Neck injuries

1. High-Yield Summary

Traumatic neck and cervical spine injuries span a wide spectrum from stable myofascial strains to catastrophic craniocervical disruptions and subaxial fracture-dislocations associated with quadriplegia. Immediate triage mandates strict adherence to Advanced Trauma Life Support (ATLS) principles with rigid in-line cervical immobilization until clinical or radiographic clearance is definitively achieved.

• Clinical Clearance Benchmarks: In alert, stable, and non-intoxicated trauma patients without distracting injuries, the Canadian C-Spine Rule (100% sensitivity) and the National Emergency X-Radiography Utilization Study (NEXUS) criteria (99.6% sensitivity) safely rule out clinically significant cervical injuries without radiography.
• Imaging Standard: Thin-slice multi-detector computed tomography (CT) from the skull base to T1 with sagittal and coronal multiplanar reformats represents the gold standard for trauma evaluation, completely supplanting plain radiographs in high-energy blunt trauma.
• Disco-Ligamentous Complex (DLC) Assessment: Magnetic resonance imaging (MRI) is mandatory in patients with focal neurological deficits, suspected ligamentous disruption, unexplained cervical pain with normal CT scans, and prior to or following closed reduction of facet dislocations.
• Classification & Surgical Thresholds: The AOSpine Subaxial Cervical Spine Injury Classification and the Subaxial Injury Classification (SLIC) system standardize decision-making. A SLIC score of 5 or greater indicates surgical stabilization, whereas 3 or fewer supports nonoperative immobilization.
• Time-Critical Neurological Rescue: In acute traumatic cervical spinal cord injury (SCI), urgent surgical decompression within 24 hours (and ideally within 8 to 12 hours) significantly improves neurological recovery. Emergent closed traction reduction is indicated for awake, communicative patients with bilateral facet dislocations experiencing progressive neurological deterioration.

2. Anatomy

The cervical spine is divided anatomically and biomechanically into the craniocervical junction (occiput to C2) and the subaxial cervical spine (C3 to C7). Structural stability relies on a delicate balance between osseous architecture and soft-tissue ligamentous restraints.

Upper Cervical Complex (C0–C2):

• Atlanto-Occipital Articulation: Composed of the cup-shaped superior articular facets of C1 and the occipital condyles. Primary stability is conferred by the tectorial membrane (rostral continuation of the posterior longitudinal ligament), alar ligaments (restraining axial rotation and lateral bending), and apical dental ligament.
• Atlantoaxial Complex: C1 lacks a vertebral body, functioning as a ring with robust lateral masses. The dens (odontoid process) of C2 projects superiorly, embraced by the transverse atlantal ligament (TAL), which provides more than 90% of translational stability at C1–C2. Disruption of the TAL allows anterior translation of the atlas, narrowing the space available for the spinal cord (Steel’s Rule of Thirds: one-third odontoid, one-third cord, one-third free space).

Subaxial Cervical Spine (C3–C7):

• Osseous Landmarks: Small vertebral bodies featuring lateral uncinate processes (joints of Luschka) that resist lateral translation. Facet joints are inclined at approximately 45 degrees in the sagittal plane, permitting substantial flexion, extension, and lateral rotation but predisposing to translation and dislocation under distractive-flexion vector forces.
• Disco-Ligamentous Complex (DLC): Divided into the anterior column (anterior longitudinal ligament [ALL], anterior two-thirds of the annulus fibrosus), middle column (posterior one-third of annulus fibrosus, posterior longitudinal ligament [PLL]), and posterior tension band (facet joint capsules, ligamentum flavum, interspinous ligament, and supraspinous ligament/ligamentum nuchae). DLC integrity is the primary determinant of mechanical stability.

Surgical Approaches & Internervous Planes:

• Anterior Smith-Robinson Approach: Utilizes the natural anatomical interfascial plane between the medial visceral column (trachea, esophagus, and recurrent laryngeal nerve) and the lateral neurovascular sheath (carotid artery, internal jugular vein, and vagus nerve). The plane is developed between the sternocleidomastoid muscle (spinal accessory nerve, CN XI) laterally and the strap muscles (ansa cervicalis) medially.
• Posterior Midline Approach: Follows the strictly avascular median plane of the ligamentum nuchae down to the bifid spinous processes and laminae. Subperiosteal dissection remains medial to the facet capsules to preserve motion segment stability at uninvolved levels.

