The cervical spine is the most common site of spinal injury in blunt trauma or automobile accidents. C1-2 are the most commonly involved levels, followed by C5-7. Approximately 20% of patients with cervical spine fracture will have more than one fractures. Majority of cervical cord injuries occur at the time of the fracture, however up to 15% may develop later due to fracture instability.
Symptoms and Signs.
Cervical spine fractures are always symptomatic. However, patients may be unconscious, intoxicated, or have distracting injury rendering the history and examination inaccurate. Patients usually present with posterior neck pain which is accentuated on palpation. Cervical cord injury can manifest with weakness, paresthesias, areflexia, flaccidity, and loss of sphincter tone.
Mechanism.
Knowing the mechanism of injury is essential for understanding its radiographic features. C-spine injuries can be classified according to the causative mechanism and its sequelae, but most cases are likely the result of multiple simultaneous forces with one predominant force (see Table 5-1 for major fracture types).
Hyperflexion.
Hyperflexion and rotation.
Hyperextension.
Hyperextension and rotation.
Vertical compression.
Lateral flexion.
Other mechanism.
Stability.
Cervical spine can be separated into three columns—anterior, middle, and posterior. Injuries to one column are considered stable. If two columns are disrupted the injury is unstable, increasing the probability of delayed spinal cord injury.
Anterior. Anterior longitudinal ligament, anterior two thirds of the vertebral body and intervertebral disk.
Middle. Posterior longitudinal ligament, posterior one third of the vertebral body and intervertebral disk.
Posterior. Posterior bony elements (pedicles, transverse processes, articular facets, laminae, and spinous processes).
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Indications.
C-spine radiographs are indicated in all trauma patients presenting with localized neck pain, deformity, altered mental status, distracting injury, neurologic deficits, or head injury. If the radiograph findings are negative in a trauma patient who has neck pain, neurologic deficits, or other reason for high clinical suspicion, a computed tomography (CT) should be performed subsequently.
Protocol.
A cross-table lateral radiograph is usually performed first to avoid moving the patient in case a C-spine fracture is present. If this appears normal, routine views are then performed, including anteroposterior (AP) and open-mouth odontoid views. The routine C-spine examination can also include angled 45 degree oblique and flexion-extension views. One should be able to see the seven cervical segments and the cervicothoracic junction for a cervical spine series to be complete. Flexion-extension views are particularly useful for detection of ligamentous disruption when the routine views (and sometimes even CT) are normal. The patient must perform the flexion and extension voluntarily without any assistance. Any external force can cause severe injury if a fracture or dislocation is present. Flexion-extension views are contraindicated if the patient is disoriented, uncooperative, or intoxicated.
TABLE 5-1 Cervical Spine Fractures. Listed are the Major Types, Organized by Predominant Mechanism of Injury
Mechanism
Fracture type
Stability
Description
Hyperflexion
Anterior subluxation
Stable
Disruption of the posterior ligament complex only (supraspinous, infraspinous, interfacetal joint capsule, and posterior longitudinal ligaments); the anulus fibrosus may be partially disrupted. The anterior longitudinal ligament is intact
Bilateral interfacetal dislocation
Unstable
Complete disruption of the posterior ligament complex PLUS the anulus fibrosus and possibly the anterior longitudinal ligament
Results in bilateral jumped facets; neurologic injury common
Simple wedge fracture
Stable
Anterior compression fracture of vertebral body; the posterior ligament complex is stretched but intact; the anulus fibrosus and anterior longitudinal ligament are intact
Clay Shoveler’s fracture
Stable
Avulsion fracture of spinous process of C7, C6, or T1 (in order of frequency).
Flexion tear-drop fracture
Unstable
Complete disruption of all ligament groups (posterior complex, anulus fibrosus, and anterior longitudinal) nteriorly displaced triangular fracture fragment from the anterior-inferior corner of the vertebral body
Angulation and displacement of vertebral body causes spinal canal narrowing; often associated with anterior cervical cord syndrome; the most serious C-spine injury
Rotation-flexion
Unilateral interfacetal dislocation
Stable
Complete unilateral disruption of facet joint capsule and posterior longitudinal ligament; partial disruption of the anulus fibrosus and the opposite facet joint capsule
Results in unilateral locked facet; fracture of involved facet is common; commonly associated with vertebral artery injury
Rotation-extension
Pillar fracture
Stable
Vertical fracture of one of the lateral masses, usually in a lower cervical vertebra
Compression
Jefferson’s fracture C1
Unstable
Fractures of anterior and posterior arches of C1 with disruption of the transverse ligament of C1 and lateral displacement of the articular masses of C1
Atlantodental interval greater than 3 mm. Can be difficult to see – watch for prevertebral soft tissue swelling
Burst fracture (lower C-spine)
Stable
Comminuted vertical fracture of vertebral body, usually a lower cervical vertebra, caused by forcing of nucleus pulposus through inferior endplate
Posterior fracture fragment commonly displaced posteriorly into spinal canal
Extension
Extension Tear-drop fracture
Unstable
Avulsion fracture involving the anterior-inferior corner of the vertebral body, disrupting the attachment of the anterior longitudinal ligament
Commonly associated with preexisting degenerative joint disease (DJD)
Posterior neural arch fracture C1
Stable
Fracture only of the posterior arch of C1
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TABLE 5-1 Cervical Spine Fractures. Listed are the Major Types, Organized by Predominant Mechanism of Injury
