Management of Traumatic Subaxial Cervical Facet Dislocation：A retrospective study of 10 patients

Management of Traumatic Subaxial Cervical Facet Dislocation：A retrospective study of 10 patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Management of Traumatic Subaxial Cervical Facet Dislocation：A retrospective study of 10 patients Qin Zhang, Tao Ding, Yi Liu, Yun-Tao Xue This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4339845/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective. To discuss the clinical efficacy of manual close reduction in emergency room and different surgery choices in treating traumatic subaxial cervical facet dislocation patients. Summary of Background Data. The treatment of traumatic subxial cervical facet dislocation is controversial. Although there are heterogeneous methods, it is challenge for surgeons to make a proper surgery choice to treat the traumatic subxial cervical facet dislocation. Methods. A retrospective study was performed on 10 case of traumatic subaxial cervical facet dislocation treated by manual close reduction and different surgery procedures from January 2019 to January 2023. There were 8 males, 2 females, with a meal age of 52.7 years (from 32 to 80 yr). Dislocation sites: 2 in C6-7, 5 in C5-6 , 3 in C4-5; 2 cases with unilateral cervical facet dislocation, 8 cases with bilateral dislocation. Results. All the patients were performed manually close reduction in emergency room as soon as the dislocation diagnosis was made. 5 patients achieved successful manual close reduction. 2 patients achieved successful close reduction through cranial traction. 7 patients undertook anterior approach, or anterior-posterior approach or posterior-anterior approach surgeries and 5 patients were postoperatively classified as grade E according to Frankel standard. All patients were followed up for average of 6 months. Conclusion. Manual close reduction in emergency room may be a good choice for traumatic subaxial cervical facet dislocation patients, if failed, cranial traction may be useful for close reduction. Emergency open reduction, neurological decompression and internal fixation should be performed if close reduction is fail. Different surgical procedures choice should base on the patent’s neurological status and the surgeon’s experience. Health sciences/Diseases/Neurological disorders Health sciences/Diseases/Trauma Health sciences/Anatomy Health sciences/Diseases Health sciences/Neurology manual close reduction subaxial cervical facet dislocation spinal cord injury complete paraplegia Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Traumatic subxial cervical facet dislocation(TSCFD) is one of the most devastating injuries and it is frequently associated with direct spinal cord or nerve root injury 1. Anatomically, subaxial cervical spine trauma consists of injuries from C3 to C7,2,3, with more than 50% of the cervical spine injuries located between C5 and C7.3 If cervical spinal cord injury (SCI) appears and leads to complete paraplegia, several negative outcomes, including physical, mental, economical, and social impairments that affect not only the patient but also their family and caregivers6-8. Although several classification systems of subaxial cervical spine injury have been described, such as classification system proposed by Alen6, the AO classification system, the Subaxial Injury Classification (SLIC) and cervical spine injury severity score(CSISS) 10,11,12, none has demonstrated superior reliability or validity9,13. As the narrowed cervical spinal canal caused by the dislocated cervical facets gives compression to the cervical spinal cord, early reduction restoring the volume of the cervical spinal canal is the most crucial event. Cranial traction seems to be an effective and fast way to achieve close reduction of TSCFD, especially in low impact injuries14,15. However, as a surgery under local/general anesthesia, the cranial traction is usually performed in operation room, where there should be a C-arm X-ray machine to be used to confirm whether the reduction is success. Although there is no report on the time cost, the process from dislocation diagnosis in emergency to cranial traction surgery in the operation room takes too lang. Thus, we try to perform the close reduction in the emergency room as soon as the dislocation diagnosis is made. Materials and methods Materials All cases diagnosed as TSCFD were retrospectively reviewed from the files of Nanjing Medical University Affiliated Wuxi People’s Hospital from January 2019 to January 2023. Data on clinical features were collected and descriptively presented. This study was approved by the local Ethical Committee. Methods The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Nanjing Medical University Committee on Human Research in the Medical Sciences and by the Nanjing Medical University Institutional Review Board. Informed consent was not required by these oversight committees due to the retrospective nature of the study. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s). Manual close reduction As soon as the TSCFD diagnosis is made, usually through CT scan, MRI is also advised if possible, manual close reduction is conducted in emergency room at once. The surgeon holds the patient's head tightly, performs longitudinal traction just like cranial traction, then gently performs flexion and extension, lateral buckling and slight rotation movements. As the reduction is achieved successfully, a noticeable clicking can be felt by both the patient and the surgeon, and there will be a significant relief in symptoms, especially in the neck and shoulder pain symptom (Fig. 1 , Case 2). CT scan is performed to confirm the reduction, then the patient is admitted to orthopedic ward using a jaw-occipital belt traction of 4kg weight to maintain a preliminary stabilization. The next treatment plan is conducted as corresponding examinations and evaluations are finished. Close reduction through cranial traction If the manual close reduction in emergency room is failed, the patient is sent to operation room, and cranial traction is performed under local anesthesia. The initial traction weight is 4 kg, the surgeon holds the patient’s head and neck performs flexion and extension, lateral buckling and slight rotation movements every 5 minutes, the reduction is confirmed by C-arm X-ray machine. If this procedure is not successful, the traction weight adds 1kg more, then the surgeon repeat the reset action mentioned above. This operation is continued until the reduction is achieved successfully, and a 4kg weight traction is used to keep a preliminary stabilization. Emergency surgery If the close reduction is not achieved through the methods mentioned above, emergency surgery is performed to obtain reduction, nerve decompression and fixation. Anterior cervical discectomy and fusion(ACDF) and anterior cervical corpectomy and fusion(ACCF) are both good choices. As the case 7 in Fig. 2 , the dislocated facet could be separated by a distractor, when the inferior articular process apex and the upper articular process apex got together (Fig. 2 E), the assistant held the skull traction device and the patient’s head, performing flexion, then the reduction could be successfully achieved with a noticeable clicking (Fig. 2 F). Then the decompression and fixation were performed and ACDF was finished. However, in some extreme situations, if the reduction can’t be achieved successfully through anterior approach, we have to close the anterior cervical incision temporarily, turn the patient over, reset and fix the facet through posterior approach, then turn over the patient again to finish ACDF/ACCF. This procedure is too complicated, and may be dangerous for the cervical spinal cord. As the case 4(Fig. 4 ), of which the right facet fractured seriously, the fracture line extended to the entire cervical vertebral plate of C6. Thus, the longitudinal traction power performed by the surgeon’s hand, or cranial traction, or a distractor couldn’t conduct to the dislocated right facet to achieved reduction, this means the dislocation of the right facet might not be reset through close reduction or anterior surgery. The dislocated right facet could also hinder the left facet reduction. Therefore, if we begin the surgery with anterior procedure, we will have to take anterior-posterior-anterior approach. So we began the surgery through posterior approach, we exposed the bilateral facets, removed small fracture fragments of the right facet, reset it roughly, then we reset the left facet by poking using a big curette. The left lateral mass screw(C6), left pedicle screw(C7) and rod system was used to fix the left facet. As the screws can’t be put perfectly because of the fracture, the right facet was left without fixation. Then, the torn supraspinous ligament was sutured, the wound was stitched up and bandaged, and the patient was turned over for ACDF. Surgery post close reduction For the close reduction successful patients, if there is a good neurological status, and the cervical spine stable structure: i. slightly damaged: conservative therapy (Case 8); ii. moderately damaged: ACDF (Case 9); iii. seriously damaged: ACDF + lateral mass/pedicle screws and rod system (Case 6). If there is a CSI and spinal cord shock: ACDF (Case 1,10). Results During the 4 years investigated, 10 cases diagnosed as TSCFD were identified. The clinical and pathological data of these patients are summarized in Table 1 . Briefly, there was male predominance (8M:2F) with a mean age at diagnosis of 52.7 years-old (range 32 to 80 years). Close reduction was achieved in 7 patients (Case2,3,5,6,8,9,10), among which 5 patients(Case2,3,6,8,9) were treated successfully in emergency room manually, and the other 5 patients were sent to operation room, treated with cranial traction, and close reduction was achieved finally in 2 patients(Case5,10). Table 1 The clinical