Facet Joint Dislocation


C spine facet joint dis




Facet joint dislocations secondary to flexion distraction injury




10% of cervical spine injuries


Theodotou et al Neurosurg 2019

- 96 patients

- bilateral facet dislocation in 53%

- spinal cord injury in 81%

- complete spinal cord injury in 32%

- equal distributed C4/5, C5/6, C6/7




1. Unifacet subluxation - interspinous process widening

2. Unifacet dislocation - 25% anterolisthesis

3. Bifacet dislocation - 50% anterolisthesis

4. Complete vertebral translation - 100% anterolisthesis


Spinal cord injury


Bilateral facet 2Bilateral facet 1


American Spinal Injury Association (ASIA) Classification

- A (complete): no motor or sensory

- B (incomplete):  no motor, some sensory intact

- C (incomplete):  > 50% muscle groups strength < grade 3

- D (incomplete):  > 50% muscle groups strength > grade 3

- E (normal) motor and sensory


Wilson et al Spine 2013

- 135 patients with facet joint dislocation

- 63% ASIA A or B

- greater severity of neurological injury with bilateral compared with unilateral facet dislocation

- 72% ASIA  A or B with bilateral

- 47% ASIA A or B with unilateral


ASIA Facet dislocation overall Unilateral (42) Bilateral (93)
A 50% 33% 59%
B 13% 14% 13%
C 13% 7% 16%
D 22% 45% 12%


Unilateral Facet Joint Dislocation


Mechanism - flexion / distraction / rotation about contra-lateral intact facet


C56 Unilateral Facet Dislocation

Unilateral facet joint dislocation on xray - 25% subluxation on lateral X-ray (<50%)


Uni facet Sagittal CT


Uni facet CT 1Uni facet CT 2


Unilateral Facet Joint Dislocation CTUnilateral facet joint dislocation CT 2

Unilateral facet joint dislocation on CT

Bilateral Facet Joint Dislocation


Cervical Bilateral Facet Joint Dislocation XrayBIlateral facet joint dislocation

>50% forward subluxation


Bilateral facet CT


Cervical Bilateral Facet Dislocation CT 2Bilateral facet dislocation CT

Bilateral jumped facets on CT




Look for herniated disc

- ? large disc could worsen neurology with skull traction / closed reduction

- ? indication for anterior approach / discetomy / fusion


Uni facet MRIBilateral facet joint MRI

Herniated disc on MRI seen after facet joint dislocation


Management Principles






Herniated disc

Closed versus open reduction

Anterior versus posterior open reduction

Anterior versus posterior fusion


Spinal cord injury management


Fehlings et al Global Spine J 2017

- evidence of modest improvements in motor function with methylprednisone infusions within 8 hours




Nagata et al. Eur Spine J 2017

- 30 patients with facet dislocation and complete motor paralysis

- 27% recovered to ASIA C - E

- early reduction (< 6 hours) associated with improved neurological outcomes


Newton et al JBJS Br 2011

- 32 patients with facet joint dislocation and complete paralysis

- 8 reduced within 4 hours - 5 made a complete recovery

- 24 reduced after 4 hours - only 1 made a useful partial recovery


Herniated disc


? need anterior approach and discectomy prior to reduction to avoid spinal cord damage


