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Unilateral Locked Facet in Cervical Spine Injuries

A. T. SCHER’

Among 525 patients who sustained trauma to the in only one-third of the cases. Associated fractures were
cervical spinal cord, 86 (16%) had unilateral locking of present in 30 cases (35%). The most common fractures
facets. If the diagnosis is not promptly made, neurological involved the vertebral bodies and spinous processes, and
recovery of root deficit will be impaired and orthopedic were usually evident on the lateral view. Less common
deformity will result. Since there is often only minimal were fractures of the neural arches and the lateral masses,
forward displacement at the site of dislocation, it is
often only recognized on the anteroposterior view. The
possible not only to miss the locking of facets but even to
oblique views sometimes demonstrated inconspicuous
erroneously conclude that no fracture or dislocation is
present. Rotation of the cervical spine above the level of fractures of the articular facets and pedicles.
dislocation results in a diagnostic appearance on the
lateral view. Rotation of the spinous processes was seen Discussion
in the anteroposterior view in only one-third of the cases.
Anatomy of Apophyseal Joints
The necessity of obtaining x-rays which adequately demon-
strate the lower cervical spine is emphasized and the The superior and inferior articular facets form an
technique briefly described. articular pillar which projects laterally at the junction of the
pedicle and lamina of the vertebral body. The rounded
Introduction
articular facets have smooth joint surfaces lined with
American Journal of Roentgenology 1977.129:45-48.

Flexion-rotation injuries are the most frequent cause of the cartilage and synovial membrane. The joint itself is bound
fractures and dislocations of the cervical spine associated together by a loose capsule which allows a wide excursion
with spinal cord injury. The most common orthopedic on movement. In flexion there may be as much as 5 mm
injury occuring after flexion-rotation trauma to the cervical of anterior displacement of the inferior articular facet of
spine is dislocation with unilateral locking of facets I 1 [ It . the upper vertebral body in relation to the lower [41.
has been our experience that the diagnosis of this condition The plane of each joint surface forms an angle of about
is usually not made on initial radiographic examination. 450 with the long axis of the spinal canal. The largest
Instead, patients are often referred with a diagnosis of angle is formed by the C4-C5 joint spaces, and caudally
“subluxation or dislocation” of the cervical spine. in a and cranially the angle decreases gradually. Because the
series of patients who had sustained unilateral inter- joint planes are perpendicular to the sagittal plane, they
locking of facets, Braakman and Vinken I 21 found that are easily visible on the lateral view of the cervical spine.
1 6 of 33 were diagnosed incorrectly. If the correct Exceptions are the C2- C3 joints which slope laterally by
diagnosis is not promptly made, reduction becomes 10-20#{176} and as a result are not clearly seen. This may
extremely difficult . In the presence of an unreduced give rise to diagnostic errors I 51.
locked facet, root recovery is impaired and persistent
orthopedic deformity will occur. Mechanism of Injury
There are two primary reasons for incorrect diagnosis: Experimental studies have shown that in order to produce
(1 ) inadequate demonstration of the lower cervical spine dislocation with unilateral interlocking a rotational element
(C6-T1 ) on the lateral view; and (2) failure to recognize as well as forward displacement are necessary [ 61 . In
the condition radiographically. This paper reviews the forced combined cervical flexion and rotation injuries, the
diagnostic radiologic features and the radiographic tech- inferior articular facet of the upper vertebra is displaced
niques necessary for correct diagnosis. forward, overrides the superior articular facet of the lower
vertebra, and becomes locked in the dislocated position.
Case Material and Findings The dislocation is illustrated in figure 1 . The term locked
From 1 963 to 1973, 525 patients who sustained trauma is appropriate in that the dislocated facet cannot return to
to the cervical spinal cord were seen in our spinal injuries its normal position unless reduction of the dislocation is
unit. Most of the injuries were sustained in motor vehicle obtained by traction, manipulation, or surgery. It has also
accidents and falls; the remainder were due to industrial been shown experimentally that the joint capsule and
accidents, assaults, and sports injuries. interspinous ligament must be completely ruptured for
Dislocation with unilateral facet interlocking was present dislocation to take place. The posterior longitudinal ligament
in 86 of the 525 cases (16%). In 68 of the 86 (79%), the and the annulus fibrosus on the affected side are usually
injury involved the C4-C5 and C5-C6 regions. The only slightly damaged [7[.
anteroposterior view was helpful in the specific diagnosis

Received May 14, 1976; accepted after revision April 4, 1977


Spinal Injuries Unit. Conradie Hospital, Cape Town, South Africa.