and pathological data of the TSCFD patients. (ACDF stands for anterior cervical discectomy and fusion) Case No. Age/Sex Mechanism Injury Neuro Deficits Close Reduciton Frankel grade pre-/post- close reduction Operation Days to Sur Clinical outcoms (Frankel grade) 1 43/M High altitude falling C5-6 bilateral facets dislocation Spinal shock, complete paraplegia Fail A/- ACDF 0 Spinal shock, complete paraplegia(A) 2 76/M Traffic accident C4-5 bilateral facets dislocation Spinal shock, complete paraplegia Success manually A/A Conservative treatment - Spinal shock, complete paraplegia(A) 3 80/M Falling down C5-6 bilateral facets dislocation, a heart accident occurred after CT scan, insensible after CPR, under the use of ventilator Numbness of limbs Success manually -/- Conservative treatment - Die of heart accident 2 days later (-) 4 48/M High altitude falling C6-7 bilateral facets dislocation Neck pain, incomplete paralysis of two upper limbs Fail D/- C6 left lateral mass screw (C7pedicle screw) + ACDF 0 Perfectly normal life(E) 5 54/F Heavy blow to the neck back C5-6 bilateral facets dislocation Neck pain, incomplete paralysis of two upper limbs Success through cranial traction D/E ACDF 7 Perfectly normal life(E) 6 42/M Falling down C5-6 bilateral facets dislocation Neck pain, incomplete paralysis of two upper limbs Success manually D/E ACDF + Left lateral mass screws 4 Perfectly normal life(E) 7 32/M Falling down C5-6 left facet dislocation Neck pain, incomplete paralysis of two upper limbs Fail D/- ACDF 1 Perfectly normal life(E) 8 60/M Traffic accident C4-5 right facet dislocation Neck pain Success manually E/E Conservative treatment - Perfectly normal life(E) 9 49/M Falling down C4-5 right facet dislocation Neck pain, incomplete paralysis of two upper limbs Success manually D/D Go to other hospital for ACDF - Perfectly normal life(E) 10 43/F Falling down C6-7 bilateral facets dislocation Spinal shock, complete paraplegia Success through cranial traction A/A ACDF 6 Spinal shock, complete paraplegia(A) The 3 close reduction failed patients (Case 1,4,7) underwent emergency surgeries in 24 hours, in which 2 patients (Case1,7) were treated with ACDF, and the other was treated with open reduction, lateral mass screw/pedicle screw fixation through posterior approach followed by an ACDF (Fig. 4 , case 4). The temporary maintenance of cervical stability was conducted through a jaw-occipital belt traction with 4Kg weight in the 7 close reduction patients. The 3 of which underwent surgeries 4, 6, 7 days later respectively, of which 2 patients (Case 5,7) undertook ACDF and the other 1 patient (Case 6) undertook ACDF followed by lateral mass screw and rod fixation through posterior approach. One of the other 4 close reduction patients died of heart accident 2 days later (Case 3), 2 patients choose conservative treatment (Case 2,8), 1 patient (Case 9) went to other hospital for ACDF surgery and get perfectly normal activity finally. The 2 ACDF patients (Case5, 7), 1 ACDF followed lateral mass screw and rod fixation through posterior approach patient (Case 6), and 1 lateral mass screw/pedicle screw fixation through posterior approach followed ACDF patient (Case 4) got an early recovery and achieved perfectly normal activity finally. Unfortunately, although ACDF was performed, 2 pamplegia patients (Case 1,10) remained complete paralysis postoperatively without significant neurological improvement. For the conservative therapy patients (Case 2,8), case 2 remained complete pamplegia after 6 months of rehabilitation therapy; case 8 stayed in bed for 7 days, then walked on the ground with a philadelphia neck brace, and returned to a normal life gradually 1 months later. Discussion Traumatic subxial cervical facet dislocation(TSCFD) is one of the most devastating injuries involving the axial skeleton. Several approaches to reduction and stabilization have been proposed with all demonstrating advantages and disadvantages16. The objective of this paper is to evaluate the manual close reduction in emergency room in the initial management of TSCFD. The secondary aim is to analyze the different surgical choices in TSCFDs. The impairment to the spinal cord and nerve root injury is the most critical event in TSCFD. The nerve root injury may lead to different degrees of upper limb dysfunction. The cervical spinal cord injury(SCI) could lead to spinal shock and complete/incomplete paraplegia, which affect not only the patient but also their family and even the society6-8. Generally speaking, injury to the cervical spinal cord typically leads to a combination of symptoms and signs resulting from immediate and delayed injuries17,18. The initial mechanical trauma tends to primarily damage the central grey matter because of its high metabolic requirement. It is thought that the grey matter is irreversibly damaged within the first hour after injury, whereas the white matter is irreversibly damaged within 72 h after injury17. It is known that the degree of the recovery and the severity of the pathological changes are directly related to the duration of the acute compression. And this is demonstrated by experiment studies in which longer compression time produces less demonstrable clinical recovery19-21. Thus, relieve the acute compression to the cervical spinal cord and nerve roots is very critical for the TSCFD patients, no matter whether there is spinal cord injury(SCI). Early reduction can restore the volume of the spinal canal, not only relieve the acute compression to the cervical spinal cord and nerve roots, but also provide a loose space for them, and this could produce demonstrable clinical recovery (Fig. 3 , case 6). Cranial traction is thought to be an effective and fast way to achieve close reduction of TSCFD14,15. It is less invasive, and allows for the decompression of the spinal cord compression due to the dislocation, and realigns the spine to an anatomic position16,22. If we perform the longitudinal traction manually in emergency room, just like cranial traction, then make flexion and extension, lateral buckling and slight rotation movements, it is possible to get close reduction of the TSCFD. In this study, 5 of the 10 TSCFD patients achieved successful manual close reduction in emergency room by this way, and this procedure started as soon as the dislocation diagnosis was made. This obviously reduced the duration of acute compression to the cervical spinal cord and nerve roots. For the patients with complete paralysis, when the close reduction is achieved, but without significant improvement in neurological status, it is difficult to make a choice about whether to proceed with the next surgery. Although we strongly recommend a surgical treatment even if it is just for the sake of early sitting up and standing with assistance in rehabilitation therapy post the surgery (Case1,10), there are still some complete paralysis patients refuse a surgery with a hopeless neurological improvement, and choose conservative treatment (Fig. 1 , Case 2). For case 8, the patient’s syndrome was only neck pain, with a normal limb function, manual close reduction was achieved successfully in emergency room. The post-reduction MRI showed the disc and the posterior ligamentous complex (PLC) were not seriously teared, or in other words, the stable structure of the cervical spine was not severely damaged, so we choose a conservative treatment. The patient sit up and walked 7 days later with a philadelphia neck brace. And returned to a normal life gradually 1 months later. As been followed-up for 6 months, there was no obvious discomfort in this patient. The optimal treatment of TSCFD has been controversial 23,24. The surgeon’s experience is a decisive factor, such as skull traction under general or local anesthesia, open reduction and internal fixation (anterior approach; anterior first and posterior second; anterior first and posterior second and then anterior approach; posterior approach; and posterior first and anterior second), and no uniform standards of treatment strategy are available yet. Many scholars advocate a single anterior approach to finish the decompression, reduction and stabilization25,26, especially in cases with unilateral dislocation. For the close reduction successful patients, anterior procedure is a good choice because it’s less invasive. For the close reduction fail patients, there is also a high success rate of reduction and good clinical results25,26. However, there are reports about the anterior approach alone may be technically challenging when intraoperative reduction is required 27, especially in patients with bilateral dislocation, and forcible reduction may increase the risk of secondary cervical spinal cord injury in patients. In a biomechanical study, Bozkus 28 found that posterior fixation system provides a batter stability than anterior fusion with a locking plate and bone graft or cage. Therefore, the question then becomes, is anterior fusion and stabilization adequate? For the complete paraplegia patients, the answer may be yes, because the patient could only sit or stand up with assistance in the rehabilitation therapy after surgery. The anterior stabilization with a locking plate and cage, and the philadelphia neck brace, could provide enough stability for the cervical spine (Table 1 . Case1,10). The posterior stabilization may be unnecessary for the complete paraplegia patients, but may increase surgery trauma, surgery time and treatment costs. Of course, this is under the precursor of successful close reduction or successful open reduction through anterior approach. For the patients with a good neurological status, only anterior fusion and stabilization may be not strong enough for the patients in early walking after surgery, in this situation, because the stable structure post cervical spine has been disrupted, neck flexion is dangerous as the fixation screws may be pulled out. Thus, a posterior fixation