SpineUniverse Case Study Library

Traumatic Unilateral Cervical Spine Perched Facet

History

A 22-year-old male was evaluated in the Emergency Department after a motor vehicle collision. He was found to have bilateral C6 comminuted lamina fractures extending to the right C6-C7 facets with grade 1 anterolisthesis of the C6 vertebral body, and perched right C6-C7 facet.

The patient reported severe mechanical neck pain, and was maintained in a hard cervical collar. He denied motor or sensory symptoms, including in his upper extremities.

Examination

  • Significant neck pain
  • Intact to light touch in all dermatomes
  • 5/5 strength in all muscle groups
  • 2+ reflexes throughout
  • No upper motor neuron signs

Pretreatment Imaging

The CT scans below (Fig. 1A, 1B) demonstrate the sagittal cervical midline.

Sagittal cervical CT scans demonstrate the midlineFigure 1A (left); Figure 1B (right)

The sagittal right paracentral position is shown in Figure 2A (below) with an axial CT scan delineating the right C6-C7 facet fracture and perched facet (Fig. 2B).

sagittal cervical CT scan shows the right paracentral position and axial view of the right C6-C7 facet fracture, perched facetFigure 2A (left); Figure 2B (right)

Diagnosis

Bilateral C6 comminuted lamina fractures, grade 1 anterolisthesis of the C6 vertebral body, and perched right C6-C7 facet.

Suggest Treatment

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Selected Treatment

Anterior cervical discectomy and fusion at C6-C7 with intraoperative manual reduction of the right C6-C7 perched facet.

Postoperative Imaging

CT scans demonstrate the sagittal cervical midline (Fig. 3A) and right paracentral position (Fig. 3B).

postoperative sagittal cervical CT scans of midline and right paracentral positionFigure 3A (left); Figure 3B (right)

Figure 3C (below) is an axial CT scan delineating the reduced right C6-C7 facet joint with a C6-C7 anterior plate.

postoperative axial CT scan shows reduced right C6-C7 facet joint with anterior plateFigure 3C

Outcome

Immediately following surgery, the patient reported resolution of his mechanical neck pain. His neurological status remained intact. He was discharged from the hospital on postoperative day one in a hard cervical collar with appropriate clinic follow-up.

Peer Discussion

This is an excellent case example of a flexion rotational injury with unilateral facet fracture dislocation. The patient was neurologically intact (another advantage) allowing some options in treatment.

Traction would likely have gained little as the fusion was warranted. Also the bilateral laminar fractures (often the consequence of the extension force) may have left the canal slightly expanded, and protected the patient from neurologic injury.

Finally, I think the use of a hard collar was intelligent postop as these patients can lose reduction, especially with an injury to the posterior ligamentous complex.

Community Case Discussion (1 comment)

SpineUniverse invites spine professionals to share their thoughts on this case.


I would do the same if the patient had arm pain. Without arm pain, I would give the option to the patient conservative treatment, by keeping him in a Philadelphia collar for a couple of weeks, after a short trial (two days) of traction to achieve alignment.
It is very likely that the pedicle (at the right) and lamina fractures spontaneously fused, as well as the perched facet. The end result would be a slightly misaligned, but stabilized segment either via fibrous union or facet fusion.
In case of persisting neck pain after a couple of weeks under collar (due to ongoing glacial instability), late surgery would be indicated.

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