Reduction of traumatic unilateral locked facet of the subaxial cervical spine: what predicts successful closed skeletal traction, and is anterior or posterior surgery superior after unsuccessful closed reduction?

Objective: Closed skeletal traction (CST) to reduce unilateral locked facets in the subaxial cervical spine can expedite spinal realignment prior to definitive surgery but is not always successful. What predicts successful closed reduction is not completely understood. In addition, whether open anterior or posterior surgery is superior for achieving successful reduction after failed closed skeletal traction has not been investigated. The authors sought to assess predictors of successful closed reduction with skeletal traction and to compare the efficacy of anterior versus posterior surgery after failed closed reduction.

Methods: The authors performed a retrospective analysis of patients presenting to a single level I trauma center with a de facto unilateral locked facet between 2008 and 2024. Patients with a complex facet fracture without a locked facet, bilateral locked facet, and/or no attempted CST were excluded. Fractures involving discrete, structurally relevant bony elements and other pathological features, and variables of reduction technique were recorded. Successful reduction was determined by restoration of anatomical alignment on fluoroscopy prior to surgery and verified with postoperative CT.

Results: Fifty-five patients met the inclusion criteria. The population was 71% male, and the mean age was 47 ± 18 years. Closed reduction was successful in 56% of patients. The mean maximum weight applied was 60 ± 33 lb. Awake CST had a 48% success rate and CST under general anesthesia (GA) had an overall success rate of 61%. Upfront CST under GA (without prior unsuccessful awake CST) had a success rate of 83%, but no cases of failed awake CST were successfully reduced with subsequent CST under GA. On multivariate analysis, a contralateral perched facet increased the odds of successful closed reduction by 32-fold and presence of neurological injury (AIS grades A-D) reduced the odds of successful closed reduction by 21-fold. In patients requiring open surgical reduction after failed CST, posterior surgery was significantly more successful than anterior surgery (100% vs 45%, p = 0.026). Of the 6 patients in whom open reduction failed via an anterior approach, 5 underwent successful reduction during subsequent posterior surgery.

Conclusions: A contralateral perched facet predicted successful CST, whereas any neurological deficit (AIS grade A-D) predicted failed CST. GA increased the odds of successful closed reduction but did not salvage failed awake CST attempts. In patients in whom CST failed and open surgical reduction was required, posterior surgery was significantly more successful than anterior surgery for reestablishing anatomical alignment.