The management of unilateral lateral mass/facet fractures of the subaxial cervical spine - The use of magnetic resonance imaging to predict instability

Study Design. Retrospective review of the clinical course and cervical spine plain radiographs, computed tomography, and magnetic resonance imaging of 24 consecutive patients for a 2-year period with a unilateral lateral mass/facet fracture. Objective. To propose a treatment algorithm for the management of unilateral lateral mass/facet fractures of the subaxial cervical spine based on ligamentous injury detected by magnetic resonance imaging. Summary of Background Data. There have been no previous reports of the use of magnetic resonance imaging to predict clinical instability. Methods, A retrospective review of the clinical course of all unilateral mass/facet fractures identified over a 2-year period was conducted. All cervical spine plain radiographs, computed tomography scans, and magnetic resonance images were reviewed by a neuroradiologist blinded to the clinical course of the patient. Magnetic resonance T1-weighted and inversion recovery images were used to evaluate the integrity of the facet region, interspinous ligament, anterior longitudinal ligament, and posterior longitudinal ligament. Results. Twenty-four unilateral lateral mass/facet fractures were identified. Only six initial cervical spine series demonstrated a bony abnormality at the level of the fracture. The fractures were identified by computed tomography and were almost all nondisplaced or minimally displaced. Less than half of the fractures extended ventrally to involve the transverse process or foramen transversarium or dorsally to involve the lamina. Twelve fractures were nonoperatively treated and 12 were treated surgically for stabilization. Ten patients in the operative group presented with or developed a subluxation. Nine of these patients had injury to at least three of the four ligaments evaluated by magnetic resonance imaging. In the nonoperative group, only three patients had extensive ligamentous injury at the level of the fracture. All three of these patients were lost to follow-up. Conclusions, Plain radiographs of the cervical spine lack sensitivity to detect the presence of lateral mass/facet fractures. The appearance of the fracture on computed tomography does not indicate instability. The degree of ligamentous injury at the level of the fracture demonstrated on magnetic resonance imaging correlates with instability in this series. Operative stabilization may be indicated for unilateral lateral mass fractures that present with a subluxation or that have injury to at least three of the following ligaments: the facet region, the interspinous ligament, the anterior longitudinal ligament, and the posterior longitudinal ligament. However, before a definitive management plan can be formulated, results from this small series require further validation.