Blunt neck trauma: Difference between revisions

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==Background==
==Background==
*Suspect vascular damage to cord if discrepancy between neuro deficit and level of spinal column injury
*Suspect vascular damage to cord, if discrepancy between [[Focal neurologic deficits|neuro deficit]] and level of spinal column injury
*Down syndome predisposes to atlanto-occipital dislocation
*[[Spinal cord injury]] is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted
*RA predisposes to C2 transverse ligament rupture
*Cord injury is more likely if ant (vertebral bodies) AND post (spinal canal) columns are disrupted  
*If find injury consider CT C-spine, x-ray rest of spine
*Penetrating injury rarely results in unstable fx


==Atlanto-occipital Dissociation==
==Clinical Features==
[[File:Atlanto-occipital Dissociation.jpeg|thumbnail|Atlanto-occipital Dissociation]]
*Signs of life-threatening neck or upper thoracic injury (look for ''TWELVE''):
*Unstable
:'''T'''racheal deviation'',
*Often associated w/ brain injury
:'''W'''ounds,
*Evaluate with the Powers ratio
:'''E'''xternal markings,
**Ratio of BC:OA > 1 suggests anterior subluxation
:'''L'''aryngeal disruption,
**BC = distance between basion and midpoint of C2 post laminar line
:'''V'''enous distention,
**OA = Distance between opisthion and ant arch of C2
:'''E'''mphysema (surgical)
*Features may include signs and symptoms of:
**[[Spinal cord injury]]
**[[Vertebral and Carotid Artery Dissection]]
**Laryngeal or [[tracheal injury]]


==C1 Fractures==
===Pediatrics===
===Burst (Jefferson)===
*In a small study of 42 patients with a cervical seatbelt sign there were no isolated  cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. <ref>Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.</ref>
*Unstable
*Fx of the ant AND post arches
**Due to axial loading transmitted through occipital condyles to the lateral masses
*Degree of instability determined by whether or not the transverse ligament is disrupted
*Suspect disruption if:
**Lateral x-ray: Increase in the predental space between C1 and dens (>3mm in adults, >5mm in children)
**Odontoid x-ray: Masses of C1 lie lateral to outer margins of articular pillars of C2
**If either of the above findings on x-ray obtain CT C-spine


===Anterior Arch (Isolated)===
==Differential Diagnosis==
*Stable
{{Blunt neck trauma DDX}}
===Posterior Arch (Isolated)===
*Stable
**Anterior arch and transverse ligament are unaffected
*Must ensure that you are not confusing this with a burst fx
**Odontoid view must be normal
*Due to forced neck extension
*Vertical fx line through posterior arch seen on lateral xray


==C2 Fractures==
===Other===
===Odontoid (Dens) Fracture===
*[[Head trauma]]
*Only stable if fx confined to avulsion of the tip (superior to transverse ligament)
*[[Thoracic trauma]]
*Frequently involves other cervical spine injuries
*25% assoc w/ neurologic injury
*Types
**Type I
***Fx above transverse ligament
***Stable
**Type II
***Fx at base of odontoid process where it attaches to C2
***Unstable
**Type III
***Extension of the fx through upper portion of body of C2
***Unstable


===Traumatic Spondylolisthesis ("Hangman's Fracture")===
==Evaluation==
[[File:Hangman fracture.png|thumb|Hangman's Fracture]]
===Workup===
*Unstable
*Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below)
*Bilateral C2 pedicle fracture (leads to C2 displacing anteriorly on C3)
**May later consider cervical MRI to further evaluate for cord injury
*Seen in MVA and diving accidents (not in suicidal hangings)
*Consider CTA neck with contrast to evaluate for vascular injury (see below)
**Forced extension of an already extended neck
*Spinal cord damage is often minimal (diameter of neural canal is greatest at C2)


==C3-C7 Fractures==
===General Approach===
===Anterior Wedge Fracture===
*If concern for cervical spine injury, use a [[cervical spine clearance]] decision rule to determine need for imaging
*Only unstable if lose over half of vertebral height OR multiple adjacent wedge fractures
*Perform a neuro exam, to determine concern for [[spinal cord injury]]
*If concern for vascular injury, use the [[Denver screening criteria]]


===Flexion Teardrop Fracture===
==Management==
*Unstable
*Prehospital
*Severe flexion > vertebral body colliding with the one below (shallow water diving injury, MVC deceleration)
**See the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]]
*Most commonly at C5-C6
*Hospital
**Displacement of teardrop shaped fragment of antero-inferior portion of sup vertebra
**Secure ABCs
**Leads to disruption of posterior longitudinal ligament
**See [[cervical spine clearance]]
*Associated with acute anterior cervical cord syndrome
**See specific diagnosis


