Risk Factors for Failure of Nonoperative Treatment for Unilateral Cervical Facet Fractures

Abstract

Study DesignRetrospective clinical study.PurposeThe purpose of this study was to determine what percentage of patients who underwent nonoperative management of unilateral non-displaced or minimally displaced facet fractures progressed radiographically and to determine what percentage of patients required surgical intervention and to identify risk factors for failure of conservative management.Overview of LiteratureAccording to most commonly used classification systems, unilateral, non-and minimally displaced facet fractures are be amendable to nonoperative management.MethodsA retrospective review of the Trauma Registry of a Level I trauma center was performed to identify all patients diagnosed with a non- or minimally displaced unilateral facet fracture which was managed nonoperatively. Several demographic variables and clinical outcomes were recorded. Using computed tomography scanning and plain radiographs, fracture pattern, listhesis, displacement, angle and percentage of the facet that included the fracture were determined. Radiographic progression was defined as the occurrence of listhesis of more than 10% of the anterior-posterior dimensions of the inferior vertebral body during radiographic follow-up. Failure of conservative management was defined as a patient requiring surgical intervention after initially being managed nonoperatively.ResultsSeventy-four patients were included. Fifteen patients (20%) progressed radiographically. However, only 2 developed radicular symptoms and none developed myelopathy or other catastrophic cord related symptoms. Seven patients (9%) underwent surgery. Indications for surgery included significant radiographic progression and/or radicular symptoms. Risk factors for failure of conservative management included presence of radiculopathy at the time of presentation, a higher body mass index, increased Injury Severity Score, greater initial fracture displacement and more than 2 mm of listhesis.ConclusionsPatients with non-displaced or minimally displaced facet fractures who do not have neurological symptoms at the time of presentation can safely be managed conservatively with careful observation and follow-up.

Minimally displaced unilateral facet fracture of cervical spine can lead to spinal cord injury: a report of two cases

“…Our first patient was the first to be reported who developed quadriplegia a few days after injury during non-operative treatment of the unilateral facet fracture. Based on a previous study, failure of non-operative treatment dictated surgery to prevent listhesis progression or worsening of radiculopathy [ 4 – 6 ]. In that study, no patients were found to have new-onset myelopathy or catastrophic spinal cord related symptoms at the follow-up.…”

“…In that study, no patients were found to have new-onset myelopathy or catastrophic spinal cord related symptoms at the follow-up. Most of the patients in the prior studies initially were treated non-operatively, and 2 to 14 weeks later treated surgically if needed [ 4 ].…”

“…For this case we used a combined anterior-posterior approach to avoid disc collapse and kyphosis. Generally, an anterior or posterior only approach yields favorable outcomes for this type of injury [ 4 – 8 ]. The patient presented numbness of her left arm but no motor weakness two years after surgery.…”

“…According to most of the commonly used classification systems for subaxial spine injuries [ 2 , 3 ], unilateral and minimally displaced facet fractures without any sign of a spinal cord injury would be directed to non-operative management. However, the failure rate of non-operative treatment varies from 20 to 80%, and no consensus exists with regard to predictors of failure after non-operative management [ 4 – 6 ]. The first patient with an unilateral facet fracture had only numbness in the right C6 dermatome but failed non-operative treatment, resulting in severe spinal cord injury.…”

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

“…van Eck et al reported that 9% of nondisplaced, unilateral facet fractures required surgical treatment within the follow-up period for significant radiographic progression of listhesis and/ or radicular symptoms. 16 These patients differ from our population because our patients included those with fracture displacement without evidence of spondylolisthesis and also included multilevel fractures. Our study population represents a more severe facet fracture pattern while achieving successful nonoperative treatment in 83.6% of patients.…”