History
A 22-year-old male was evaluated in the Emergency Department after a motor vehicle collision. He was found to have bilateral C6 comminuted lamina fractures extending to the right C6-C7 facets with grade 1 anterolisthesis of the C6 vertebral body, and perched right C6-C7 facet.
The patient reported severe mechanical neck pain, and was maintained in a hard cervical collar. He denied motor or sensory symptoms, including in his upper extremities.
Examination
Significant neck pain
Intact to light touch in all dermatomes
5/5 strength in all muscle groups
2+ reflexes throughout
No upper motor neuron signs
Pretreatment Imaging
The CT scans below (Fig. 1A, 1B) demonstrate the sagittal cervical midline.
The sagittal right paracentral position is shown in Figure 2A (below) with an axial CT scan delineating the right C6-C7 facet fracture and perched facet (Fig. 2B).
Diagnosis
Bilateral C6 comminuted lamina fractures, grade 1 anterolisthesis of the C6 vertebral body, and perched right C6-C7 facet.
Selected Treatment
Anterior cervical discectomy and fusion at C6-C7 with intraoperative manual reduction of the right C6-C7 perched facet.
Postoperative Imaging
CT scans demonstrate the sagittal cervical midline (Fig. 3A) and right paracentral position (Fig. 3B).
Figure 3C (below) is an axial CT scan delineating the reduced right C6-C7 facet joint with a C6-C7 anterior plate.
Outcome
Immediately following surgery, the patient reported resolution of his mechanical neck pain. His neurological status remained intact. He was discharged from the hospital on postoperative day one in a hard cervical collar with appropriate clinic follow-up.
This is an excellent case example of a flexion rotational injury with unilateral facet fracture dislocation. The patient was neurologically intact (another advantage) allowing some options in treatment.
Traction would likely have gained little as the fusion was warranted. Also the bilateral laminar fractures (often the consequence of the extension force) may have left the canal slightly expanded, and protected the patient from neurologic injury.
Finally, I think the use of a hard collar was intelligent postop as these patients can lose reduction, especially with an injury to the posterior ligamentous complex.