Delayed bilateral facet dislocation at L4-5: A case report

A rare case of lumbar facet fracture-dislocation and review of the literature

Key Clinical Message

Lumbar facet fracture-dislocation is rare, often due to hyperflexion with rotational force. Abnormal scoliosis on radiography is a key sign, prompting further imaging. Facetectomy and laminectomy ensure safe reduction, while instrumented fusion is an effective surgical treatment.

Abstract

Traumatic lumbar facet dislocation is an uncommon condition, particularly when unilateral lumbar facet dislocation is accompanied by a contralateral facet fracture. The patient had a locked facet joint at the left L4-L5, a fracture of the right superior articular process of L5 and a comminuted fracture at the peritrochanteric region of the right femur following a fall. Emergent operation was conducted, starting with open reduction and fixation for the right proximal femur, followed by posterior open reduction and posterolateral fusion with instrumentation, without interbody fusion, for the lumbar spine injury. The patient exhibited positive outcomes throughout the follow-up. This article highlights the trauma mechanism of lumbar facet dislocation, emphasizing hyperflexion with rotational force. Abnormal local scoliosis is a distinctive imaging sign of facet joint dislocation. Facetectomy and laminectomy are recommended for safe reduction and instrumented fusion is considered a safe and effective surgical treatment for facet joint dislocation injuries.

L4-L5 Facet Dislocation Treated in a Delayed Fashion with Excellent Early Clinical Results

Introduction

Introduction: Lumbar facet fracture-dislocations are rare injuries that are generated from a significant trauma. Literature regarding these injuries is limited to case reports, and there are even more limited reports concerning whether the delay of operative intervention in neurologically intact patients can achieve good clinical results if concomitant injuries and/or medical issues preclude urgent operative intervention. There has been no consensus on which operative techniques are effective in achieving an anatomic reduction of these injuries.

Objectives

A case report of an L4-L5 facet fracture-dislocation with delayed operative intervention and previously not reported adjunctive reduction technique is presented with an excellent clinical outcome result being achieved.

Case Report

A 38-year-old female who presented with an L4-L5 facet fracture-dislocation without neurological deficit after an unknown mechanism of injury. Due to concerns for elevated risk of intra and perioperative complications from general anesthesia secondary to recent drug use, the patient ultimately underwent open reduction and L4-L5 posterior instrumentation and fusion, with a resection of the superior aspect of the L5 pedicle being performed to help achieve reduction. The patient did not report any significant lower back pain and remained motor intact at 6-month post-operative, with the only neurological symptom during her post-operative course being hypesthesias in the right L5 dermatome at 6-week post-operative.

Conclusion

Excellent clinical results can be achieved with delayed open reduction and posterior stabilization in patients that sustain lumbar facet-fracture dislocations. The precise timing for operative management for patients who sustain these injuries is unknown, but medical stability should be considered before proceeding with an operative intervention in neurological intact patients. Partial resection of the pedicle is a safe and effective reduction technique in certain fracture-dislocation patterns.

Traumatic Bilateral L3-4 Facet Dislocation With Open Decompression and Short Segment Fusion

Traumatic lumbar facet dislocations are exceedingly rare, with reported cases primarily involving the lumbosacral junction. This injury arises from very high flexion distraction forces imparted on the lumbar spine. Herein we describe a bilateral L3-4 facet dislocation, a particularly rare injury pattern, using a short-segment posterior decompression and fusion followed by an interbody fusion through a lateral approach. Our case involves a 24-year-old man who presented to the emergency department after a high-speed, head-on motor vehicle collision. He was a restrained passenger with no prior significant medical history. He was found to have multisystem injuries, the most notable a L3-4 bilateral lumbar facet dislocation. The patient was neurologically intact upon his presentation but developed radiculopathy several hours into his hospital admission. He was treated operatively through a posterior decompression and instrumented short-segment fusion as well as a subsequent interbody fusion through a lateral approach at the same level. Pure lumbar spine facet dislocations outside the lumbosacral junction, especially bilateral dislocations, are exceedingly rare and often result in neurological deficits. A literature review reveals only a few cases outside of Asia, all of which were treated with decompression and either short- or long-segment fusion. No accepted treatment algorithm for this injury has been established. Open treatment is almost always indicated. Decompression and short-segment fusion is a valid treatment option, but patient and injury characteristics must be considered on an individualized basis.Level of Evidence: 5.

Traumatic Spondylolisthesis of the Fourth Lumbar Vertebra Without Neurologic Deficit or Fracture of the Posterior Elements

Acute traumatic spondylolisthesis in the lumbosacral spine is an uncommon injury. Traumatic dislocation of the fourth lumbar vertebra over the fifth lumbar vertebra (L4/L5) is extremely rare since few studies have been reported in the current literature. We report on a 53-year-old man, who had a motor vehicle accident and sustained an injury of the lumbar spine without neurological impairment. The radiographic evaluation disclosed an L4/L5 traumatic spondylolisthesis, classified as Meyerding grade III without any fracture of the posterior vertebral elements. To the best of our knowledge, this is the sixth case of L4 traumatic spondylolisthesis without concomitant fracture of the posterior vertebral elements and the third case without any neurological deficit among them. The patient underwent open reduction and posterior instrumentation. Intraoperatively, the posterior ligamentous complex, the capsules of the facet joints and also the disc were found torn, although facets, neural arch, and pedicles were intact. Following decompression and reduction of the spondylolisthesis without any neurologic complications, we performed pedicle screws and rods fixation from the third to the fifth lumbar vertebra (L3-L5). The patient had an uneventful recovery and returned to his previous activity three months after surgery. The four-year follow-up evaluation showed normal spinal alignment, successful pain-free fusion without neurologic complications. Flexion/distraction injury without simultaneous rotation at the L4/L5 segment during traffic accidents or the fall of a heavy object on the bent back accompanied with posterior ligament weakness is thought to be the probable mechanism for this type of injury. Concomitant neurologic impairment is associated with the majority of L4/L5 spondylolisthesis cases. Posterior decompression, reduction, and posterior instrumentation enhances bony fusion, improves the patient's neurologic status and restores the sagittal alignment.

Unilateral Lumbar Facet Dislocation: Case Report and Review of the Literature

BACKGROUND

Facet dislocations of the lumbar spine, particularly without neurologic injury, are rare occurrences after major trauma. Although there are documented cases of lumbosacral dislocation in the published literature, strictly lumbar unilateral facet dislocation is rare.

CASE DESCRIPTION

We report a case of a unilateral facet dislocation at L4-L5 after a single vehicle motorcycle accident. This injury was treated with posterior open reduction and instrumented stabilization with good results.

CONCLUSIONS

Given the rarity of this injury pattern, the management of this type of injury is not established. Careful imaging to make the diagnosis is crucial, and we recommend a surgical treatment in the form of an open reduction and instrumented stabilization. In our case, we achieved good outcomes with a posterior approach.