Bilateral cervical locked facets are a serious condition that may result in complete spinal cord injury. Though the treatment is not standardized advances in radiology and surgical techniques led the surgeons to operate on the patients earlier. We report a case with bilateral cervical locked faset. He was treated with early surgery and had the chanceof early rehabilitation.
Bilateral cervical locked facets; Early surgery
Bilateral locked facets occur by a hyperflexion mechanism and commonly associated with neurological involvement . This type of spinal injury is the most severe form and seen in about % 5 of the cases . Bilateral faset dislocation occurs when a vertebras inferior facet dislocates anteriorly over the vertebras superior facet due to hyperflexion? locking in the intervertebral foramens, creating a severely unstable fracture . Fracture of facets, lamina and spinous processes may be coexistent. Early decompression has been frequently proposed  Treatment is not standardized. We present a diving accident with bilateral locked cervical facets.
A 16-year –old male patient was transfered to the emergency department from a peripheral hospital after diving into a pool. Methyl-prednisolone treatment was started. On arrival Glascow coma scale was 15. His motor and sensory level of C 6 was determined. Neurologycal deficit was complete with urinary retenntion and he had no rectal tone (ASIA A). Cervical spine computed tomography showed C 5 fracture dislocation with complete bilateral locked facets (naked facet sign) . Servical vertebral MRI showed nearly complete cord compression the patient was transferred to operation room. He was intubated under anestesia and after application of Gardner -Wells tongs, closed reduction was unsuccessful. Therefore following open reduction with decompression from posterior route, screws were inserted into the articular masses of the spinal segments using Mageryl technique , and fixation was completed with rods. After closure of the wound the patient was positioned supine .After cervical 5 corpectomy and discectomy, fibula greft was fixed with anterior cervical plate and screws. Intraopeerative radiology and postoperative computed tomography showed the cervical spine alignment and decompression of the spinal canal was adequate. Postoperative neurological examination didn’t show any any change in motor or sensory function. Two days later due to respiratory complications he was intubated and needed respiratory support. Then he was transferred to a specialized hospital about respiratory disease. After the termination of therapy he was hospitalized in a specialized rehabilitation centre in another city.
Discussion and Conclusion
Bilateral cervical locked facets occur by severe flexion injuries. [1,4,5] Disruption of ligaments of apophyseal joints, ligamentum flavum, longitudinal and interspinous ligaments also occurs. As seen in our case, diving accidents seen in approximately 15% of the cases  with complete spinal cord injury in 65- 87%. Computed tomography shows ‘naked facet sign’ as the appropriate articulating mate is either absent or on the wrong side of the facet (Greenberg MS., 2010). Preoprative MRI is generally recomended since 1990s  and enabled us to evaluate the status of the spinal cord and potential offending soft tissue or bony structure placing the spinal cord at risk . Decompression of the neural structures, reduction of the malalignment and restoration of spinal stability was our goal in this case as accepted in the literature . Most of the authors agree with early closed reduction, realignement- stabilization, and high dose methylprednisolone treatment. Similarly, we applied the same treatment but as it was not successful, we continued our treatment with early open reduction- stabilization.Although timing of surgery differs according to different authers and no prospective study was made for this issue, early decompression less than 24-72 hr. has been frequently proposed . Posterior wiring has been the standard cervical stabilization technique since the late 1800s but in cases like ours, involving facet or lamina fracture, this technique is not accommodated. Therefore we chose posterior articular screwing technique followed by anterior corpectomy and fixation. Since late 1980s Roy-Camille R et all reported clinical series of posterior cervical plating with good results achieved up to 85 %. Although the surgical approach is not standardized, combined anterior and posterior fixation is superior in terms of stability  as in our case.
Early decompression and fixation is important for patients with bilateral cervical locked fasets inorder to give chance for early rehabilitation. Advances in radiology and surgical techniques durng the last 25 years encored the surgeons in easier decision making and operating on such patiens earlier.7099