The surgical management of traumatic cervical facet dislocations requires attention to four key elements: decompression, reduction, fixation, and fusion. Variations in treatment strategies arise from differences in reduction success between closed reduction, anterior open reduction, and posterior open reduction techniques, the requirement for three-column spinal fixation, the presence of traumatic intervertebral disc herniation, and the timing of injury (acute, delayed, or old dislocation). This complexity has led to the adoption of multiple surgical approaches, including anterior-alone, posterior-alone, combined anterior-posterior, posterior-anterior, and even staged anterior-posterior-anterior strategies [1–3].

Among these options, the anterior-only approach (discectomy, open reduction, and instrumental fusion) is widely recommended. It has two main advantages: lower risk of secondary spinal cord injury in the presence of traumatic intervertebral disc herniation [4–6], and reduced surgical trauma and shorter operative time compared with posterior or combined approach [3,7,8]. However, the anterior-only approach carries two principal limitations: anterior reduction failure rates ranging from 4% to 40% [3,9]; and approximately 30% failure rate of anterior vertebral screw fixation at C6/7 and C7/T1 levels or in cases of severe vertebral and articular process fractures [10,11]. Both scenarios may necessitate additional posterior surgery. The posterior-alone approach facilitates reduction and three-column pedicle screw fixation [12], but is associated with greater surgical morbidity and a higher risk of neurological deterioration when retropulsed disc fragments are present [13]. Therefore, the posterior approach is typically reserved for cases involving posterior cord compression due to fractured posterior elements or irreducible fracture dislocations refractory to open or closed anterior reduction. To establish itself as a standalone treatment, an anterior-only procedure must achieve both a 100% reduction success rate and provide sufficiently rigid anterior fixation to obviate the need for supplemental posterior surgery.

To address these challenges, the authors developed two novel anterior reduction techniques: (1) modified kyphotic paramedian distraction using Caspar pins and (2) anterior facetectomy [14]. Additionally, a specialized anterior cervical pedicle screw plate system was designed to optimize fixation [15]. The initial clinical outcomes were reported in a 2019 case series of 63 patients [16], which subsequently led to the development of a comprehensive surgical protocol incorporating these techniques. The present retrospective study evaluated the efficacy of this protocol, which integrates both the reduction techniques and the instrumentation, in 87 consecutive patients with acute, delayed, or old subaxial cervical facet dislocations, with a minimum follow-up of 12 months.

All 87 patients successfully underwent anterior surgical procedures. No intraoperative vertebral artery or nerve root injuries occurred, and none of the patients required supplemental posterior surgery. All patients achieved successful reduction (Table 2). Success rates were 67% for closed reduction, 81% for modified Caspar pin kyphotic paramedian distraction, and 100% for anterior facetectomy. No supplemental posterior procedures were required. Most failed closed reductions occurred at C6/7 and C5/6. The modified kyphotic paramedian distraction was successful in all C3/4 and C4/5 cases, as well as most C6/7 cases. Anterior facetectomy achieved reduction at all C5/6, C6/7, and C7/T1 levels, including old dislocations. Four patients required bilateral anterior facetectomy due to old dislocations with severe articular process fractures. No vertebral artery or nerve root injuries occurred during facetectomy. Among old dislocations, the success rate was 11% with the modified Caspar pin kyphotic-paramedian distraction versus 100% with anterior facetectomy. Compared with modified kyphotic paramedian distraction, anterior facetectomy achieved a higher success rate of reduction but required longer operative time (p<0.01 for both) (Table 2).

All patients achieved stable fixation with an anterior vertebral screw plate (n=59) or anterior pedicle screw plate (n=28). Compared with anterior vertebral screw palate fixation, anterior pedicle screw fixation required longer fixation time (8.6±4.3 minutes vs. 46.3±15.3 minutes), longer operation time (69.2±23.5 minutes vs. 110.6±26.5 minutes), and greater blood loss (68.6±24.1 mL vs. 96.3±75.2 mL) (p<0.05 for all) (Table 3). Postoperative radiographs, MRI, and CT confirmed appropriate cervical alignment and accurate pedicle screw placement within the pedicle cortex. At ≥12 months’ follow-up, fusion was achieved in all patients, as verified by CT (Fig. 3). No instrumentation failures occurred. Neurological improvement of ≥1 ASIA grade was observed in 29 patients (43.9%), with no cases of neurological deterioration (Table 4).

In this study, the anterior-only procedure achieved successful reduction, complete decompression, rigid internal fixation, and fusion in patients with cervical facet dislocation. The advantages of this approach are threefold: (1) reduced risk of secondary spinal cord injury and minimized surgical trauma; (2) a 100% reduction success rate with the combined use of modified kyphotic paramedian distraction and anterior facetectomy, applicable in acute, delayed, as well as old dislocations of <8 weeks; and (3) provision of a three-column fixation with the anterior cervical pedicle screw plate. To the best of our knowledge, this represents the most effective algorithm for anterior-only reduction and fixation of cervical facet dislocations.

