An anterior-first two-stage surgical strategy for neglected traumatic facet dislocation of subaxial cervical spine: a technical note

Neglected subaxial cervical traumatic facet dislocation (TFD) presents unique surgical challenges due to fibro-osseous ankylosis and severe segmental instability. Traditional three-stage procedures are effective in complex cases but may increase operative complexity because of repeated patient repositioning and multiple surgical corridors. This study aimed to describe an anterior-first two-stage algorithm for neglected TFD and to report preliminary feasibility observations, including the selective use of a single-screw zero-profile cage as an anterior spacer. Five patients with neglected subaxial TFD (≥ 3 weeks post-injury) underwent surgery between May 2021 and February 2024. Stage 1 involved anterior discectomy, scar and osteophyte release, and traction-based alignment assessment. If realignment was achieved, anterior cervical discectomy and fusion (ACDF) was performed; if not, a zero-profile cage secured with a single cranial screw was inserted before proceeding to Stage 2 posterior release, reduction, and lateral mass fixation. Clinical outcomes were assessed using the American Spinal Injury Association (ASIA) grade, Visual Analog Scale (VAS) for neck pain, and Neck Disability Index (NDI). Radiographic alignment, fusion, and perioperative parameters were recorded. Five patients (4 men, 1 woman; mean age 49.6 years; mean delay 40.8 weeks) were included. Three patients underwent ACDF plus posterior fixation, whereas two required single-screw zero-profile cage placement before posterior reduction and fixation. Mean operative time was 196 min, mean blood loss was 180 mL, and mean hospital stay was 8 days. Mean VAS decreased from 4.4 to 0.4, mean NDI decreased from 23.8 to 1.6, and three patients improved by one ASIA grade. Mean anterior translation decreased from 44.6% preoperatively to 4.7% at final follow-up, and mean local segmental alignment improved from 18.0° of kyphosis to 0.5° of lordosis. Radiographic evidence of fusion or stable arthrodesis was observed in all patients, with no cage migration, implant loosening, redislocation, or loss of correction. This technical note suggests that an anterior-first, traction-guided two-stage strategy may be technically feasible in selected patients with neglected subaxial cervical TFD. Owing to the small sample size and lack of controls, efficacy, safety, and superiority cannot be established.