Neurovascular Danger Zones:

• Vertebral Arteries: Arise from the subclavian arteries, enter the transverse foramina typically at C6, ascend through C2, and loop sharply over the posterior arch of C1 before penetrating the posterior atlanto-occipital membrane. Anomalous medial loop courses or high-riding vertebral arteries at C2 increase perforation risks during C1–C2 transarticular or C2 pedicle screw instrumentation.
• Recurrent Laryngeal Nerve (RLN): Loops under the right subclavian artery on the right side and under the aortic arch on the left. The right RLN has a more variable, oblique trajectory, rendering it slightly more vulnerable during high anterior right-sided exposures (C3–C4).
• Cervical Sympathetic Trunk: Lies on the longus colli fascia lateral to the vertebral bodies. Excessive lateral retraction of the longus colli muscle during anterior plating can produce Horner syndrome (ptosis, miosis, anhidrosis).

3. Pathogenesis

Cervical spine injuries result from mechanical energy vectors applied to the cranium and torso, classified according to primary force vectors: flexion, extension, axial loading (compression), distraction, and rotation.

• Upper Cervical Mechanics:
  • Atlanto-Occipital Dissociation (AOD): High-energy distraction and extreme hyperextension/hyperflexion disrupt the craniocervical ligamentous complex (tectorial membrane and alar ligaments), resulting in internal decapitation.
  • Atlas (Jefferson) Fractures: Pure axial compression drives the wedge-shaped occipital condyles into the sloping lateral masses of C1, bursting the anterior and posterior arches.
  • Odontoid Fractures: Shear forces combined with flexion (anterior displacement) or extension (posterior displacement). In young adults, this occurs during high-speed motor vehicle crashes; in elderly osteopenic patients, low-energy ground-level falls with facial strikes generate sufficient hyperextension torque to fracture the dens waist.
  • Hangman’s Fracture (Traumatic Spondylolisthesis of the Axis): Hyperextension combined with axial loading (or rebound hyperflexion/distraction), causing bilateral fracture through the pars interarticularis or neural arch of C2.
• Subaxial Cervical Spine Mechanics:
  • Distraction-Flexion Injury: Progression from hyperflexion sprain to unilateral facet subluxation, perched facets, and complete bilateral jumped/dislocated facets. Complete dislocation results in 50% anterior translation, complete disruption of the DLC, and a high incidence of complete cord transection or anterior cord syndrome.
  • Flexion-Compression (Teardrop Fractures): Severe axial loading with flexion forces the anteroinferior corner of the vertebral body to shear off (“teardrop” fragment), while the posterior body fragment retropulses into the spinal canal, producing complete 3-column disruption and quadriplegia.
  • Hyperextension Injuries in Spondylosis: Low-energy hyperextension in an elderly canal-compromised cervical spine compresses the spinal cord between osteophytic ridges anteriorly and buckled ligamentum flavum posteriorly, characteristically resulting in Central Cord Syndrome without bone fracture.

4. Natural History

Cervical trauma demonstrates a bimodal age distribution: high-energy motor vehicle crashes and contact athletic collisions predominate in individuals aged 15 to 30 years, whereas low-energy ground-level falls in patients older than 65 years account for an increasing proportion of fractures due to osteopenia, cervical spondylosis, and balance impairments. Cervical spine injuries occur in approximately 3% to 4% of all blunt trauma presentations.

Without timely recognition and appropriate stabilization, natural history outcomes are devastating:

• Missed Subaxial Instability & Facet Subluxations: Progressive post-traumatic kyphotic collapse, delayed neurological deterioration from persistent cord compression, chronic neuropathic pain, and severe axial neck disability.
• Type II Odontoid Fractures: Conservatively managed Type II fractures in elderly cohorts display nonunion rates exceeding 35% to 50% when managed with cervical orthoses. Fibrous nonunion can remain asymptomatic initially but carries a lifelong risk of catastrophic myelopathy or sudden fatal cord compression from minor secondary low-energy trauma.
• Traumatic Spinal Cord Injury (SCI): Acute cervical SCI carries high early mortality (up to 20% in high cervical complete tetraplegia). However, patients with incomplete cord injuries (AIS grades B, C, and D) who undergo urgent surgical decompression and mean arterial pressure optimization demonstrate meaningful rates of functional motor recovery.