There is no clear consensus on the optimal surgical approach (anterior, posterior, or combined) for cervical facet dislocation. Contributing factors include traumatic intervertebral disc herniation, variable failure rates of different reduction techniques, level-specific fixation requirements, extent of posterior element injury, and chronicity of dislocations. Conventional anterior techniques are limited by their inability to apply focal force directly to locked facets, resulting in failure rates of 4%–40% for anterior open reduction [3,7,8]. In such cases, supplemental posterior reduction or a posterior-only approach is often required. The posterior approach achieves reliable reduction and provides three-column stabilization with pedicle screw fixation, but is associated with greater iatrogenic soft-tissue injury and an increased risk of secondary spinal cord injury in the presence of traumatic intervertebral disc herniation [4–6]. The anterior reduction techniques used in the present study achieved a 100% success rate, supporting the effectiveness of this anterior-only algorithm.

Three principal reduction techniques are available for facet dislocations: closed reduction, anterior open reduction, and posterior open reduction [20]. Closed reduction provides the earliest opportunity for reduction to relieve spinal cord compression, but its success rate ranges from 30% to 100% [21], and it carries a risk of secondary spinal cord injury in the presence of traumatic intervertebral disc herniation [5,6,8]. In the present study, the surgical management protocol stratified patients into three groups: (1) candidates for urgent surgery at admission, (2) those with contraindications to urgent surgery, and (3) those with old dislocations. Emergency surgeries were performed promptly after admission to decompress the spinal cord, mirroring the timing of early closed reduction procedures. Patients unsuitable for urgent surgery underwent early closed reduction. As a tertiary referral center, our cohort consisted mainly of delayed-presentation cases, most of whom were transfers from other hospitals or emergency departments with initially missed injuries. Particularly, our modified anterior techniques were effective not only for severe dislocations but also for delayed (3–21 days) and old (>21 days) cases. The maximum interval from injury to open reduction in this series was 64 days (Table 1). When the two techniques were compared, anterior facetectomy showed superior success at C6/7 and C7/T1 levels as well as in old dislocations compared with kyphotic paramedian distraction (Table 2). Anterior facetectomy achieved a 100% reduction rate, comparable to posterior open reduction outcomes for delayed and old cases. However, due to the limited number of old cases, it is unclear whether this technique can be applied to bilateral dislocations of over 8 weeks duration with severe facet joint fractures.

Cervical facet dislocation represents a three-column injury in the AO classification [22]. Consequently, some authors argue that anterior-only fixation may provide insufficient stability in cases with articular process injury [10,11,23], recommending supplemental posterior fixation for severe posterior column damage [24]. Others have reported failure rates of approximately 30% for anterior vertebral screw fixation at C6/7 and C7/T1, necessitating additional posterior surgery [10,11]. These concerns underscore the need to tailor fixation methods to the specific injury pattern at each level. In the present algorithm, anterior vertebral screw plates were applied for C3/4, C4/5, and selected C5/6 cases, whereas anterior pedicle screw plates were used for C7/T1, C6/7, selected C5/6, and in patients undergoing facetectomy, to achieve three-column stabilization. At ≥12 months of follow-up, no implant failures were observed, indicating stability comparable to posterior fixation.

The present study achieved satisfactory clinical outcomes while minimizing operative time and blood loss. Consistent with our prior investigation [25], the anterior-only approach maintained a 100% reduction success rate while substantially reducing surgical morbidity compared with conventional posterior-anterior techniques. Neurological improvement in this series was also comparable to outcomes reported with posterior-only approaches [12,13]. Previous studies have documented neurologic improvement rates of 20%–76.2% with posterior or combined approaches [9,13,26], whereas our anterior-only technique resulted in improvement of at least one ASIA grade in 43.9% of patients, with no cases of neurologic deterioration (Table 4). Notably, despite the predominance of delayed (48 patients) and old (nine patients) dislocations (Table 2), neurological outcomes remain favorable (Table 4).

While the clinical outcomes are encouraging, several limitations should be acknowledged. First, this study represents a single-surgeon experience at a specialized spine center and involves a modest sample size. Second, patients with systemic comorbidities (e.g., osteoporosis, ankylosing spondylitis) or posterior pathologies requiring intervention (e.g., epidural hematomas, ligamentum flavum rupture, laminar fractures) were excluded. Third, the old dislocation subgroup was small (n=9), with a maximum delay of 64 days; alternative approaches may be preferable in more complex cases involving prolonged delay, severe comminution, or multilevel injuries. Fourth, although anterior facetectomy and cervical pedicle screw fixation proved safe in this series [15,27], both techniques require advanced technical expertise due to their anatomical complexity.

In summary, the anterior-only reduction approach, incorporating modified kyphotic paramedian distraction with Caspar pins and anterior facetectomy, achieved a 100% reduction rate in acute, delayed, and old cervical facet dislocations. Anterior cervical pedicle screw plate fixation provided reliable three-column stabilization with high fusion rates at follow-up. This protocol eliminated the need for posterior or combined approaches in all cases, demonstrating both safety and efficacy in the management of cervical facet dislocations.