Am J Roentgenol 129:45-48. July 1977 45


46 SCHER

Fig 1 -l)Iustration of unilateral interlocking of facets in cervical spine.


overriding inferior Reprinted with permission from Schneider RC Head and Neck Injuries
in Football. Baltimore. Williams & Wilkins, 1971)
orticular facet

Radiographic Technique
In patients with acute injury to the cervical spinal cord,
the radiographic projections must provide optimal visual-
ization of the entire cervical spine, while avoiding un-
necessary manipulation of the patient’s head and neck. We
have found that the “pulled lateral view” or, if unsuccessful,
the “swimmer’s view” will in most cases demonstrate the
lower cervical and first thoracic vertebrae adequately.
In the pulled lateral view the patient is supine with the
film placed on the lateral aspect of the shoulder. The
shoulders are pulled down by two assistants who stand on
either side of the patient. Grasping the arms above the
elbow, they then pull the arms across the chest and down-
ward toward the feet. Light countertraction to the head is
applied using radiotranslucent halter or tongbar if the
patient is undergoing skull traction. This countertraction
American Journal of Roentgenology 1977.129:45-48.

serves to maintain the position of the head against the


pull on the shoulder. There should be close supervision by
a physician to ensure that the neck is not inadvertently
flexed or extended.
In the so-called swimmers view the patient is supine with
the cassette placed on the lateral aspect of the shoulder.
The arm on the same side as the cassette is raised above
the head while the opposite arm is pulled down toward the
UNILATERAL LOCKED FACET 47
American Journal of Roentgenology 1977.129:45-48.

F.g. 3.-A, L...... .. .... ...trating unilateral Ic 4-C5 level. Note that vertebra) bodies at site of dislocation are not displaced
B, Schematic representation.

feet to depress the shoulder. The tube is centered on the superior and inferior articular facet) of articular facets per
head of the humerus at the level of the acromion process. vertebra is visible. Above the level of dislocation a double
Care must be taken that the film and tube are parallel. set of articular facets for each vertebra will be present. This
While the anteroposterior view may be helpful, the is because of the rotation of the vertebrae which now
diagnosis is usually made on the lateral view. Once the effectively lie in an oblique position in relation to x-ray
diagnosis is made, it is still necessary to determine the side beam (fig. 2).
of the lesion. Standard 45#{176}
oblique views do not provide This appearance may not be immediately obvious but
good visualization of the apophyseal joints. We have should be sought routinely in cases of cervical spine
found that 20#{176}
oblique views, as described by Lodge and trauma. The diagnosis is often missed because too much
Higginbottom F31 , are most useful in demonstrating this attention is given to the shift of the vertebral bodies in
and in providing further visualization of the apophyseal relation to one another; thus the essential lesion, the
joints. Often fractures of the pedicles of tips of the arti- interlocking, is overlooked. In nine of our cases the forward
cular facets are demonstrated. displacement of the vertebral body was minimal and was
initially thought to be the only finding. An illustrative case
Diagnostic Appearance
is shown in figure 3.
Use of the correct radiographic technique will ensure Other features demonstrated on the lateral view include
adequate demonstration of the entire cervical spine and fractures of the spinous processes and divergence of the
prevent diagnostic errors due to failure of visualization of spinous processes at the level of dislocation. The latter is
the traumatized region. However, lack of familiarity with due to rupture of the posterior ligamentous complex which
the diagnostic appearance on the lateral and anteropos- must occur before dislocation will take place.
tenor views can often lead to incorrect diagnosis, even Anteroposterior view. Several investigators have stressed
when adequate x-rays are available. that in the anteroposterior view, the spinous processes
Lateral view. Rotation of the cervical spine above the above the level of the facet locking will be rotated toward
level of dislocation results in a diagnostic appearance on the locked side. This is expected due to the rotational
the lateral view. The articular facets of the vertebrae below component necessary to produce the dislocation 161 (fig. 4).
the level of dislocation lie symmetrically parallel to each When present, this appearance serves to confirm the
other in a true lateral position, so that only one set (a diagnosis made on the lateral view and also indicates the
48 SCHER

side of dislocation. However, this appearance was seen in


only one-third of our cases, in agreement with the findings
of Braakman and Vinken 121 . The anteroposterior view
is of considerable value in demonstrating fractures of the
neural arches or lateral masses; in fact it is often only on
this view that these features are visualized.

REFERENCES

1. Cheshire DJE: The stability of the cervical spine following


conservative treatment of fracture and J
dislocation. Int
Paraplegia 7:193-203, 1970
2. Braakman A, Vinken PJ: Old luxations of the lower cervical
spine. J Bone Joint Surg [ Br] 50:52-60, 1968
3. Lodge I. Higgenbottom E: Fractures and dislocations of the
cervical spine. X-ray Focus 7:1-6, 1966
4. Penning L: Diagnostic clues by x-ray: injuries of the lower
cervical spine. Acta Neurochir (Wien) 22:234- 244, 1970
5. Braakman A, Penning L: Injuries of the cervical spine. Am-
sterdam, Execerpta Medica, 1 971
6. Roaf A: A study of the mechanics of spinal injuries. J Bone and
Joint Surg [Br] 42:810-823, 1960
American Journal of Roentgenology 1977.129:45-48.

7. Beatson AT: Fractures and dislocations of the cervical spine.


J Bone Jo/nt Surg [Br] 45:21-35, 1963

Fig. 4 -Anteroposterior view demonstrating rotation of spinous pro-


cess of C6 to left indicating presence of unilateral interlocking of facets
at C6-C7 level on left side