Bilateral inter-faceted dislocation of cervical

spine: Closed reduction with traction weights

– Small and slow or lose it all (neurology)
Goh BH

Department of Orthopedics and Traumatology

University Malaya Medical Centre
Jalan Lembah Pantai 59100
Kuala Lumpur

Introduction:

The cervical spine is the most vulnerable spine segment and probably the most
frequently injured portion of spine after a high velocity trauma. Bilateral facet dislocation
accounts for 10 % plus minus 5% of all cervical spine injuries (Albert). Excessive dislocation
over the cervical spine regions normally causes significant spinal cord damage, for example
cord transection or nerve root avulsion leading to significant neurological deficit. The
management of cervical spine facet dislocation continues to generate considerable
controversy with arguments over its manual reduction protocol, surgical approach or
combined (Albert). These injuries are unstable and will have poor healing potential if
persistently mobile.
Methods described to treat these patients are prolonged cervical traction,
immobilization with a Halo thoracic brace, posterior cervical wiring or lateral mass plates,
anterior cervical fixation with cervical screw plate and combined antero-posterior
stabilization (Ki HL). Some literature had demonstrated that traction upto 140 pounds = 63.5
kg were safely used for effectively reducing the dislocations - those without fracture,
involving C4-C7 done by experienced practitioners under closed scrutiny (Cotler). Gradual
increment of weight per period of time with watchful neurological assessment with serial
plain radiograph taken every increment till reduction achieved is the primary management
protocol for closed tractional reduction for bifaceted cervical dislocation. These patients’
neurological examination of motor function and sensation was done and recorded at each
interval (Cotler).

Case report:

This is a 50 year old Indonesian worker with no underlying co-morbids. Allegedly had
a fall on day of presentation from one storey height while repairing the roof of a house. He
was brought to the casualty by colleagues. Post trauma, complains of axial cervical pain.
There was no lost of consciousness. Patient also had not attempted to mobilized after the
fall. There was no vomiting, no seizures and no abdominal pain. No weakness and no
numbness over all 4 limbs. On examination, patient was alert, moving all limbs. Axial cervical
tenderness (lower cervical). Power of both lower and upper limb was grossly 5/5 with
sensation intact 2/2 except of left sided C6 dermatome some reduced sensation.
Normotonia, normoreflexia and Babinski down going. Xray was taken and showed listhesis
over C6,C7 – Bifaceted C6C7 dislocation. Patient proceeded with a CT scan of the cervical as
an extension from the CT brain TRO ICB, for confirmation of the diagnosis with visualization
of the extend of the facet dislocation. Plan was then explained to the patient, for a closed
tractional reduction with gradual weight increment.

Figure 1: Sagital view CT scan non contrasted showing dislocation over the C6C7.

Figure 2: Sagital view of CT showing bifaceted dislocation with its 3D reconstructed CT at

C6C7 level.
Gardner-Wells tongs were applied. Area of pinning was shaved, a small 1cm incision was
made over the area of application. Pin was applied with sterile technique – Pin insertion site
was at 1cm just above the tragus of the ears both side below the equator of the skull. The
risk and procedure had been clearly explained to the patient prior to application.

Figure 3: Series of radiograph post 2 kg added on traction. A total of 8kg prior to

confirmatory scan by CT (Computerised tomography)

Figure 4: CT cervical post series of gradual reduction – post 8 kg reduction.

Traction was applied with gradual increment of weights for the patient. 2kg was
applied initially with 2 kg increment every 30 minutes, with serial neurological monitoring
and check xray. There were difficulty in the check xrays in view of the patient bulkier habitus
and the bifaceted dislocation being at the lower cervicals. Difficulty in getting a clear
visualization of the reduction. The x-rays were taken initially with bilateral arm traction
lateral radiograph. However due to the shoulder soft tissue shadow, only C5 was visualized.
Second attempt, swimmers view attempted with assisted arm traction, however the
radiograph is still not visible. Finally, attempt of “reverse” swimmers view: whereby the
opposite arm is adducted and the other abducted. The visualization is better but still not
completely clear. Upon the 8th kg traction, with xray suggestive of reduction , 2 kg had been
removed and the traction replaced to allow some neck flexion, by elevating the skull
traction above the head level. Patient is then pushed to CT scan for confirmation of
reduction. The traction in maintained throughout the scan. However, the CT shows failure of
reduction, as not clearly evidence by the radiograph. Patient had no neurology at the end of
the reduction .
In view that the persistent dislocation due to failure of reduction, the tractional
weight continues. However there was an attempt of a hike increment of 8kg upon the 8 kg
weightage – giving a total of 16 kg. Within minutes the patient developed neurology –
complete neurology with power from 5/5 to 0-2 on the lower limbs. Immediately the
weightage had been removed with strict neurological monitoring. There is a slow but
gradual improvement in neurology. The tractional reduction by weightage method is then
abandoned awaiting surgical intervention.
Patient was councelled for C6C7 reduction and instrumentation fusion of C5 – T1.
Post surgery – patient is monitored strictly for his neurological recovery. Post surgery, check
xray of cervical radiograph was taken and a repeat CT scan few days later.