may be necessary. For the case 6 (Fig. 3 ) and case 4 (Fig. 4 ), pedicle/lateral mass screws and rod system was used on one side (there were fractures on the other side, which made it difficult to put the screws accuratly), the torn supraspinous ligament was sutured before the wound closure, added with the ACDF, a 270° fusion was achieved through all these procedures, and it was strong enough for early walking after surgery. Although there are reports that most of the dislocations can be reset through anterior approach25,26, there is report that 25% dislocations could not be reduced using a single anterior approach26. In this situation, the surgeons have to close the anterior wound temporarily, turn the patient over, reset and fix the facet through posterior approach, then turn over the patient again to finish the anterior surgery. This anterior-posterior-anterior procedure is too complicated, and may be dangerous for the cervical spinal cord. So if we expect there will be a failed reduction through anterior approach, a posterior-anterior procedure may be a good choice. For case 4(Fig. 4 ), the right articular process of C6 fractured seriously, the fracture line extended to the entire cervical vertebral plate, this made the longitudinal traction power can’t conduct to the dislocated right facet, thus it may be impossible to achieve close reduction of the dislocated right facet, or achieve open reduction through anterior surgery, and the dislocated right facet may also hinder the left facet reduction. Both the manual close reduction in emergency room and the close reduction under cranial traction in operation room were all failed. In the posterior surgery, we saw the fractured right articular process exactly, which was keeping still under traction power, and the longitudinal traction power can’t conduct to the dislocated and fracture right facet. Until after the unnecessary fracture fragments of the right facet was removed and the right facet was roughly reset (Fig. 4 C, H), the left facet reduction was achieved finally by being pried and reset using a large curette. Then the left lateral mass/pedicle screws and rod were used while the right facet was left without fixation, the torn supraspinous ligament was sutured, the wound was closed, and the patient was turned over for ACDF. This posterior-anterior procedure seems better than a possible anterior-posterior-anterior procedure. Although there is a report that a stand-alone posterior approach is adopt to treat TSCFD 29. It needs multi segments fixation to prevent screws being pulled out during multidimensional cervical spine movement, and this comes often at the cost of sacrifice stability of multiple segments. At the same time, we believe that it is inappropriate to leave the ruptured disc untreated, in which a possible disc herniation could make a continuous compression to the cervical spinal cord. We must watch out for the incidence of neurological deterioration related to closed reduction. The ruptured disc fragments may be enrolled into the cervical spinal canal during the close reduction maneuver, which may bring new acute compression, or aggravate the existing compression to the cervical spinal cord. However, it has been reported that the risk of neurologic deterioration from early closed reduction may be lower than previously thought 30. There is report about the incidence of neurological deterioration related to closed reduction remains low. with reported rates of transient deficits of 2–4% and permanent deficits of < 1% 31. So MRI may be necessary for TSCFD patients, which could detect whether there is a disc herniation or a ruptured disc fragment, which may be enrolled into cervical spinal canal during close reduction, aggravating the compression to the cervical spinal cord. In this series of 10 TSCFD cases, 7 patients undertook MRI examination before manual close reduction. If there is definitely a free body in the cervical spinal canal (Fig. 3 D, Fig. 4 D), close reduction may be dangerous to the cervical spinal cord. An anterior approach to perform disc discectomy may be more important than close reduction in this situation. Obviously, reduction after decompression through an anterior approach is much more safe. If the reduction is failed, we should close the anterior wound temporarily, turn the patient over, perform the posterior reduction and fixation, then turn the patient over again to finish the anterior fusion and stabilization finally. Although this anterior-posterior-anterior procedure is complicated, it may be more safe to the cervical spinal cord than the posterior-anterior procedure. However, it seems that the analysis above is only a theoretical possibility. There is an obvious disc herniation in case 6 (Fig. 3 D), which is not enrolled into the cervical spinal canal during the close reduction maneuver (Fig. 3 H), and it doesn’t bring new acute compression, or aggravate the existing compression to the cervical spinal cord (Fig. 3 H). The patient’s neurological symptom is relieved after manual close reduction. For the case 4, there is also an obvious disc herniation (Fig. 4 D), after multiple attempts but failed close reduction, open reduction posteriorly is performed, before the disc discectomy anteriorly, and the neurological status is not only not aggravated but also improved significantly. These two cases indicate that neurological symptom aggravation after close reduction may be only a low probability event, and it is consistent with previous reports31. The obvious weakness of this study lies in its retrospective nature and the heterogeneous methods that were used to treat TSCFD. Conclusion Manual close reduction in emergency room is an effective and fast way for the TSCFD patients. Cranial traction and close reduction should follow the unsuccessful manual close reduction. The surgical procedure choice should base on the patient’s neurological status, and the surgeon’s experience. The anterior, anterior-posterior, posterior-anterior, anterior-posterior-anterior approaches are all effective choices. The goal of the treatment is decompression, reduction and stabilization. Declarations Author Contribution Qin Zhang and Tao Ding, take the surgery, formal analysis and original draft preparation; Yi Liu, data curation; Yun-Tao Xue review and editing. All authors have read and agreed to the published version of the manuscript. Data availability statement Research data will be shared upon reasonable request to the corresponding author. References Fredø HL, Rizvi SAM, Lied B, Rønning P, Helseth E. The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway. Scand J Trauma Resusc Emerg Med.2012;20:85:17–21:. doi: 10.1186/1757-7241-20-85 Torretti JA, Sengupta DK. Cervical spine trauma. Indian J Orthop 2007;41(4):255–267 Joaquim AF, Lawrence B, Daubs M, Brodke D, Patel AA. Evaluation of the subaxial injury classification system. J Craniovertebr Junction Spine 2011;2(2):67–72 Aebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J 2010;19(1, Suppl 1):S33–S39 Gelb DE, Hadley MN, Aarabi B, et al. Initial closed reduction of cervical spinal fracture-dislocation injuries. Neurosurgery. 2013;72 Suppl 2:73–83. doi: 10.1227/NEU.0b013e318276ee02 Seif M, David G, Huber E, et al. Cervical cord neurodegeneration in traumatic and non-traumatic spinal cord injury. J Neurotrauma. 2020;37:860–7. Jin C, Zhao L, Wu J, et al. Traumatic cervical spinal cord injury: relationship of MRI findings to initial neurological impairment. Eur Spine J. 2021;30:3666–75. Morishita Y, Kawano O, Maeda T. The pathophysiology of cervical spinal cord injury: what are the differences between traumatic injury and degenerative disorder. Spinal Cord Ser Cases. 2022;8:50. Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP (1982) A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 7:1–27 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Euro Spine J 3:184–201 Orthpaedic Trauma Association. Fracture and dislocation compendium (1996) J Orthop Trauma 10 (Suppl 1):1–154 Patel AA, Dalley A, Brodke DS, Daubs M, Anderson PA, Hurlbert RJ, Vaccaro AR, Spine Trauma Study Group (2008) Subaxial cervical spine trauma classification: the Subaxial Injury Classification system and case examples. Neurosurg Focus 25:E8 Kwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF (2006) Subaxial cervical spine trauma. J Am Acad Orthop Surg :78–89 Newton D, England M, Doll H, Gardner BP. The case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. J Bone Joint Surg Br. 2011;93(12):1646–1652. doi: 10.1302/0301-620X.93B12.27048 Aarabi B, Mirvis S, Shanmuganathan K, et al. Comparative effectiveness of surgical versus nonoperative management of unilateral, nondisplaced, subaxial cervical spine facet fractures without evidence of spinal cord injury: clinical article. J Neurosurg Spine. 2014;20(3):270–277. doi: 10.3171/2013.11 . SPINE13733 Lee JY, Nasar A, Eek JC, et al. Controversies in the treatment of cervical spine dislocations. Spine J 2009; 9: 418–3 . Harrop JS, Sharan A, Ratliff J (2006) Central cord injury: pathophysiology,management, and outcomes. Spine J 6:198–206 Maynard FM Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH, Ducker TB et al (1997) International standards for neurological and functional classification of spinal cord injury.Spinal Cord 35:266–274 Tator CH (2006) Review of treatment trials in human spinal cord injury: issues, difficulties, and recommendations. Neurosurgery59:957–82 Delamarter RB, Sherman J, Carr JB (1995) Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg Am 77:1042–1049 Fehlings MG, Tator CH (1999) An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies.J Neurosurg 91:1–11 Branche MJ, Ozturk AK, Ramayya AG, McShane BJ, Schuster JM. Neurologic status on presentation as predictive measurement in success of closed reduction in traumatic cervical facet fractures. World Neurosurg. 