Clinical Outcomes of Cervical Facet Fractures Treated Nonoperatively With Hard Collar or Halo Immobilization

Abstract

Study Design:Retrospective review.Objectives:To evaluate the rate of nonoperative treatment failure for cervical facet fractures while secondarily validating computed tomography–based criteria proposed by Spector et al for identifying risk of failure of nonoperative management.Methods:Single-level or multilevel unilateral cervical facet fractures from 2007 to 2014 were included. Exclusion criteria included spondylolisthesis, dislocated or perched facets, bilateral facet fractures at the same level, floating lateral mass, thoracic or lumbar spine injuries, or spinal cord injury. Patients were placed into 3 groups for evaluation: immediate operative management, successful nonoperative management, and failed nonoperative treatment requiring surgical intervention.Results:Eighty-eight patients (106 facets) were included. Twenty-one patients underwent operative treatment with anterior cervical discectomy and fusion or posterior spinal instrumentation and fusion without any failures. Sixty-seven of these patients were treated nonoperatively with either a hard collar (n = 62) or halo vest (n = 5). Eleven patients failed nonoperative treatment (16.4%), all with an absolute fracture height of at least 1 cm and 40% involvement of the absolute height of the lateral mass. Of the 56 patients successfully treated through nonoperative measures, 8 (14.3%) had fracture measurements exceeding both operative parameters.Conclusion:We conclude that it is safe and appropriate for patients with unilateral cervical facet fractures to receive a trial period of nonoperative management. However, patients who weigh over 100 kg, have comminuted fractures, or have radiographic measurements outside of the proposed computed tomography criteria for nonoperative treatment should be educated on the risks of treatment failure.

Establishing the Injury Severity of Subaxial Cervical Spine Trauma

“…For facet fractures with instability (F2), similar inferences can be made given the controversial nature of facet fracture management particularly when unstable. 32 – 34 Additionally, for other variables in the classification, only the N3 ( P = 0.02) neurological grade showed significant variation across surgeon experience, with variability noted in mid-career surgeons, likely secondary to the aforementioned controversies in the management of incomplete spinal cord injuries.…”

“… 32 – 34 Various studies in spine trauma discuss the persistently controversial management of cervical facet fractures, with F3 injuries generally requiring surgical intervention for instability. 32 – 34 In a recent case series, Manoso et al 32 identified 60 consecutive cases of floating lateral mass cervical facet fractures between C3-C7, and found that all patients treated nonoperatively developed instability, whereas all patients treated with two-level fusions did not show evidence of radiographic failure and maintained alignment. Comparatively, Vedantam et al 33 retrospectively reviewed 35 patients with subaxial cervical facet fractures, six of whom had F3 injuries.…”

Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures

“…This classification scheme has demonstrated adequate interobserver agreement and intra-observer reproducibility in multiple studies [1,5,[7][8][9]. Even with an ideal classification scheme, significant heterogeneity remains with regard to the work-up and treatment of subaxial unilateral facet fractures [10][11][12][13][14][15].…”

“…This disparity in outcomes has resulted in a lack of consensus-based algorithms for deciding between operative and nonoperative treatments. Within that, the type of immobilization and surgical approach used for nonoperative and operative management, respectively, is a matter of surgeon preference and experience [10,14,19,[21][22][23][24][25]. Computed tomography (CT)-and magnetic resonance imaging (MRI)based criteria for classifying and predicting failure have also been investigated, but controversy ensues regarding the imaging necessary to appropriately work-up facet fractures [12,20].…”

Commentary on “Contiguous-Level Unilateral Cervical Spine Facet Dislocation—A Report of a Less Discussed Subtype”

“…6 Weight of the patient, comminution of fracture fragments, associated posterior element fracture, height of fracture, and multilevel facet fractures are all predictors of failure of conservative treatment. 6,7 The corollary we can draw from this is that not only is operative intervention mandatory in UFD, one must also look carefully for signs of covert adjacent segment injury like undisplaced facet fractures (which may be a milder form of the contiguous UFD described by Das et al 3 ) and if found would mandate inclusion of more levels in the fixation.…”