Figure 5: AP and lateral radiograph of cervical post reduction and instrumentation fusion
Figure 6: CT scan post reduction and fixation for confirmation of reduction.

The patient then gradually improves neurologically and rehabilitation post surgery.
Patient is followed up in the clinic with good progress.

Discussion

Bilateral facet dislocation occurs when a vetebrae’s inferior facet dislocates anteriorly
over the lower vertebra’s superior facet, locking in the intervertebral foramens, creating a
severely unstable fracture (Shanda). CT has the highest sensitivity for C spine injury and is
the most preferred imaging modality. Allen and Ferguson classification is used for research
purposes to classify subaxial spine injuries. It is based on the mechanism of injury and
position of the neck during injury. This classification was proposed by Allen and Ferguson in
1982 and remains the most widely used system for describing subaxial cervical spine injury
(Radiopedia).

Classification (Radiopedia)
 flexion and compression
 vertical compression
 flexion and distraction (facet joint dislocation)
 extension and compression
 extension and distraction
 lateral flexion

Figure 7: Allen Ferguson classification of subaxial cervical spine injury (Radiopedia).

The naked facet sign (also known as the hamburger sign or reverse hamburger bun

sign) refers to the CT appearance of an uncovered vertebral articular facet when the facet
joint is dislocated (Daffner). This CT sign is characteristic of a flexion-distraction injury and
indicates severe ligamentous disruption and spinal instability. Normally, at axial CT, the
vertebral facet (apophyseal) joint space looks like a hamburger: the superior articular
process of the vertebra below forms the semicircular “bun” on top of the “meat patty,” and
the inferior articular process of the vertebra above forms the bun beneath the patty. When
the facet joint is dislocated, the articular facets become uncovered, or naked (Daffner). The
top bun of the hamburger (the superior articular facet) now lies posteriorly. This is
the hamburger sign/reverse hamburger bun sign, which may be either unilateral or bilateral
depending on whether facet dislocation is unilateral or bilateral (Daffner). 
Figure 8: Comparison between normal and dislocated cervical facet (Daffner)
A. Depicted burger: illustrating the term hamburger and reverse hamberger sign
B. Axial cut of CT showing the naked sign
C. Axial cut illustration of facet
D. Sagital view of above and lower vertebrae
E. CT imaging

How about the requirement of a pre reduction MRI? MRI Is recommended for patients
with cervical spinal fracture dislocations if they can’t be examined during closed reduction
due to altered mentation secondary to a trauma for instance (Radiopedia). In clinical
settings, cervical facet dislocations is associated with narrowing of the spinal canal due to
displacement. Reduction of dislocation deformity helps to restore spinal alignment and
diameter of the boney canal by eliminating boney compression of spinal cord (Radiopedia).
Several papers and updates of qualitative medical evidence based review are published to
address several issues:
1. The safety and efficacy of reducing cervical spine deformity with fractures or
dislocations
2. Neurological risk following closed reduction of acute traumatic cervical dislocations.
3. Extra cost (financial burden)

Closed reduction of a faceted dislocation by manipulation was first described by

Walton in 1893 (Walton). Crutchfield then introduced tongs for inline traction in 1933, using
similar technique for successful traction reduction (Daniel E)(Albert B). The efficacy of closed
reduction had shown good outcome over several published case reports and studies. The
incidence of neurological reduction remains low. Before 2001, reported neurological
complication rate was less than 1% - multi journal review (Daniel E). Current literature
review failed to uncover any other reports of patient suffering from a permanent
neurological deficit related to the closed reduction. Transient neurological deficit had been
reported with incidence of 2-4% (Daniel E). The deficits reverses spontaneously or improves
following reduction of weights. Causes of neurological deterioration associated with closed
reduction includes overdistractions, failure to recognize a more rostral non contigious
lesion, disk herniation, epidural hematoma and spinal cord oedema (Ki Hong). Neurological
status is closely monitored during the reduction. The levels of neurological compromise
determined according to frankel grade during admission and last followed up examination.
Tractional reduction protocol varies from country to country - the followings are followed by
New Zealand via principles of slow gradual increment over time with strict neurological
monitoring (www.closedreduction.co.nz): summary