2018;114:e344–e349. doi:10.1016/j. wneu.2018.03.001 Lee JY, Nasar A, Eek JC, et al. Controversies in the treatment of cervical spine dislocations. Spine J 2009; 9: 418–3. Feng G, Hong Y, Li L, et al. Anterior decompression and nonstructural bone grafting and posterior fixation for cervical facet dislocation with traumatic disc herniation. Spine 2012; 37: 2082–88. Ordonez BJ, Benzel EC, Naderi S, et al. Cervical facet dislocation: techniques for ventral reduction and stabilization. J Neurosurg 2000; 92 : 18–23 . Reindl R, Ouellet J, Harvey EJ, et al. Anterior reduction for cervical spine dislocation. Spine (Phila Pa 1976) 2006; 31 : 648–52 Paxinos O, Ghanayem AJ, Zindrick MR, et al. Anterior cervical discectomy and fusion with a locked plate and wedged graft effectively stabilizes flexion-distraction stage-3 injury in the lower cervical spine: A biomechanical study. Spine. 2009;34: E9–15. Bozkus H, Ames CP, Chamberlain RH, et al. Biomechanical analysis of rigid stabilization techniques for three-column injury in the lower cervical spine. Spine (Phila Pa 1976) 2005; 30: 915–22 . Norisyam Y, Lim HS, Bahrin Z, Foo CH. Bilateral Cervical Facet Dislocation Due to Catastrophic Shallow Water Diving: A Case Report. Cureus. 2023;15(11):e48846. doi: 10.7759/cureus.48846 . PMID: 38106714; PMCID: PMC10722344. Grant GA, Mirza SK, Chapman JR, et al. Risk of early closed reduction in cervical spine subluxation injury. J Neurosurg Spine. 1999;90:13–18. Khezri N, Ailon T, Kwon BK. Treatment of Facet Injuries in the Cervical Spine. Neurosurg Clin N Am. 2017;28(1):125–37. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4339845","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":299656953,"identity":"8ae1409c-d0f5-47e2-8092-cc719fda6ff1","order_by":0,"name":"Qin Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDACCSjJz95+8EFCRQ0JWiR7ziQbPDhzjGgtDAwGNxLMJB+2MBPWIT+7+dnDL2UWeUAtaRWJDWwM/O3dCXi1MM45Zm4sc06iWPLMw2M3EnfIMEicObsBrxZmiQQzack2icS+4wlpNxLPsDEYSOTi18Imkf4NrKXhQIJZQWIbM2EtPBI5ZpIfgVomnEgwYyBKi4RETpk0wzmJxJnAQJZIOHOMh6Bf5Gekb5P8UVaX2A+Myo8/Kmrk+Nt78WsBAWYeNiSXElQOAow/2AgrGgWjYBSMghEMAJJ4SqGSyJRLAAAAAElFTkSuQmCC","orcid":"","institution":"Wuxi People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qin","middleName":"","lastName":"Zhang","suffix":""},{"id":299656954,"identity":"97a3274d-8996-451e-beb9-d9173295ce51","order_by":1,"name":"Tao Ding","email":"","orcid":"","institution":"Wuxi People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Ding","suffix":""},{"id":299656955,"identity":"56d15a17-36f2-4e9a-bd89-05c85b8a7411","order_by":2,"name":"Yi Liu","email":"","orcid":"","institution":"Wuxi People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Liu","suffix":""},{"id":299656956,"identity":"7a30570d-72c5-4762-baaa-d0142833e398","order_by":3,"name":"Yun-Tao Xue","email":"","orcid":"","institution":"Wuxi People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yun-Tao","middleName":"","lastName":"Xue","suffix":""}],"badges":[],"createdAt":"2024-04-29 02:47:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4339845/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4339845/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56204627,"identity":"458ff654-b05a-4a34-b3ee-67ada971b3e2","added_by":"auto","created_at":"2024-05-09 20:47:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":174813,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2. A 76-years old man was injuried in a traffic accident with spinal shock and complete paraplegia. Central sagittal sequence of the cervical CT showed more than 50% anterior subluxation of C4 on C5(B). Both the left(A) and right(C) facets were dislocated and locked. The \u0026nbsp;anterior and posterior longitudinal ligaments, the disc, and the cervical spinal cord were all severely injuried according MRI(D). In the emergency room, the surgeon held the patient’s head tightly, performed longitudinal traction, made flexion and extension, lateral buckling and slight rotation movements until there was an obvious clicking. Close reduction was confirmed by CT examination. Central sagittal sequence of cervical CT(F) post reduction showed restoration of the spinal canal volume and a good cervical spine alignment. The left(E) and right(G) facets were reset successfully. The MRI(H) found the C4-5 disc, the cervical spinal cord, the anterior and posterior ligament structure were all severely injuried. The spinal shock and complete paraplegia were not improved after reduction, the patient refused surgery and went for rehabilitation treatment but without a good result.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4339845/v1/aa91ed3578a879f4cc8d37a1.png"},{"id":56204646,"identity":"19fe6e9d-ca2c-465a-816b-26ebe2c423ec","added_by":"auto","created_at":"2024-05-09 20:47:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":190136,"visible":true,"origin":"","legend":"\u003cp\u003eCase 7. The patient was 32 years old, injuried in a falling down. The syndromes were neck pain, and the slight decrease in muscle strength of two upper limbs. Central sagittal sequence of the cervical CT showed a little anterior subluxation of C5 on C6(A). The left facet was dislocated and locked(B). The C5-C6 disc was ruptured and cervical spinal cord was undamaged according MRI(C). Close reduction was fail, and emergency surgery was conducted. Before the surgery, the dislocated left facet was clearly visible under C-arm X-ray machine(D). In the surgery, the dislocated left facet was separated by a distractor, when the inferior articular process apex and the upper articular process apex touched together(E), the assistant held the skull traction device and the patient’s head, performing flexion, then the reduction was successfully achieved(F). ACDF was performed(G,H), and the patient retrieved to a perfectly normal life finally.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4339845/v1/8b2b0f2810e8b817d008f31f.png"},{"id":56204659,"identity":"73a2ff67-50b3-4774-9eac-6c5a54f7319c","added_by":"auto","created_at":"2024-05-09 20:47:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":244884,"visible":true,"origin":"","legend":"\u003cp\u003eCase 6. A 42-years old man was injuried in falling down. The syndromes were neck pain, and incomplete paralysis of two upper limbs (the muscle strength was grade 2). Central sagittal sequence of the cervical CT showed about 50% anterior subluxation of C5 on C6(B). The left(A) and right(C) facets were dislocated and locked. The C5-C6 disc, the anterior and posterior longitudinal ligaments, and the posterior cervical ligament complex were torn seriously, and the cervical spinal cord was severely injuried through MRI(D). Close manual reduction was performed in the emergency room at once. A noticeable clicking was felt by both the patient and the surgeon when reduction was achieved, and the patient felt a significant symptoms relief, especially the neck pain symptom, and also, the two upper limbs’ muscle strength increased from grade 2 to grade 4 immediately. The reduction was confirmed by cervical CT scan, the restoration of the spinal canal volume and a good cervical alignment were detected through central sagittal sequence of CT(F) and MRI(H). The left (E) and right (G) facets were reducted successfully, and the C5 right inferior articular process fracture was detect pre-(C) and post-(G) reduction. 4 days later, ACDF was performed firstly, then the patient was turned over for posterior fixation, left lateral mass(C5-6) screws and rod system was adopted(I,J,K,L). The patient achieved excellent upper limb function and the ability of walking on the ground the day after surgery, and retrieved to a perfectly normal activity finally.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4339845/v1/ddd762475e81bf08b5b5a733.png"},{"id":56204566,"identity":"8e5c2820-f80d-49ea-97f2-abdb63f83f09","added_by":"auto","created_at":"2024-05-09 20:46:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":322895,"visible":true,"origin":"","legend":"\u003cp\u003eCase 4. The male patient was injuried in a high altitude falling with the symptoms of neck pain, incomplete paralysis of two upper limbs. Central sagittal sequence of the cervical CT showed more than 50% anterior subluxation of C6 on C7(B). The left(A) and right(C) facets were dislocated and locked. The right facet fractured seriously, the fracture line extended to the entire cervical vertebral plate(C,E). The C5-C6 disc, the anterior and posterior longitudinal ligaments, the posterior cervical ligament complex were all torn seriously, and the cervical spinal cord was also damaged through MRI(D). Close reduction failed despite multiple attempts, and emergency surgery was conducted. Firstly, we performed the posterior operation, the dislocated two facets were exposed, the unnecessary fracture fragments of the right facet was removed and the right facet was roughly reset(C,H), and the left facet was pried and reset using a large curette. The C6 left lateral mass screw, C7 left pedicle screw and rod were used for left facet fixation. As the screws can’t be inserted to the fractured lateral mass/pedicle, the right facet was left without fixation(C,H). The torn supraspinous ligament was sutured. Then the wound was closed and the patient was turned over for ACDF(F,G). The patient got out of bed and walked on the ground the day after the surgery, and retrieved to a perfectly normal ability finally.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4339845/v1/c1e6b3c29b3ab15a240a9a75.png"},{"id":63252477,"identity":"b06a922e-b9e4-47b9-9479-c3b1f4f5e44d","added_by":"auto","created_at":"2024-08-26 07:27:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1667163,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4339845/v1/95e42b7c-be6b-465d-94b3-7b7efe06aeb1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of Traumatic Subaxial Cervical Facet Dislocation：A retrospective study of 10 patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraumatic subxial cervical facet dislocation(TSCFD) is one of the most devastating injuries and it is frequently associated with direct spinal cord or nerve root injury 1. Anatomically, subaxial cervical spine trauma consists of injuries from C3 to C7,2,3, with more than 50% of the cervical spine injuries located between C5 and C7.3\u003c/p\u003e \u003cp\u003eIf cervical spinal cord injury (SCI) appears and leads to complete paraplegia, several negative outcomes, including physical, mental, economical, and social impairments that affect not only the patient but also their family and caregivers6-8.