Traumatic bilateral cervical facet dislocation:a comprehensive review and evidence-based treatment algorithm.

Abstract

Traumatic bilateral cervical facet dislocation (BFD) represents a high-energy, highly unstable spinal injury with a significant risk of neurological compromise. BFD poses substantial diagnostic and therapeutic challenges across the acute-to-delayed care continuum. Variability in injury morphology, timing of presentation, and patient factors often leads to wide discrepancies in clinical management. This review synthesizes biomechanical principles, diagnostic protocols, classification systems, and surgical strategies from the available literature, with critical appraisal of anterior, posterior, and circumferential approaches. We identify key clinical inflection points, such as the presence of disc extrusion, endplate fracture, irreducibility, and chronicity, that determine optimal intervention. Imaging modalities including CT, MRI, and CT angiography are reviewed in context, and the role of pre-reduction MRI is highlighted in risk mitigation. A novel treatment algorithm is presented, integrating radiographic findings, neurological status, and timing. In neurologically intact patients with reducible injuries, anterior decompression and fixation offers a safe and efficient pathway. In delayed or fixed dislocations, posterior-first or staged approaches may be necessary, particularly when osteotomies or circumferential correction is warranted. Closed reduction is addressed with caution due to risk of cord injury, especially in the absence of pre-reduction imaging. This article offers a practical framework for spine surgeons navigating the rare but high-stakes scenario of BFD. By consolidating contemporary evidence with expert interpretation, we provide a structured pathway to improve safety, consistency, and neurological outcomes.