5. Clinical Presentation

History

A comprehensive trauma history should establish the exact mechanism of injury, velocity, vector of head impact, loss of consciousness, seatbelt use, airbag deployment, steering wheel deformity, or height of fall. In athletes, inquire about spear-tackling or axial crown impact. Clinicians must specifically elicit the onset and progression of acute midline neck pain, sensory loss, upper- or lower-extremity paresthesias (“burning hands”), subjective weakness, and bowel or bladder incontinence.

Physical Examination

Initial evaluation follows the ATLS protocol with in-line cervical stabilization during airway management. Once stabilized, the cervical collar is carefully opened while an assistant maintains manual in-line immobilization.

• Inspection & Palpation: Inspect the anterior and posterior neck for contusions, lacerations, tracheal deviation, and seatbelt sign. Palpate the entire midline posterior cervical spinous processes from the inion to T1. Note focal midline tenderness, a palpable interspinous gap or step-off (signifying posterior tension band disruption), and paraspinal muscle spasm.
• International Standards for Neurological Classification of SCI (ISNCSCI): Document motor strength across all key myotomes (C5 deltoid/biceps, C6 wrist extensors, C7 triceps, C8 flexor digitorum profundus, T1 abductor digiti minimi) and light touch/pinprick sensation across C2 to T1 dermatomes. Assess deep tendon reflexes, pathologic upper motor neuron signs (Hoffmann sign, clonus, Babinski reflex), and complete the anorectal exam (voluntary anal sphincter contraction, deep anal pressure, anal wink, and bulbocavernosus reflex to distinguish complete injury from spinal shock).

The following table outlines the diagnostic accuracy of validated clinical clearance rules in alert, stable trauma patients:

6. Imaging and Diagnostic Studies

The diagnostic imaging workup must be systematic, reproducible, and tailored to the clinical status and stability of the patient.

• Multi-Detector Computed Tomography (CT):
  • Gold Standard: Non-contrast thin-slice (≤1 mm) CT from occiput to T1 with sagittal, coronal, and 3D reformats has a sensitivity of 98% to 100% for osseous fractures and subluxations. Plain three-view radiographs are obsolete in high-energy trauma centers due to inadequate visualization of the C7–T1 junction and craniocervical junction.
• Craniocervical Alignment Parameters (Measurements on CT/Radiographs):
  • Basion-Dens Interval (BDI): Distance from the tip of the basion to the apex of the dens; abnormal if >8.5 mm on CT (>12 mm on plain radiographs), diagnostic of atlanto-occipital dissociation.
  • Basion-Axial Interval (BAI): Distance from the basion to the vertical line along the posterior cortex of the C2 vertebral body (Harris line); abnormal if >8.5 mm anteriorly or >7.0 mm posteriorly.
  • Powers Ratio: Distance from basion to posterior arch of C1 divided by distance from anterior arch of C1 to opisthion (BC/AO). A ratio >1.0 indicates anterior atlanto-occipital subluxation.
  • Atlanto-Dens Interval (ADI): Distance between the posterior surface of the anterior C1 arch and the anterior border of the dens. Normal ≤3 mm in adults (≤5 mm in children). An ADI >3.5 mm indicates transverse atlantal ligament compromise.
  • Rule of Spence (Atlas lateral mass displacement): Overhang of the lateral masses of C1 on C2 on open-mouth view or coronal CT; combined lateral overhang >7.0 mm indicates rupture of the transverse atlantal ligament.
• Magnetic Resonance Imaging (MRI):
  • Indications: Essential in patients with neurological deficits, incomplete SCI, suspected ligamentous injury, obtunded trauma patients with unexplained widening of interspinous spaces, and in facet dislocations before or after reduction to evaluate for traumatic disc herniation.
  • Key Sequences: T2-weighted and Short Tau Inversion Recovery (STIR) sequences highlight edema in the spinal cord, prevertebral soft tissues, interspinous ligaments, and facet capsules. T2* gradient-echo or susceptibility-weighted imaging (SWI) detects intramedullary hematoma (associated with poorer prognosis than cord edema alone).
• Computed Tomography Angiography (CTA):
  • Indications (Modified Denver Screening Criteria): Cervical spine fracture involving the transverse foramen, facet dislocation/subluxation, C1–C3 fracture, basilar skull fracture, or unexplained focal neurological deficit. Identifies vertebral artery dissection, pseudoaneurysm, or occlusion.