\u003c/p\u003e \u003cp\u003eAlthough several classification systems of subaxial cervical spine injury have been described, such as classification system proposed by Alen6, the AO classification system, the Subaxial Injury Classification (SLIC) and cervical spine injury severity score(CSISS) 10,11,12, none has demonstrated superior reliability or validity9,13.\u003c/p\u003e \u003cp\u003eAs the narrowed cervical spinal canal caused by the dislocated cervical facets gives compression to the cervical spinal cord, early reduction restoring the volume of the cervical spinal canal is the most crucial event. Cranial traction seems to be an effective and fast way to achieve close reduction of TSCFD, especially in low impact injuries14,15. However, as a surgery under local/general anesthesia, the cranial traction is usually performed in operation room, where there should be a C-arm X-ray machine to be used to confirm whether the reduction is success. Although there is no report on the time cost, the process from dislocation diagnosis in emergency to cranial traction surgery in the operation room takes too lang. Thus, we try to perform the close reduction in the emergency room as soon as the dislocation diagnosis is made.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMaterials\u003c/h2\u003e \u003cp\u003eAll cases diagnosed as TSCFD were retrospectively reviewed from the files of Nanjing Medical University Affiliated Wuxi People\u0026rsquo;s Hospital from January 2019 to January 2023. Data on clinical features were collected and descriptively presented. This study was approved by the local Ethical Committee.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Nanjing Medical University Committee on Human Research in the Medical Sciences and by the Nanjing Medical University Institutional Review Board. Informed consent was not required by these oversight committees due to the retrospective nature of the study. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eManual close reduction\u003c/h2\u003e \u003cp\u003eAs soon as the TSCFD diagnosis is made, usually through CT scan, MRI is also advised if possible, manual close reduction is conducted in emergency room at once. The surgeon holds the patient's head tightly, performs longitudinal traction just like cranial traction, then gently performs flexion and extension, lateral buckling and slight rotation movements. As the reduction is achieved successfully, a noticeable clicking can be felt by both the patient and the surgeon, and there will be a significant relief in symptoms, especially in the neck and shoulder pain symptom (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Case 2). CT scan is performed to confirm the reduction, then the patient is admitted to orthopedic ward using a jaw-occipital belt traction of 4kg weight to maintain a preliminary stabilization. The next treatment plan is conducted as corresponding examinations and evaluations are finished.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eClose reduction through cranial traction\u003c/h2\u003e \u003cp\u003eIf the manual close reduction in emergency room is failed, the patient is sent to operation room, and cranial traction is performed under local anesthesia. The initial traction weight is 4 kg, the surgeon holds the patient\u0026rsquo;s head and neck performs flexion and extension, lateral buckling and slight rotation movements every 5 minutes, the reduction is confirmed by C-arm X-ray machine. If this procedure is not successful, the traction weight adds 1kg more, then the surgeon repeat the reset action mentioned above. This operation is continued until the reduction is achieved successfully, and a 4kg weight traction is used to keep a preliminary stabilization.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEmergency surgery\u003c/h2\u003e \u003cp\u003eIf the close reduction is not achieved through the methods mentioned above, emergency surgery is performed to obtain reduction, nerve decompression and fixation. Anterior cervical discectomy and fusion(ACDF) and anterior cervical corpectomy and fusion(ACCF) are both good choices. As the case 7 in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the dislocated facet could be separated by a distractor, when the inferior articular process apex and the upper articular process apex got together (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE), the assistant held the skull traction device and the patient\u0026rsquo;s head, performing flexion, then the reduction could be successfully achieved with a noticeable clicking (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF). Then the decompression and fixation were performed and ACDF was finished.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHowever, in some extreme situations, if the reduction can\u0026rsquo;t be achieved successfully through anterior approach, we have to close the anterior cervical incision temporarily, turn the patient over, reset and fix the facet through posterior approach, then turn over the patient again to finish ACDF/ACCF. This procedure is too complicated, and may be dangerous for the cervical spinal cord. As the case 4(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e), of which the right facet fractured seriously, the fracture line extended to the entire cervical vertebral plate of C6. Thus, the longitudinal traction power performed by the surgeon\u0026rsquo;s hand, or cranial traction, or a distractor couldn\u0026rsquo;t conduct to the dislocated right facet to achieved reduction, this means the dislocation of the right facet might not be reset through close reduction or anterior surgery. The dislocated right facet could also hinder the left facet reduction. Therefore, if we begin the surgery with anterior procedure, we will have to take anterior-posterior-anterior approach. So we began the surgery through posterior approach, we exposed the bilateral facets, removed small fracture fragments of the right facet, reset it roughly, then we reset the left facet by poking using a big curette. The left lateral mass screw(C6), left pedicle screw(C7) and rod system was used to fix the left facet. As the screws can\u0026rsquo;t be put perfectly because of the fracture, the right facet was left without fixation. Then, the torn supraspinous ligament was sutured, the wound was stitched up and bandaged, and the patient was turned over for ACDF.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eSurgery post close reduction\u003c/h2\u003e \u003cp\u003eFor the close reduction successful patients, if there is a good neurological status, and the cervical spine stable structure: i. slightly damaged: conservative therapy (Case 8); ii. moderately damaged: ACDF (Case 9); iii. seriously damaged: ACDF\u0026thinsp;+\u0026thinsp;lateral mass/pedicle screws and rod system (Case 6). If there is a CSI and spinal cord shock: ACDF (Case 1,10).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the 4 years investigated, 10 cases diagnosed as TSCFD were identified. The clinical and pathological data of these patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Briefly, there was male predominance (8M:2F) with a mean age at diagnosis of 52.7 years-old (range 32 to 80 years). Close reduction was achieved in 7 patients (Case2,3,5,6,8,9,10), among which 5 patients(Case2,3,6,8,9) were treated successfully in emergency room manually, and the other 5 patients were sent to operation room, treated with cranial traction, and close reduction was achieved finally in 2 patients(Case5,10).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe clinical and pathological data of the TSCFD patients. (ACDF stands for anterior cervical discectomy and fusion)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge/Sex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMechanism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInjury\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeuro Deficits\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClose Reduciton\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFrankel grade pre-/post- close reduction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDays to Sur\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eClinical outcoms\u003c/p\u003e \u003cp\u003e(Frankel grade)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh altitude falling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC5-6 bilateral facets dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpinal shock, complete paraplegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eA/-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSpinal shock, complete paraplegia(A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC4-5 bilateral facets dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpinal shock, complete paraplegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess manually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eA/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSpinal shock, complete paraplegia(A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFalling down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC5-6 bilateral facets dislocation, a heart accident occurred after CT scan, insensible after CPR, under the use of ventilator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumbness of limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess manually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-/-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDie of heart accident 2 days later (-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh altitude falling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC6-7 bilateral facets dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck pain, incomplete paralysis of two upper limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD/-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eC6 left lateral mass screw (C7pedicle screw)\u0026thinsp;+\u0026thinsp;ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePerfectly normal life(E)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54/F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeavy blow to the neck back\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC5-6 bilateral facets dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck pain, incomplete paralysis of two upper limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess through cranial traction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD/E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePerfectly normal life(E)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFalling down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC5-6 bilateral facets dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck pain, incomplete paralysis of two upper limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess manually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD/E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eACDF\u0026thinsp;+\u0026thinsp;Left lateral mass screws\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePerfectly normal life(E)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFalling down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC5-6 left facet dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck pain, incomplete paralysis of two upper limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD/-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePerfectly normal life(E)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC4-5 right facet dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess manually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eE/E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eConservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePerfectly normal life(E)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49/M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFalling down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC4-5 right facet dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeck pain, incomplete paralysis of two upper limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess manually\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eD/D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGo to other hospital for ACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePerfectly normal life(E)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43/F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFalling down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC6-7 bilateral facets dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpinal shock, complete paraplegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccess through cranial traction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eA/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eACDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSpinal shock, complete paraplegia(A)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe 3 close reduction failed patients (Case 1,4,7) underwent emergency surgeries in 24 hours, in which 2 patients (Case1,7) were treated with ACDF, and the other was treated with open reduction, lateral mass screw/pedicle screw fixation through posterior approach followed by an ACDF (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, case 4).\u003c/p\u003e \u003cp\u003eThe temporary maintenance of cervical stability was conducted through a jaw-occipital belt traction with 4Kg weight in the 7 close reduction patients. The 3 of which underwent surgeries 4, 6, 7 days later respectively, of which 2 patients (Case 5,7) undertook ACDF and the other 1 patient (Case 6) undertook ACDF followed by lateral mass screw and rod fixation through posterior approach. One of the other 4 close reduction patients died of heart accident 2 days later (Case 3), 2 patients choose conservative treatment (Case 2,8), 1 patient (Case 9) went to other hospital for ACDF surgery and get perfectly normal activity finally.\u003c/p\u003e \u003cp\u003eThe 2 ACDF patients (Case5, 7), 1 ACDF followed lateral mass screw and rod fixation through posterior approach patient (Case 6), and 1 lateral mass screw/pedicle screw fixation through posterior approach followed ACDF patient (Case 4) got an early recovery and achieved perfectly normal activity finally. Unfortunately, although ACDF was performed, 2 pamplegia patients (Case 1,10) remained complete paralysis postoperatively without significant neurological improvement.\u003c/p\u003e \u003cp\u003eFor the conservative therapy patients (Case 2,8), case 2 remained complete pamplegia after 6 months of rehabilitation therapy; case 8 stayed in bed for 7 days, then walked on the ground with a philadelphia neck brace, and returned to a normal life gradually 1 months later.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTraumatic subxial cervical facet dislocation(TSCFD) is one of the most devastating injuries involving the axial skeleton. Several approaches to reduction and stabilization have been proposed with all demonstrating advantages and disadvantages16. The objective of this paper is to evaluate the manual close reduction in emergency room in the initial management of TSCFD. The secondary aim is to analyze the different surgical choices in TSCFDs.\u003c/p\u003e \u003cp\u003eThe impairment to the spinal cord and nerve root injury is the most critical event in TSCFD. The nerve root injury may lead to different degrees of upper limb dysfunction. The cervical spinal cord injury(SCI) could lead to spinal shock and complete/incomplete paraplegia, which affect not only the patient but also their family and even the society6-8. Generally speaking, injury to the cervical spinal cord typically leads to a combination of symptoms and signs resulting from immediate and delayed injuries17,18. The initial mechanical trauma tends to primarily damage the central grey matter because of its high metabolic requirement. It is thought that the grey matter is irreversibly damaged within the first hour after injury, whereas the white matter is irreversibly damaged within 72 h after injury17.\u003c/p\u003e \u003cp\u003eIt is known that the degree of the recovery and the severity of the pathological changes are directly related to the duration of the acute compression. And this is demonstrated by experiment studies in which longer compression time produces less demonstrable clinical recovery19-21. Thus, relieve the acute compression to the cervical spinal cord and nerve roots is very critical for the TSCFD patients, no matter whether there is spinal cord injury(SCI). Early reduction can restore the volume of the spinal canal, not only relieve the acute compression to the cervical spinal cord and nerve roots, but also provide a loose space for them, and this could produce demonstrable clinical recovery (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e, case 6).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCranial traction is thought to be an effective and fast way to achieve close reduction of TSCFD14,15. It is less invasive, and allows for the decompression of the spinal cord compression due to the dislocation, and realigns the spine to an anatomic position16,22. If we perform the longitudinal traction manually in emergency room, just like cranial traction, then make flexion and extension, lateral buckling and slight rotation movements, it is possible to get close reduction of the TSCFD. In this study, 5 of the 10 TSCFD patients achieved successful manual close reduction in emergency room by this way, and this procedure started as soon as the dislocation diagnosis was made. This obviously reduced the duration of acute compression to the cervical spinal cord and nerve roots.\u003c/p\u003e \u003cp\u003eFor the patients with complete paralysis, when the close reduction is achieved, but without significant improvement in neurological status, it is difficult to make a choice about whether to proceed with the next surgery. Although we strongly recommend a surgical treatment even if it is just for the sake of early sitting up and standing with assistance in rehabilitation therapy post the surgery (Case1,10), there are still some complete paralysis patients refuse a surgery with a hopeless neurological improvement, and choose conservative treatment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Case 2).\u003c/p\u003e \u003cp\u003eFor case 8, the patient\u0026rsquo;s syndrome was only neck pain, with a normal limb function, manual close reduction was achieved successfully in emergency room. The post-reduction MRI showed the disc and the posterior ligamentous complex (PLC) were not seriously teared, or in other words, the stable structure of the cervical spine was not severely damaged, so we choose a conservative treatment. The patient sit up and walked 7 days later with a philadelphia neck brace. And returned to a normal life gradually 1 months later. As been followed-up for 6 months, there was no obvious discomfort in this patient.\u003c/p\u003e \u003cp\u003eThe optimal treatment of TSCFD has been controversial 23,24. The surgeon\u0026rsquo;s experience is a decisive factor, such as skull traction under general or local anesthesia, open reduction and internal fixation (anterior approach; anterior first and posterior second; anterior first and posterior second and then anterior approach; posterior approach; and posterior first and anterior second), and no uniform standards of treatment strategy are available yet.