Cervical spine fracture-dislocations continue to represent a significant challenge in trauma patients due to the imminent risk of neurological deterioration associated with potentially inadequate timing and modality of surgical management [
1‐
3]. Fractures or dislocations of the posterior cervical elements are typically managed by an attempt for initial closed reduction with temporary external fixation in a Halo vest, followed by definitive posterior spinal fusion, as indicated [
4‐
7]. However, a “classic” challenge for the management of cervical facet dislocations is represented by the potential of an associated injury to the anterior spinal column with a disc herniation into the anterior spinal canal [
8]. In this scenario, an imprudent closed reduction maneuver may lead to the iatrogenic compression of the spinal cord with the potential for subsequent devastating neurological consequences [
9‐
12]. The option of obtaining advanced imaging by MRI prior to a closed reduction maneuver remains controversial [
13,
14]. While MRI undoubtedly represents the most sensitive diagnostic tool to evaluate for associated disc herniation, ligament injury, and traumatic myelopathy [
15,
16], concerns about the standard use of MRI in the work-up of cervical facet dislocations relate to the delayed timing of early spinal realignment, considerations related to cost effectiveness, resource utilization, and the restricted availability of MRI across the globe [
13,
17,
18]. Impressively, early studies on the use of MRI in cervical spine injuries revealed a presence of traumatic disc herniation in more than 40% of all patients [
8]. In absence of MRI, the concept of closed reduction of the cervical spine in awake and alert patients has been largely proven safe and feasible [
19‐
21], yet, selected cases of catastrophic deterioration of the neurological status after closed reduction maneuvers have been reported [
10,
14,
22,
23]. In certain instances of cervical fracture-dislocations, patients owe an intact neurologic status to the fracture of the posterior elements, such as pedicle or lamina fractures (so-called “saving” laminotomy), which result in increased spinal canal space and thus prevent a traumatic spinal cord compression [
21,
24]. The definitive surgical management of cervical fracture-dislocations with associated traumatic disc herniation is achieved via anterior, posterior or combined (anterior-posterior and anterior-posterior-anterior) approaches [
2,
25,
26], however, in the setting of a neurologically intact patient, there is a general consensus to start the procedure through an anterior approach for spinal canal decompression [
6]. In the present case report, we present a rare injury pattern of a cervical spine fracture-dislocation with rotational instability, posterior perched facet, and complete anterior extrusion of the intervertebral disc in a young and active patient without associated spinal cord injury. A safe surgical management strategy is presented and placed into context of the peer-reviewed literature in the field.