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Cervical Spine Fracture

Cervical spine fractures are potentially deadly conditions that arise after trauma, exaggerated extension or flexion. Gravity depends on the location, stability, and pattern of the injury.


Presentation

Patients present with symptoms like pain located on the posterior side of the neck, spontaneous or induced by palpation, leading to a decrease of the motion range and paresthesias in the territories of the affected nerves. Neck muscles may be spastic [1] and tender and an ecchymosis may be present at the fracture site. Muscular spasticity may be persistent if the condition remains undiagnosed [2]. Vertebral malalignment may be visible or palpable.

Clinical examination may find one or more of the following: spinal or neurogenic shock, hypotension with paradoxical bradycardia, fecal incontinence, urinary retention, ileus, priapism, poikilothermia, areflexia, flaccidity, weakness or paresthesias of the arms or legs. Pain may also radiate to the arms and legs and be associated with proprioceptive deficiency and deep tendon reflex loss if spinal cord injury exists. In this case, patients also have difficulty breathing. Distal pulses remain uncompromised.

Unstable fractures are characterized by involvement of more than one vertebral column and increased intervertebral disc space height or interspinous distance. The intervertebral disc space height may also be increased, with having the same significance.

Clinical examination can observe specific cord syndromes. Central cord syndrome is characterized by greater upper extremity deficit compared to lower limb impairment. In anterior cord syndrome, patients present with paralysis that sets in immediately after the injury, while posterior cord syndrome causes disruption of the dorsal nervous columns. Complete spinal cord injury has the worse prognosis and consists of a complete absence of motor and sensorial function.

A frequent type of injury after automobile accidents is whiplash, that may become symptomatic immediately or 6-12 hours afterward. Accuses consist of neck, jaw, interscapular, shoulder or arm pain, reduced motion range of the neck, headache, vertigo, nausea, vision abnormalities and paresthesia in the arms and legs, as well as dysphagia caused by a retropharyngeal hematoma. In this case, neurologic examination reveals reflex hyperactivity and abnormal plantar response [3].

While evaluating a suspected cervical spine fracture patient, the clinician should not forget to evaluate cranial nerves [4]. The patient should be alert during the examination, and even if so, neurological examination sensitivity may be inadequate [5], therefore clinical protocols should be followed [6] and injury severity score should be calculated [7].

Arm Pain
  • Accuses consist of neck, jaw, interscapular, shoulder or arm pain, reduced motion range of the neck, headache, vertigo, nausea, vision abnormalities and paresthesia in the arms and legs, as well as dysphagia caused by a retropharyngeal hematoma.[symptoma.com]
  • Although the patient certainly sustained a cervical strain/sprain, there was no explanation or diagnosis for the arm pain/numbness/tingling.[chiro.org]
  • This condition can cause neck pain/stiffness, arm pain, weakness in the hands, muscle spasms, loss of coordination and sometimes loss of bowel or bladder control.[centerforneuroandspine.com]
  • Cailliet R: Neck and Arm Pain. Philadelphia, F.A. Davis, 1964. Claypool DS: Cervical Rib. Roentgenological Briefs, American Council on Chiropractic Roentgenology. Date unknown. Colson JHC: Progressive Exercise Therapy, ed 3.[chiro.org]
Neck Pain
  • CLINICAL FEATURES: A 40-year-old woman sought chiropractic care for neck pain and weakness in both arms after a motor vehicle accident. Neck flexion worsened the weakness in her upper extremities, her radiating neck pain, and upper extremity pain.[ncbi.nlm.nih.gov]
  • We present the case of a fully conscious, ambulatory patient with no complaint of neck pain and only mild tenderness on examination who nevertheless had sustained an unstable fracture-dislocation of the cervical spine.[ncbi.nlm.nih.gov]
  • We present the case of an alert ambulatory patient with no complaint of neck pain, no tenderness of the neck on physical examination, and no history of trauma who, while being evaluated for fever, was found to have an unstable cervical-spine fracture[ncbi.nlm.nih.gov]
Spine Pain
  • What Cervical Spine Pain Could Mean Neck pain can be debilitating and there is a wide range of possible causes.[centerforneuroandspine.com]
  • Emergency medical personal arrived at the scene and found the patient alert and oriented, with complaints of right shoulder weakness and cervical spine pain.[ispub.com]
Hyperreflexia
  • Hyperreflexia, clonus, Babinski signs, and Hoffmann signs indicate spinal cord compression, although areflexia is common initially in an emergency injury.[orthopaedicsone.com]
  • Autonomic hyperreflexia The chronic phase in which spinal reflexes reappear is characterized by autonomic hyperreflexia in a high proportion of patients.[trauma.org]
Cervical Radiculopathy
  • If the nerve is affected, neurological symptoms such as pain and weakness can radiate down the path of the nerve into the arm and/or hand ( cervical radiculopathy ).[spine-health.com]
  • A trial of conservative treatment with emphasis on postural alignment is preferred in cases demonstrating signs of either cervical radiculopathy and/or myelopathy.[chiro.org]
Forgetful
  • While evaluating a suspected cervical spine fracture patient, the clinician should not forget to evaluate cranial nerves.[symptoma.com]
Encephalopathy
  • […] of a 36-year-old man diagnosed with an isolated cervical spine fracture, where an associated carotid artery lesion was initially overlooked and diagnosis was made after development of a neurological deterioration secondary to a posterior reversible encephalopathy[ncbi.nlm.nih.gov]