Onishi et al Eur Spine J 2022

- systematic review of 197 patients with facet dislocations and herniated disc

- 2 studies with treated with posterior reduction

- 4 studies with patients reduced with skull traction

- worsened neurology seen in one patient


Management plan


Jiang et al Med Sci Monit 2017

- 52 patients with incomplete or normal neurology


Facet management flow 1Facet management flow 2


Closed reduction




In the setting of spinal cord injury, reduced dislocation < 4 hours

Makes surgical fixation and timing easier




Closed reduction

- skull traction

- halo-vest Z-shaped reduction

- manipulation under anesthesia


MUA v skull traction


Lee 1994 JBJS

- 210 patients manipulated under anesthesia vs traction

- traction more successful 88% vs 73%

- traction safer as patient awake & can monitor neurology


Cranio-cervical skull tong traction




Chen et al Zhongguo Jiaoxing 2011

- 68 facet dislocations

- skull traction successful 76% bilateral facet dislocations

- skull traction successful 22% unilateral facet dislocations


Tong traction 1Tong traction 2




Patient awake and able to communicate if neurology worsening

- best performed in operating room as can use cross table image intensifer

- Gardener Wells tongs 1" above  and behind pinna

- below equator / maximum diameter of skull to prevent slippage

- place towels under head to recreate flexion deformity

- start 10 lb for head, then 5 lb for each cervical level every 10 min

- repeat X-ray after each weight increase

- monitor neurological status-  if neurology worsens, release all traction

- maximum 40% body weight

- once facet unlocked, removed towels to extend head


Manipulation under anesthesia



- experienced surgeon

- failure closed reduction

- unilateral facet dislocation

- intention to proceed to open reduction + fusion if required



- GA + image intensifier + skull tongs

- head flexed 45° & rotated 45° away from side of facet dislocation

- traction in above position, then rotate to side of facet dislocation

- should hear click on reduction

- gently extend to stabilize

- similar method if bilateral, but no rotation (flexion / traction / extension)


Surgical Fixation


Neurospine 2023 Reduction Techniques PDF




Anterior approach

Posterior approach

Combined 360 degree fixation


Anterior approach and ACDF



- lower infection rates

- simpler patient positioning in multi-trauma patient

- can perform discectomy prior to reduction



- ? more difficult to perform open reduction

- ? stable enough fixation given damage to posterior ligamentous structures



- decompression / discectomy

- reduction manoeuvre if needed using pins in vertebral bodies

- bone graft and plate


ACDF post C56 Unilateral Facet Dislocation


Posterior approach



- easier to reduce as direct access to facets

- biomechanically stronger fixation



- increased wound problems

- ? risk of increased neurology with herniated disc



- distraction manoeuvre

- instrument between pedicles to reduce

- posterior stabilization or anterior stabilization


Unilateral Facet Dislocation Posterior Stabilisation


Combined anterior and posterior approach



- severely unstable fractures

- endplate fractures

- facet joint fractures


Bilateral facet 2Facet dis 360 fusion 1Facet dis 360 2




Operative versus nonoperative treatment


Dvorak et al Spine 2007

- 90 isolated unilateral facet dislocations

- better outcomes with operative treatment


Dvorak et al Evid Based Spine Care J 2010

- systematic review of 6 papers on unilateral facet dislocation

- treatment failure, persistent pain, and neurological deterioration higher with nonoperative treatment


Anterior alone reduction and fixation


Lee et al. Global Spine Journal 2021

- systematic review of anterior alone reduction and fusion

- 7 studies and 350 patients

- vast majority able to reduce dislocation with open approach

- 1% failure rate with anterior fixation


Theodotou et al Neurosurg 2019

- 96 patients

- 63% had attempted closed reduction, successful in half

- anterior reduction and ACDF

- 92/96 (96%) satisfactory alignment

- 8/96 (8%) required posterior instrumentation for unsatisfactory alignment or loss of position


Posterior alone reduction and fixation


Park et al J Neurosurg Spine 2015

- 21 patients with facet dislocation, 7 with herniated disc

- treated with open reduction and posterior pedicle screw fixation

- patients with herniated disc decompressed via posterolateral approach


Anterior versus posterior


Kwon et al J Neurosurg Spine 2007

- RCT of posterior versus anterior stabilization for unilateral facet joint dislocations

- 42 patients

- anterior approach had lower infection, better union rates, improved xray alignment

- increased risk postoperative swallowing difficulties with anterior approach


Neurological outcome

Cervical Cord Injury Post Unilateral Facet Dislocation

MRI post reduction and ACDF demonstrating spinal cord injury


Wilson et al Spine 2013

- closed or open reduction and fixation

- unilateral facet: 62% improved one or more grade, 24% improved two or more grades

- bilateral facet: 57% improved one ore more grade, 13% improved two or more grades