===Extension Teardrop Fracture===
==Disposition==
*Unstable
*Based on specific diagnosis
*Abrupt neck extension > anterior longitudinal ligament avulses anteroinferior corner
**Avulsed fragment is greater in height than width (contrast with flexion teardrop)
*Often occurs at C5-C7 associated with diving accidents
**Associated with central cord syndrome


===Spinous Process Fracture (Clay Shoveler's)===
==See Also==
*Stable
*[[Penetrating neck trauma]]
*Isolated fracture of one of the spinous processes of the lower cervical vertebrae
*[[Cervical spine clearance]]
 
*[[Canadian cervical spine rule]]
===Burst Fracture===
*[[NEXUS cervical spine rule]]
*Unstable if:
*[[Strangulation]]
**Associated neurologic deficits
*[[Vertebral and carotid artery dissection]]
**Loss of >50% of vertebral body height
**>20 degrees of spinal angulation
**Compromise of >50% of spinal canal
**Axial compression > nucleus pulposus forced into vertebral body
*Imaging
**Lateral x-ray - Comminuted body and loss of vertebral height
**AP x-ray - Vertical fracture of the body
 
==Facet Dislocations==
===Bilateral===
*Unstable
*Complete spinal cord injury most often results
*Disruption of annulus fibrosus and ant longitudinal ligament > ant displacement of spine
*Imaging
**Lateral xray: vertebral body will be displaced >50% of its width
 
===Unilateral===
*Stable
*Imaging
**Lateral x-ray: vertebral body will be displaced <50% of its width
**Anterior x-ray: affected spinous process points toward side that is dislocated
*Spinal cord injury rarely occurs


== Vascular Injuries ==
==External Links==
*Carotid and vertebral artery injuries can occur with blunt c-spine trauma
*[https://coreem.net/podcast/episode-173-0-blunt-neck-trauma/ Blunt Neck Trauma from CoreEM]
**Half of patients present with initially normal neuro exam
**OR for carotid/vertebral artery injury of 8.6 with c-spine fracture
**OR for vertebral artery injury of 30.6 with transverse process fracture
**Vertebral angiography for transverse process fractures extending into transverse foramen or evidence of vertebral-basilar insufficiency(90% show dissection or occlusion of vertebral artery)
*Indications for screening (CTA or MRA) for vascular injury
**Unexplained neuro deficit with hyperflexion or extension injury
**Blunt trauma to neck or seatbelt injury
**C-spine or skull base fractures involving vascular foramina
**Le Fort II or III facial fractures
 
==See Also==
*[[Spinal Cord Trauma]]
*[[Spinal Cord Compression (Non-Traumatic)]]
*[[Neurogenic Shock]]
*[[C-spine (NEXUS)]]
*[[C-Spine X-Ray]]
*[[Fractures (Main)]]


==Source==
==References==
*National Spinal Cord Injury Statistical Center (NSCISC). Spinal Cord Injury. Facts and Figures at a Glance. Birmingham, Ala: NSCISC; July 1996
<references/>
*Ivy ME, Cohn SM. Addressing the myths of cervical spine injury management. Am J Emerg Med. Oct 1997;15(6):591-5
*Woodring JH, Lee C, Duncan V. Transverse process fractures of the cervical vertebrae: are they insignificant? J Trauma. June 1993; 34(6):797-802.
*Tintinalli's


[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 12:51, 22 February 2020

Background

  • Suspect vascular damage to cord, if discrepancy between neuro deficit and level of spinal column injury
  • Spinal cord injury is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted

Clinical Features

  • Signs of life-threatening neck or upper thoracic injury (look for TWELVE):
Tracheal deviation,
Wounds,
External markings,
Laryngeal disruption,
Venous distention,
Emphysema (surgical)

Pediatrics

  • In a small study of 42 patients with a cervical seatbelt sign there were no isolated cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. [1]

Differential Diagnosis

Neck Trauma

Other

Evaluation

Workup

  • Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below)
    • May later consider cervical MRI to further evaluate for cord injury
  • Consider CTA neck with contrast to evaluate for vascular injury (see below)

General Approach

Management

Disposition

  • Based on specific diagnosis

See Also

External Links

References

  1. ↑ Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.
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