Workup

Although patients may have no complaints related to neck tenderness, they need to have a radiological evaluation if they have a neurologic deficit, altered sensorial function or other significant injuries, according to Canadian C-Spine Rules and National Emergency X-Radiography Utilization Group [8] [9]. These rules also apply to children. If sitting and walking are possible and the patient can rotate the head by 45 degrees both ways, the level of suspicion of cervical fracture is diminished.

On the other hand, computer tomography examination is urgent if the patient has a Glasgow coma scale below 13, has been intubated or a rapid diagnosis is needed.

When the radiological evaluation is considered necessary, all classical five views should be ordered: anteroposterior, oblique, odontoid, swimmer's and cross-table lateral. If available, a computer tomography [10] or magnetic resonance imaging [11] examination is useful, being more sensitive. Magnetic resonance is superior in describing ligament and disc lesions. Even if symptoms are limited to the cervical spine, motor vehicle accident victims should have the whole spine examined if a cervical spine fracture is demonstrated [12]. Furthermore, the clinician should keep in mind that C1-C3 spine fractures may be associated with vertebral artery injury [13].

Treatment

  • Individual hospital treatment variation also decreased over the study period. Further clinical studies examining the optimal treatment for spine trauma may lead to continued decreases in treatment variability. Copyright 2018 Elsevier Inc.[ncbi.nlm.nih.gov]
  • The patient's complex injuries were managed by conservative treatment of the fracture-dislocation and later by ligation of the proximal and distal vertebral artery for trapping of the fistula.[ncbi.nlm.nih.gov]
  • Abstract STANDARDS: There is insufficient evidence to support treatment standards. GUIDELINES: There is insufficient evidence to support treatment guidelines.[ncbi.nlm.nih.gov]
  • Abstract The present study aimed to explore surgical treatments and assess the effects based on the features of cervical spine fracture in patients with ankylosing spondylitis (AS) and to summarize the experiences in perioperative management.[ncbi.nlm.nih.gov]
  • (The treatments weren't randomly assigned, but were up to the choice of the treating physician.) Dr. Boakye and colleagues compared the short and long-term outcomes of the surgical and nonsurgical treatment groups.[disabled-world.com]

Prognosis

  • If there aren’t any neurological symptoms or damage to the brainstem, the prognosis is favorable.[sacramentoinjuryattorneysblog.com]
  • Complete spinal cord injury has the worse prognosis and consists of a complete absence of motor and sensorial function.[symptoma.com]
  • Incomplete cord injuries (those with some sensory or motor function) have a significantly better prognosis! Perineum examination important as predictor of prognosis![orthopaedicsone.com]
  • (Outcomes/Resolutions) The long-term prognosis of Cervical Fractures depends on the severity of the injury, which can range from complete recovery to total paralysis (quadriplegia) The prognosis is usually good in individuals whose Cervical Fractures[dovemed.com]

Etiology

  • Specifi c etiology of motor ve hicle crash.[dx.doi.org]
  • Reid DC, Henderson R, Sabol L, et al (1987) Etiology and clinical course 0f missed spine fractures. J Trauma 27:980–986 CrossRef PubMed Google Scholar 22. Roberge RG (May 1993) Unstable occult cervical-spine fracture. Letter to the editor.[link.springer.com]
  • […] and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • (Etiology) Some common causes of Cervical Fractures include: A high-energy impact traumatic event such as an automobile accident A fall from a significant height Participation in any rough or high-impact sport Domestic violence, street fights Location[dovemed.com]