7. Classification

Modern management relies on validated classification systems that link injury morphology, disco-ligamentous stability, and neurological status directly to treatment algorithms.

8. Treatment

Medical & Resuscitative Therapy

• Mean Arterial Pressure (MAP) Optimization: In patients with traumatic spinal cord injury, hemodynamic management requires maintaining MAP at 85 to 90 mmHg for 5 to 7 days post-injury using aggressive intravenous fluid resuscitation and vasopressor infusions (e.g., norepinephrine or phenylephrine) to maintain critical spinal cord perfusion pressure.
• Pharmacologic Considerations: High-dose methylprednisolone (NASCIS protocol) is no longer recommended as standard of care due to significant risks of systemic sepsis, severe gastrointestinal hemorrhage, and wound complications without conferring consistent, meaningful functional motor recovery.
• Anticoagulation / VTE Prophylaxis: Subcutaneous low-molecular-weight heparin (LMWH) should be initiated within 24 to 48 hours post-injury once intracranial bleeding and surgical hematoma risks are stabilized, combined with mechanical pneumatic compression.

Nonoperative Treatment

• Rigid Cervical Orthosis (Miami J or Aspen Collar): Indicated for stable injuries including isolated spinous/transverse process fractures, non-displaced C1 fractures with intact transverse ligament, Type I odontoid fractures, stable Type III odontoid fractures, Type I Hangman’s fractures, and AOSpine Type A0/A1 compression fractures without DLC involvement. Duration is typically 6 to 12 weeks with serial upright flexion-extension lateral radiographs at conclusion of immobilization.
• Halo-Vest Immobilization: Provides rigid cranial pin fixation and axial control. Indicated for minimally displaced Type II odontoid fractures in young patients and selected Levine Type II Hangman’s fractures. Contraindicated in elderly patients (>65 years) due to prohibitively high morbidity (pulmonary complications, pneumonia, pin loosening, falls, and mortality rates exceeding 20% to 30%).

Operative Treatment

• Closed Traction Reduction: Emergent closed reduction using Gardner-Wells tongs or a halo ring with incremental axial traction (starting at 10 to 15 lbs and increasing by 5 to 10 lbs per disc level under serial lateral fluoroscopy and continuous neurological examinations) is indicated for awake, communicative patients with acute jumped/dislocated facets. If the patient becomes obtunded, experiences neurological deterioration during traction, or has a pre-reduction MRI demonstrating a large herniated disc fragment retropulsed behind the dislocated vertebral body, closed traction must be aborted immediately in favor of emergent anterior open surgical decompression.
• Anterior Cervical Discectomy & Fusion (ACDF): The procedure of choice for subaxial distractive-flexion injuries with traumatic disc herniations, teardrop fractures, or failed closed reductions. Provides direct anterior decompression of retropulsed disc and bone fragments, restoration of disc height and cervical lordosis, and rigid anterior plate fixation.
• Posterior Cervical Decompression & Fusion: Utilizes lateral mass screws (C3 to C6 via Roy-Camille or Magerl trajectories) and pedicle screws (C2 and C7/T1) interconnected with titanium rods. Indicated for severe posterior element disruption (AOSpine Type B2/B3), irreducible locked facets requiring open facetectomy, multi-level posterior ligamentous incompetence, or osteoporotic spines requiring long-segment fixation.
• Anterior Odontoid Screw Fixation: Direct osteosynthesis with one or two 3.5 mm or 4.0 mm cannulated lag screws preserving normal C1–C2 rotational motion. Candidates must have an acute (<3 to 4 weeks) Type II fracture with an intact transverse atlantal ligament and a favorable fracture line oblique from anterior-inferior to posterior-superior.
• Posterior C1–C2 Fusion (Harms & Goel Technique): Involves C1 lateral mass screws paired with C2 pedicle or pars/translaminar screws connected with rods and supplemented with autologous bone graft. Gold standard for unstable or chronic Type II odontoid nonunions, disrupted transverse ligaments, and failed anterior odontoid screws.

