MRI‐Based Surgical Planning for Irreducible Subaxial Cervical Fracture‐Dislocation With Bilateral Locked Facet Joints: A Retrospective Cohort Study

• Published in: Orthopaedic surgery Vol. 17; no. 6; pp. 1844 - 1851
• Main Authors: Leng, Ao, Meng, Lingzhi, Li, Jiacheng, Shi, Song, Guo, Mingming, Yu, Hailong, Wang, Qi
• Format: Journal Article
• Language: English
• Published: Melbourne John Wiley & Sons Australia, Ltd 01.06.2025; John Wiley & Sons, Inc; Wiley
• Subjects: Adult; Aged; bilateral locked facet joints; cervical dislocation; Cervical Vertebrae - diagnostic imaging; Cervical Vertebrae - injuries; Cervical Vertebrae - surgery; Cohort analysis; Comparative analysis; Contusions; Decision making; Female; Fracture Dislocation - diagnostic imaging; Fracture Dislocation - surgery; Humans; Iatrogenesis; Joint Dislocations - diagnostic imaging; Joint Dislocations - surgery; Magnetic resonance imaging; Magnetic Resonance Imaging - methods; Male; Middle Aged; Patients; Retrospective Studies; Spinal cord; Spinal Fractures - diagnostic imaging; Spinal Fractures - surgery; Surgeons; Surgery; Surgical outcomes; surgical reduction; Vertebrae; Young Adult; Zygapophyseal Joint - diagnostic imaging; Zygapophyseal Joint - injuries; Zygapophyseal Joint - surgery; surgical reduction; cervical dislocation; bilateral locked facet joints
• ISSN: 1757-7853; 1757-7861
• DOI: 10.1111/os.70054

ABSTRACT Objective Subaxial cervical fracture‐dislocation with bilateral locked facet joints represents a critical spinal injury. The management of this condition remains a subject of debate, particularly regarding the optimal surgical approach. This study aims to introduce a quantified indicator to guide surgical decision‐making and to assess its safety in clinical practice. Methods We retrospectively compared 62 patients treated according to the Spinal Cord Buffer Space (SCBS) criteria with 63 patients treated before SCBS was introduced. Briefly, SCBS was measured on preoperative MRI to quantitatively assess whether sufficient buffer space exists for the spinal cord, ensuring that a posterior reduction can be performed without causing iatrogenic spinal cord injury. The neural status was assessed with the American Spinal Injury Association (ASIA) impairment scale. Local sagittal alignment was evaluated at the dislocation level. Fisher's exact test and independent t‐test were used to compare the parameters between the two groups. Results Surgical planning according to SCBS is relatively safe, with no patient experiencing neurologic deterioration after operation (p = 0.014). Forty‐two patients with preoperative grade E on ASIA had no postoperative changes. Thirteen patients with preoperative grade D recovered to grade E after surgery, while 7 patients remained grade D but reported improved limb function. In comparison, 63 patients were treated before SCBS was introduced. Among 47 patients with preoperative grade E, 43 patients remained grade E while 4 patients were downgraded to grade D. For 16 patients with preoperative grade D, there were 2 patients with postoperative grade C, 6 patients with postoperative grade D, and 8 patients with postoperative grade E. No loosening, displacement, or breakage of the implants was observed in both groups during the follow‐up. Conclusions SCBS is a reliable and quantified indicator for surgical planning, and can significantly reduce the incidence rate of iatrogenic neurologic deterioration. For patients with a positive SCBS, posterior reduction can be safely performed. In contrast, for patients with a negative SCBS, anterior decompression should be prioritized. In this study, we present the concept of SCBS and proved that SCBS is a reliable and quantitative indicator in surgical decision‐making for patients with irreducible subaxial cervical fracture‐dislocation with bilateral locked facet joints. For patients with positive SCBS, a posterior reduction with lateral mass/pedicle screw fixation was safe to perform, without causing iatrogenic injury during the procedure. For patients with negative SCBS, a staged anterior–posterior–anterior procedure should be performed.