Epidemiology

  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Hu R, Mustard CA, Burns C (1996) Epidemiology of incident spinal fracture in a complete population. Spine 21:492–499 CrossRef PubMed Google Scholar 16. Jefferson G (1920) Fracture of the atlas vertebra.[link.springer.com]
  • PubMed Google Scholar Leucht P, Fischer K, Muhr G, Mueller EJ: Epidemiology of traumatic spine fractures. Injury. 2009, 40: 166-172. 10.1016/j.injury.2008.06.040.[sjtrem.biomedcentral.com]
  • Ferimento por projétil de arma de fogo na coluna vertebral: estudo epidemiológico [Gunshot wounds of the spine: epidemiological study] Coluna/Columna. 2002; 1(2) :83–7. Disponível em: . Acessado em 2012 (9 out). 3.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology The goals of resuscitation should be stabilization of the cervical spine, prevention of secondary injury, reduction of the fracture as soon as possible and protection of the spinal cord.[trauma.org]
  • Compared to adults, children have a different fulcrum because of a relatively large head, the vertebrae are not completely ossified, and the ligaments are firmly attached to articular bone surfaces that are more horizontal, making the pathophysiology[emedicine.medscape.com]
  • Haldeman, S: The Pathophysiology of the Spinal Subluxation. In Goldstein M (ed): The Research Status of Spinal Manipulative Therapy. Washington, DC, Government Printing Office, NINCDS Monograph No. 15 DHEW Publication No.[chiro.org]

Prevention

  • Abstract The development and use of seatbelts has saved numerous lives and prevented serious injuries in the setting of automobile crashes.[ncbi.nlm.nih.gov]
  • Measures to prevent head and neck injury in boxing are discussed.[ncbi.nlm.nih.gov]
  • The complication of aspiration pneumonia was preventable. Meticulous and repeated examination of the cranial nerve function in this type of injury is recommended.[ncbi.nlm.nih.gov]
  • Early recognition of hyperextension of the fetal head in utero and planned cesarean section are important prevention methods.[ncbi.nlm.nih.gov]
  • Older adults are at increased risk of C2 fractures, a serious injury that requires prompt treatment to prevent injury to the cervical (neck) portion of the spinal cord.[disabled-world.com]

References

Article

  1. Schliack H, Schaefer P. Hypoglossal and accessory nerve paralysis in a fracture of the occipital condyle. Nervenarzt. 1965;36(8):362–364.
  2. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR Am J Roentgenol. 1978;131(4):729–731.
  3. Carroll LJ, Holm LW, Hogg-Johnson S, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4):S83-S92.
  4. McCleary AJ. A fracture of the odontoid process complicated by tenth and twelfth cranial nerve palsies: A case report. Spine. 1993;18:932–935.
  5. Duane TM, Dechert T, Wolfe LG, et al. Clinical Examination and its reliability in identifying cervical spine fractures. J Trauma. 2007;62:1405–1410.
  6. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk Criteria in patients with trauma. N Engl J Med. 2003;349:2510–2518.
  7. Albrecht RM, Malik S, Kingsley DD, et al. Severity of cervical spine ligamentous injury correlates with mechanism of injury, not with severity of blunt head trauma. Am Surg. 2003;69:261–265.
  8. Kanwar R, Delasobera BE, Hudson K, et al. Emergency department evaluation and treatment of cervical spine injuries. Emerg Med Clin North Am. 2015;33(2):241-282.
  9. Leonard JC, Kuppermann N, Olsen C et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011;58(2):145-155.
  10. Mulkens TH, Marchal P, Daineffe S, et al. Comparison of low-dose with standard-dose multidetector CT in cervical spine trauma. AJNR Am J Neuroradiol. 2007;28(8):1444-1450.
  11. Kumar Y, Hayashi D. Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. BMC Musculoskelet Disord. 2016;17:310.
  12. Winslow JE 3rd, Hensberry R, Bozeman WP, et al. Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures. J Trauma. 2006;61(3):686-687.
  13. Hagedorn JC 2nd, Emery SE, France JC, et al. Does CT Angiography Matter for Patients with Cervical Spine Injuries?. J Bone Joint Surg Am. 2014;96(11):951-955.

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Last updated: 2018-06-21 23:16