Indications & Contraindications

Absolute Surgical Indications:

• Progressive neurological deficit in the presence of demonstrable canal compromise or facet dislocation.
• Mechanical instability: SLIC score ≥5, bilateral jumped facets, complete DLC rupture, or gross translational deformity (>3.5 mm translation, >11 degrees angulation relative to adjacent level).
• Displaced Type II odontoid fracture in patients who are surgical candidates.
• Levine-Edwards Type IIA, Type III, or irreducible Type II Hangman’s fractures.
• Incomplete acute traumatic spinal cord injury with ongoing cord compression (STASCIS trial criteria).

Contraindications:

• Severe hemodynamic instability or uncorrected polytrauma shock precluding life-saving operative survival.
• Closed cervical traction in the presence of severe skull fractures, scalp avulsions, or known craniocervical dissociation (distraction injury).
• Anterior odontoid screw fixation in fractures with comminution of the dens base, severe barrel-chest or kyphotic body habitus precluding surgical trajectory, or fracture orientation from anterosuperior to posteroinferior.

9. Outcome

Prognosis following cervical spine trauma depends directly on the initial neurological deficit, timeliness of decompression, and mechanical restoration of spinal stability.

• Neurological Recovery: Prospective data from the landmark Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrate that early surgical decompression (<24 hours from injury) yields a 2.83-fold higher odds of achieving at least a 2-grade improvement on the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at 6-month follow-up compared to delayed decompression (19.8% vs. 8.8%, p=0.044). Patients with central cord syndrome or incomplete deficits (AIS C/D) demonstrate the greatest capacity for functional ambulation and hand function recovery.
• Osseous Union Rates:
  • Subaxial ACDF & Posterior Fusion: Arthrodesis rates consistently exceed 95% to 98% with modern rigid titanium instrumentation and structural cage/graft constructs.
  • Odontoid Fixation: Posterior C1–C2 Harms constructs achieve fusion rates greater than 96% to 98% across all age demographics. Anterior odontoid screw fixation achieves union in 80% to 88% of strictly selected young patients but drops below 60% in elderly patients with osteoporotic bone.
• Patient-Reported Outcome Measures (PROMs): Patients successfully stabilized without neurological injury typically return to baseline or mild chronic disability (Neck Disability Index [NDI] <15%, Short Form-36 physical component score within 1 standard deviation of population norms). In contrast, patients with residual radiculopathy or persistent myelopathy experience long-term functional impairment requiring ongoing occupational and physical rehabilitation.

10. Complications

Complications following traumatic cervical injuries are categorized chronologically as immediate, early postoperative, or late deformities:

11. Pearls and Pitfalls

• The “Normal Radiograph” Trap: Plain radiographs have an unacceptable false-negative rate exceeding 25% for subtle cervical fractures and dislocated facets, particularly at the craniocervical and cervicothoracic (C7–T1) junctions. In any high-energy blunt trauma patient, proceed immediately to thin-slice multi-detector CT.
• Look for the “Second Fracture”: Approximately 10% to 15% of patients with a traumatic cervical spine fracture harbor a non-contiguous second spine fracture in the thoracic or lumbar regions. Full-spine CT imaging from skull base to sacrum is mandatory.
• The Distraction Injury Red Flag (Levine Type IIA): In Hangman’s fractures, distinguish Type II (angulation + translation from hyperextension-rebound) from Type IIA (severe angulation with minimal translation from flexion-distraction). Applying axial traction to a Type IIA fracture will cause catastrophic over-distraction and spinal cord transaction. Never apply skull traction to a Type IIA Hangman’s fracture.
• The Pre-Reduction MRI Mandate in Obtunded Patients: In awake, communicative patients, urgent closed traction reduction can proceed with serial neurological exams. However, in an obtunded or uncooperative trauma patient with jumped facets, emergent MRI is mandatory prior to closed or open reduction to rule out an extruded herniated disc that could crush the spinal cord during closed reduction.
• Avoid Halo-Vests in Octogenarians: The complication and 1-year mortality rates of halo-vest immobilization in elderly patients with Type II odontoid fractures exceed 30% to 40% due to aspiration, pneumonia, loss of balance, and delirium. Rigid cervical collar immobilization or surgical stabilization (posterior C1–C2 fusion) provides superior survival and functional outcomes.