\u003c/p\u003e \u003cp\u003eMany scholars advocate a single anterior approach to finish the decompression, reduction and stabilization25,26, especially in cases with unilateral dislocation. For the close reduction successful patients, anterior procedure is a good choice because it\u0026rsquo;s less invasive. For the close reduction fail patients, there is also a high success rate of reduction and good clinical results25,26. However, there are reports about the anterior approach alone may be technically challenging when intraoperative reduction is required 27, especially in patients with bilateral dislocation, and forcible reduction may increase the risk of secondary cervical spinal cord injury in patients. In a biomechanical study, Bozkus 28 found that posterior fixation system provides a batter stability than anterior fusion with a locking plate and bone graft or cage.\u003c/p\u003e \u003cp\u003eTherefore, the question then becomes, is anterior fusion and stabilization adequate? For the complete paraplegia patients, the answer may be yes, because the patient could only sit or stand up with assistance in the rehabilitation therapy after surgery. The anterior stabilization with a locking plate and cage, and the philadelphia neck brace, could provide enough stability for the cervical spine (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Case1,10). The posterior stabilization may be unnecessary for the complete paraplegia patients, but may increase surgery trauma, surgery time and treatment costs. Of course, this is under the precursor of successful close reduction or successful open reduction through anterior approach. For the patients with a good neurological status, only anterior fusion and stabilization may be not strong enough for the patients in early walking after surgery, in this situation, because the stable structure post cervical spine has been disrupted, neck flexion is dangerous as the fixation screws may be pulled out. Thus, a posterior fixation may be necessary. For the case 6 (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e) and case 4 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e), pedicle/lateral mass screws and rod system was used on one side (there were fractures on the other side, which made it difficult to put the screws accuratly), the torn supraspinous ligament was sutured before the wound closure, added with the ACDF, a 270\u0026deg; fusion was achieved through all these procedures, and it was strong enough for early walking after surgery.\u003c/p\u003e \u003cp\u003eAlthough there are reports that most of the dislocations can be reset through anterior approach25,26, there is report that 25% dislocations could not be reduced using a single anterior approach26. In this situation, the surgeons have to close the anterior wound temporarily, turn the patient over, reset and fix the facet through posterior approach, then turn over the patient again to finish the anterior surgery. This anterior-posterior-anterior procedure is too complicated, and may be dangerous for the cervical spinal cord. So if we expect there will be a failed reduction through anterior approach, a posterior-anterior procedure may be a good choice. For case 4(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e), the right articular process of C6 fractured seriously, the fracture line extended to the entire cervical vertebral plate, this made the longitudinal traction power can\u0026rsquo;t conduct to the dislocated right facet, thus it may be impossible to achieve close reduction of the dislocated right facet, or achieve open reduction through anterior surgery, and the dislocated right facet may also hinder the left facet reduction. Both the manual close reduction in emergency room and the close reduction under cranial traction in operation room were all failed. In the posterior surgery, we saw the fractured right articular process exactly, which was keeping still under traction power, and the longitudinal traction power can\u0026rsquo;t conduct to the dislocated and fracture right facet. Until after the unnecessary fracture fragments of the right facet was removed and the right facet was roughly reset (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003eC, H), the left facet reduction was achieved finally by being pried and reset using a large curette. Then the left lateral mass/pedicle screws and rod were used while the right facet was left without fixation, the torn supraspinous ligament was sutured, the wound was closed, and the patient was turned over for ACDF. This posterior-anterior procedure seems better than a possible anterior-posterior-anterior procedure.\u003c/p\u003e \u003cp\u003eAlthough there is a report that a stand-alone posterior approach is adopt to treat TSCFD 29. It needs multi segments fixation to prevent screws being pulled out during multidimensional cervical spine movement, and this comes often at the cost of sacrifice stability of multiple segments. At the same time, we believe that it is inappropriate to leave the ruptured disc untreated, in which a possible disc herniation could make a continuous compression to the cervical spinal cord.\u003c/p\u003e \u003cp\u003eWe must watch out for the incidence of neurological deterioration related to closed reduction. The ruptured disc fragments may be enrolled into the cervical spinal canal during the close reduction maneuver, which may bring new acute compression, or aggravate the existing compression to the cervical spinal cord. However, it has been reported that the risk of neurologic deterioration from early closed reduction may be lower than previously thought 30. There is report about the incidence of neurological deterioration related to closed reduction remains low. with reported rates of transient deficits of 2\u0026ndash;4% and permanent deficits of \u0026lt;\u0026thinsp;1% 31.\u003c/p\u003e \u003cp\u003eSo MRI may be necessary for TSCFD patients, which could detect whether there is a disc herniation or a ruptured disc fragment, which may be enrolled into cervical spinal canal during close reduction, aggravating the compression to the cervical spinal cord. In this series of 10 TSCFD cases, 7 patients undertook MRI examination before manual close reduction. If there is definitely a free body in the cervical spinal canal (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eD, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003eD), close reduction may be dangerous to the cervical spinal cord. An anterior approach to perform disc discectomy may be more important than close reduction in this situation. Obviously, reduction after decompression through an anterior approach is much more safe. If the reduction is failed, we should close the anterior wound temporarily, turn the patient over, perform the posterior reduction and fixation, then turn the patient over again to finish the anterior fusion and stabilization finally. Although this anterior-posterior-anterior procedure is complicated, it may be more safe to the cervical spinal cord than the posterior-anterior procedure.\u003c/p\u003e \u003cp\u003eHowever, it seems that the analysis above is only a theoretical possibility. There is an obvious disc herniation in case 6 (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eD), which is not enrolled into the cervical spinal canal during the close reduction maneuver (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eH), and it doesn\u0026rsquo;t bring new acute compression, or aggravate the existing compression to the cervical spinal cord (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eH). The patient\u0026rsquo;s neurological symptom is relieved after manual close reduction. For the case 4, there is also an obvious disc herniation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003eD), after multiple attempts but failed close reduction, open reduction posteriorly is performed, before the disc discectomy anteriorly, and the neurological status is not only not aggravated but also improved significantly. These two cases indicate that neurological symptom aggravation after close reduction may be only a low probability event, and it is consistent with previous reports31.\u003c/p\u003e \u003cp\u003eThe obvious weakness of this study lies in its retrospective nature and the heterogeneous methods that were used to treat TSCFD.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eManual close reduction in emergency room is an effective and fast way for the TSCFD patients. Cranial traction and close reduction should follow the unsuccessful manual close reduction. The surgical procedure choice should base on the patient\u0026rsquo;s neurological status, and the surgeon\u0026rsquo;s experience. The anterior, anterior-posterior, posterior-anterior, anterior-posterior-anterior approaches are all effective choices. The goal of the treatment is decompression, reduction and stabilization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eQin Zhang and Tao Ding, take the surgery, formal analysis and original draft preparation; Yi Liu, data curation; Yun-Tao Xue review and editing. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eResearch data will be shared upon reasonable request to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eFred\u0026oslash; HL, Rizvi SAM, Lied B, R\u0026oslash;nning P, Helseth E. The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway. Scand J Trauma Resusc Emerg Med.2012;20:85:17\u0026ndash;21:. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1757-7241-20-85\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTorretti JA, Sengupta DK. Cervical spine trauma. Indian J Orthop 2007;41(4):255\u0026ndash;267\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJoaquim AF, Lawrence B, Daubs M, Brodke D, Patel AA. Evaluation of the subaxial injury classification system. J Craniovertebr Junction Spine 2011;2(2):67\u0026ndash;72\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAebi M. Surgical treatment of upper, middle and lower cervical injuries and non-unions by anterior procedures. Eur Spine J 2010;19(1, Suppl 1):S33\u0026ndash;S39\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGelb DE, Hadley MN, Aarabi B, et al. Initial closed reduction of cervical spinal fracture-dislocation injuries. Neurosurgery. 2013;72 Suppl 2:73\u0026ndash;83. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1227/NEU.0b013e318276ee02\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSeif M, David G, Huber E, et al. Cervical cord neurodegeneration in traumatic and non-traumatic spinal cord injury. J Neurotrauma. 2020;37:860\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJin C, Zhao L, Wu J, et al. Traumatic cervical spinal cord injury: relationship of MRI findings to initial neurological impairment. Eur Spine J. 2021;30:3666\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMorishita Y, Kawano O, Maeda T. The pathophysiology of cervical spinal cord injury: what are the differences between traumatic injury and degenerative disorder. Spinal Cord Ser Cases. 2022;8:50.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAllen BL Jr, Ferguson RL, Lehmann TR, O\u0026rsquo;Brien RP (1982) A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 7:1\u0026ndash;27\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMagerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Euro Spine J 3:184\u0026ndash;201\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOrthpaedic Trauma Association. Fracture and dislocation compendium (1996) J Orthop Trauma 10 (Suppl 1):1\u0026ndash;154\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePatel AA, Dalley A, Brodke DS, Daubs M, Anderson PA, Hurlbert RJ, Vaccaro AR, Spine Trauma Study Group (2008) Subaxial cervical spine trauma classification: the Subaxial Injury Classification system and case examples. Neurosurg Focus 25:E8\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF (2006) Subaxial cervical spine trauma. J Am Acad Orthop Surg\u003c/span\u003e\u003cspan\u003e:78\u0026ndash;89\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNewton D, England M, Doll H, Gardner BP. The case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. J Bone Joint Surg Br. 2011;93(12):1646\u0026ndash;1652. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.93B12.27048\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAarabi B, Mirvis S, Shanmuganathan K, et al. Comparative effectiveness of surgical versus nonoperative management of unilateral, nondisplaced, subaxial cervical spine facet fractures without evidence of spinal cord injury: clinical article. J Neurosurg Spine. 2014;20(3):270\u0026ndash;277. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2013.11\u003c/span\u003e\u003c/span\u003e. SPINE13733\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLee JY, Nasar A, Eek JC, et al. Controversies in the treatment of cervical spine dislocations. Spine J 2009; 9: 418\u0026ndash;3 .\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHarrop JS, Sharan A, Ratliff J (2006) Central cord injury: pathophysiology,management, and outcomes. Spine J 6:198\u0026ndash;206\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaynard FM Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH, Ducker TB et al (1997) International standards for neurological and functional classification of spinal cord injury.Spinal Cord 35:266\u0026ndash;274\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTator CH (2006) Review of treatment trials in human spinal cord injury: issues, difficulties, and recommendations. Neurosurgery59:957\u0026ndash;82\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDelamarter RB, Sherman J, Carr JB (1995) Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg Am 77:1042\u0026ndash;1049\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFehlings MG, Tator CH (1999) An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies.J Neurosurg 91:1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBranche MJ, Ozturk AK, Ramayya AG, McShane BJ, Schuster JM. Neurologic status on presentation as predictive measurement in success of closed reduction in traumatic cervical facet fractures. World Neurosurg. 2018;114:e344\u0026ndash;e349. doi:10.1016/j. wneu.2018.03.001\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLee JY, Nasar A, Eek JC, et al. Controversies in the treatment of cervical spine dislocations. Spine J 2009; 9: 418\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFeng G, Hong Y, Li L, et al. Anterior decompression and nonstructural bone grafting and posterior fixation for cervical facet dislocation with traumatic disc herniation. Spine 2012; 37: 2082\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOrdonez BJ, Benzel EC, Naderi S, et al. Cervical facet dislocation: techniques for ventral reduction and stabilization. J Neurosurg 2000; 92 : 18\u0026ndash;23 .\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eReindl R, Ouellet J, Harvey EJ, et al. Anterior reduction for cervical spine dislocation. Spine (Phila Pa 1976) 2006; 31 : 648\u0026ndash;52\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePaxinos O, Ghanayem AJ, Zindrick MR, et al. Anterior cervical discectomy and fusion with a locked plate and wedged graft effectively stabilizes flexion-distraction stage-3 injury in the lower cervical spine: A biomechanical study. Spine. 2009;34: E9\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBozkus H, Ames CP, Chamberlain RH, et al. Biomechanical analysis of rigid stabilization techniques for three-column injury in the lower cervical spine. Spine (Phila Pa 1976) 2005; 30: 915\u0026ndash;22 .\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNorisyam Y, Lim HS, Bahrin Z, Foo CH. Bilateral Cervical Facet Dislocation Due to Catastrophic Shallow Water Diving: A Case Report. Cureus. 2023;15(11):e48846. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.48846\u003c/span\u003e\u003c/span\u003e. PMID: 38106714; PMCID: PMC10722344.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGrant GA, Mirza SK, Chapman JR, et al. Risk of early closed reduction in cervical spine subluxation injury. J Neurosurg Spine. 1999;90:13\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhezri N, Ailon T, Kwon BK. Treatment of Facet Injuries in the Cervical Spine. Neurosurg Clin N Am. 2017;28(1):125\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"manual close reduction, subaxial cervical facet dislocation, spinal cord injury, complete paraplegia","lastPublishedDoi":"10.21203/rs.3.rs-4339845/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4339845/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective.\u003c/strong\u003e To discuss the clinical efficacy of manual close reduction in emergency room and different surgery choices in treating traumatic subaxial cervical facet dislocation patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSummary of Background Data. \u003c/strong\u003eThe treatment of traumatic subxial cervical facet dislocation is controversial. Although there are heterogeneous methods, it is challenge for surgeons to make a proper surgery choice to treat the traumatic subxial cervical facet dislocation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods. \u003c/strong\u003eA retrospective study was performed on 10 case of traumatic subaxial cervical facet dislocation treated by manual close reduction and different surgery procedures from January 2019 to January 2023. There were 8 males, 2 females, with a meal age of 52.7 years (from 32 to 80 yr). Dislocation sites: 2 in C6-7, 5 in C5-6\u003c/p\u003e\n\u003cp\u003e, 3 in C4-5; 2 cases with unilateral cervical facet dislocation, 8 cases with bilateral dislocation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults.\u003c/strong\u003e All the patients were performed manually close reduction in emergency room as soon as the dislocation diagnosis was made. 5 patients achieved successful manual close reduction. 2 patients achieved successful close reduction through cranial traction. 7 patients undertook anterior approach, or anterior-posterior approach or posterior-anterior approach surgeries and 5 patients were\u003c/p\u003e\n\u003cp\u003epostoperatively classified as grade E according to Frankel\u003c/p\u003e\n\u003cp\u003estandard. All patients were followed up for average of 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion. \u003c/strong\u003eManual close reduction in emergency room may be a good choice for traumatic subaxial cervical facet dislocation patients, if failed, cranial traction may be useful for close reduction. Emergency open reduction, neurological decompression and internal fixation should be performed if close reduction is fail. Different surgical procedures choice should base on the patent’s neurological status and the surgeon’s experience.\u003c/p\u003e","manuscriptTitle":"Management of Traumatic Subaxial Cervical Facet Dislocation：A retrospective study of 10 patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 20:45:38","doi":"10.21203/rs.3.rs-4339845/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c155532c-c6c5-425f-8aba-da5ed29c4411","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31613398,"name":"Health sciences/Diseases/Neurological disorders"},{"id":31613399,"name":"Health sciences/Diseases/Trauma"},{"id":31613400,"name":"Health sciences/Anatomy"},{"id":31613401,"name":"Health sciences/Diseases"},{"id":31613402,"name":"Health sciences/Neurology"}],"tags":[],"updatedAt":"2025-02-19T09:53:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-09 20:45:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4339845","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4339845","identity":"rs-4339845","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}