: Anterior approach; Delayed presentation; Lower cervical facet dislocations; Neglected; Posterior approach.

Figure 1

C-spine CT-scan sagittal slices image demonstrating a neglected C6–C7 facet dislocation. Note the osteocartilaginous tissues bridging C6 and C7 (red arrow) and locking of facets (red arrowhead).

Figure 2

C-spine CT imaging showing neglected dislocation C4–C5. Note the anterolisthesis C4–C5 (red arrow) and bony fusion of the facet (red arrowhead).

Figure 3

Summary of approaches used neglected lower cervical facet dislocations. (*cases underwent corpectomy and in situ fixation; A: Anterior; P: Posterior; A–P: Anterior–Posterior; A–P–A: Anterior–Posterior–Anterior; P–A: Posterior–Anterior; P–A–P: Posterior–Anterior–Posterior; A–P–A–P: Posterior–Anterior–Posterior).

Figure 4

Neglected dislocation of C5–C6 (slide A). Reduction and combined anterior–posterior fixation (slide B).

Figure 5

Dynamic radiographs of the cervical spine showing neglected dislocation C5–C6 treated conservatively. Note the stability of the dislocated segment and anterior auto-fusion.

Figure 6

Irreducible neglected dislocation C6–C7 (slide A). Corpectomy C7 and fixation in situ using mesh cage and plate (slide B).