12. Controversy

1. Optimal Timing of Surgical Decompression in Acute Traumatic SCI:

While the STASCIS prospective study established the safety and superior neurological outcomes of decompression within 24 hours of injury, modern spine trauma research focuses on whether “ultra-early” surgical decompression (<8 to 12 hours) provides incremental neurological benefits. Proponents emphasize that persistent mechanical cord compression exacerbates secondary ischemic injury, apoptosis, and neurovascular collapse. Opponents argue that transferring critically unstable polytrauma patients directly to the operating suite before adequate cardiopulmonary and physiological resuscitation increases systemic complications and secondary intraoperative hypotension, potentially harming the injured cord.

2. Management of Type II Odontoid Fractures in the Elderly:

The optimal management of Type II dens fractures in octogenarians remains heavily debated. Conservative treatment with a rigid cervical collar avoids operative surgical risks and anesthesia complications but results in fibrous nonunion rates of 40% to 60%. Conversely, surgical fixation via posterior C1–C2 fusion achieves near 100% union and eliminates the risk of late catastrophic cord compression but exposes frail geriatric patients to significant operative blood loss, wound infection, and perioperative medical morbidity. Recent multicenter registries indicate that a stable, pain-free fibrous nonunion with collar management often provides satisfactory quality of life without shortening overall life expectancy compared to surgical interventions.

3. Closed Traction Reduction vs. Emergent ACDF for Cervical Facet Dislocations:

Controversy persists regarding the mandatory timing of MRI prior to closed traction reduction in awake, neurologically intact or incomplete patients. Some centers advocate immediate closed traction reduction in the emergency bay to rapidly restore canal diameter, arguing that delays spent obtaining an emergency MRI prolong spinal cord ischemia. Other centers enforce mandatory MRI before any manipulation to detect occult disc herniation (found in up to 30% to 50% of facet dislocations), which could retropulse and worsen cord compression during closed reduction maneuvers.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Hoffman JR, Mower WR, Wolfson AB et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000. doi:10.1056/NEJM200007133430203 [Level I: Prospective Multi-Center Validation Study]
• Stiell IG, Wells GA, Vandemheen KL et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001. doi:10.1001/jama.286.15.1841 [Level I: Prospective Multi-Center Cohort Study]
• Fehlings MG, Vaccaro A, Wilson JR et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012. doi:10.1371/journal.pone.0032037 [Level II: Prospective Multi-Center Cohort Study]
• Vaccaro AR, Hulbert RJ, Patel AA et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine (Phila Pa 1976). 2007. doi:10.1097/BRS.0b013e3181557b92 [Level II: Multi-Center Validation Study]
• Vaccaro AR, Koerner JD, Radcliff KE et al. AOSpine subaxial cervical spine injury classification system. Eur Spine J. 2016. doi:10.1007/s00586-015-3831-3 [Level II: International Multi-Center Validation Study]

15. Master Class Pro-Tip

When attempting closed reduction of acute bilateral jumped facets in an awake and communicative patient using Gardner-Wells tongs, position the pins 1 cm above the pinna of the ear, strictly below the equator of the skull, and slightly posterior to the external auditory meatus to induce a flexion vector during initial traction. Apply weight incrementally starting at 10 to 15 lbs and increasing by 5 lbs per intervertebral level under continuous serial lateral fluoroscopy and repetitive sensory and motor neurological checks. The absolute clinical pearl: Once the articular facets unlock and clear each other, immediately apply gentle extension and simultaneously reduce the axial traction weight to 5 to 10 lbs. Continuing high-weight traction after facet unlocking risks catastrophic over-distraction and severe secondary neurological deficit.

Master Class Surgical Pearl: Closed Reduction of Cervical Facet Dislocations