1. Brief neurological exam focused on identified deficits

1. Subjective report
2. Distal light touch
3. Gross finger and toe movement
2. Initial weight: 2-4kg (5-10lb)
1. Brief neurological exam and lateral cervical spine X-ray
2. Pin sites checked
3. Increment 2-4kg (5-10lb) every 5 minutes
1. Brief neurological exam and lateral cervical spine X-ray
2. Repeat until maximum weight or other end point
4. Reverse Trendelenberg can provide counter traction using patients body weight
5. After successful reduction – to reduce 1kg and to reconfirm with urgent MRI.
6. Watchful neurological assessment & looks for signs of overdistraction – KIV reduction of
weights.
7.  Urgent MRI, proceed to open decompression or expedite transfer

Due to these reports of neurological deterioration following reduction had lead to

some authors recommending pre reduction MRI to access for ventral cord compromise
caused by traumatic disk reduction (Daniel B). The risk of extruded disk material
exacerbating neurological compression is of main concern. Prereduction MRI assessment
requires time and transportation 9 (Daniel B). This may lead to delay of reduction and extra
unneccesary movement of C spine that may increased risk of neurological compromise in
case of highly unstable fracture or dislocation. Therefore the prereduction MRI must be of
sufficient value to warrant the delay in treatment and the association with potential
morbidity of transport (Daniel B). As several studies had reported post reduction MRI with
disk herniation.
There are numerous causes of neurological deterioration in patients whom harbour
unstable cervical spinal injuries. These include inadequate immobilization, unrecognised
rostral injuries, over distraction, loss of reduction, cardiac-respiratory-hemodynamic
instability (Alireza). Therefore, an appropriately trained specialist must supervene then
treatment, including attempted closed reduction, of patient with cervical spine fracture
dislocation injuries. Patient who fail attempted closed reduction of cervical fracture injuries
have a higher chance of anatomical obstacles to reduction, including disk herniation and
facet fractures. Therefore, those patient who failed closed reduction should undergo more
detailed imaging or MRI before attempts at open reduction. Patients with these bifaceted
who cannot be examined because of head injury or intoxication cannot be assessed for
neurological deterioration, pre reduction MRI is highly recommended (Alireza).
Post reduction whether successful or failed will need stabilization fixation. Choices of
anterior fixation or combined antero-postrior fixation if up for debate based on surgeon.
preference and indication, for example anterior approach in cases with disk herniation
requiring discectomy and fusion. Issue on best method of stabilization remains
controversial. These surgical moldalities reports low failure rate. Treatment failure occurred
in 8% of facet fracture dislocations treated with anterior cervical discectomy, fusion and
platting (Alireza). In absence of an endplate fracture, ACDF is a reasonable sufficient
treatment option.

References:

Albert B du toit et Robert Dunn. Clinical Article; Bifaceted dislocation of cervical spine acute
management and outcome. SA Orthopedics Journal – Spring 2008: Page 30

Ki HL et al. The Management of bilateral interfactal dislocation with anterior fixation in

cervical spine: Comparison with combined antero-posterior fixation. J Korean Neurosurg soc
42: 305-310 2017.

Cotler JM et al. Closed reduction of traumatic cervical spine dislocation using traction weight
upto 140 pounds. Pub Meds; Spine (Phila Pa 1976), 1993 Mar 1;18(3): 386-390

Daffner. CT diagnosis of facet dislocations: The “hamburger bun” & “reverse hamburger
bun” signs. JEM. 2002; 23;387-394

Ivancic et al. Mechanism of cervical spinal cord injury during bilateral facet dislocation.
Spine. 2007; 15;32: 2467-2473

Walton GL. A new method of reducing dislocation of cervical vertebrae. J Nerv Ment Dis.
1893; 20: 609

Daniel E Gelb. Initial closed reduction of cervical spinal fracture – dislocation injuries.
Neurosurgery. 2013. 72: 73-83

Ki Hong Kim. The management of bilateral interfacetal dislocation with anterior fixation in
cervical spine – Comparison with combined antero posterior fixation. J Korean Neurosurg
Soc 42. 2007 ; 305 – 310

https://radiopaedia.org/articles/naked-facet-sign-vertebral-column

http://closedreduction.co.nz/guideline/

https://radiologykey.com/wp-content/uploads/2016/01/9781604060232_c010_f001.jpg

https://radiopaedia.org/articles/allen-and-ferguson-classification-of-subaxial-cervical-spine-
injuries

Shanda Gomes et al. Bilateral cervical spine facet dislocation. Images in Emergency
medicine. WestJEM 2009; 10:19
Alireza K et al. Trauatic Cervical Unilateral and bilateral facet dislocations treated with
anterior cervical discectomy and fusion has a low failure rate. AO Spine – Global Spine
Journal. 2017, Vol 7(2) 110-115