Blunt neck trauma

Background

Three column concept of spinal fracture stability

• Suspect vascular damage to cord if discrepancy between neuro deficit and level of spinal column injury
• Down syndome predisposes to atlanto-occipital dislocation
• 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

Prehospital Immobilization

Please see the NAEMSP National Guidelines for Spinal Immobilization

Diagnosis by Level

Atlanto-occipital dissociation

• Atlanto-occipital dissociation
• C1
  • Jefferson fracture

Anterior Arch (Isolated)

• Stable

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 (Axis) Fractures

Odontoid (Dens) Fracture

• Only stable if fx confined to avulsion of the tip (superior to transverse ligament)
• Frequently involves other cervical spine injuries
• 25% assoc w/ neurologic injury
• consult ortho/nsg/trauma
• Types
  • Type I: Oblique avulsion fx of tip of odontoid; alar ligament avulsion
    • Stable
    • atlanto-occipital instability should be ruled out with flexion and extension films
  • Type II: Fx at base of odontoid process where it attaches to C2; Fx through waist
    • Unstable
    • high nonunion rate due to interruption of blood supply
      • Young: Halo if no risk factors for nonunion, Surgery if risk factors for nonunion
      • Elderly: Collar if not surgical candidates, Surgery if surgical candidates
  • Type III: Extension of the fx through upper portion of body of C2
    • Unstable
• Imaging
  • Xray: AP, lateral, open-mouth odontoid view of cervical spine
  • CT for further assessment if fracture identified

Traumatic Spondylolisthesis ("Hangman's Fracture")

Hangman's Fracture

• Unstable
• Bilateral C2 pedicle fracture (leads to C2 displacing anteriorly on C3)
• Seen in MVA and diving accidents (not in suicidal hangings)
  • Forced extension of an already extended neck
• Spinal cord damage is often minimal (diameter of neural canal is greatest at C2)

C3-C7 Fractures

Anterior Wedge Fracture

• Only unstable if lose over half of vertebral height OR multiple adjacent wedge fractures

Flexion Teardrop Fracture

• Unstable
• Severe flexion > vertebral body colliding with the one below (shallow water diving injury, MVC deceleration)
• Most commonly at C5-C6
  • Displacement of teardrop shaped fragment of antero-inferior portion of superior vertebra
  • Leads to posterior displacement of vertebral body and disruption of posterior longitudinal ligament
• Associated with acute anterior cervical cord syndrome

Extension Teardrop Fracture

• Unstable
• 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)

• Stable
• C7>C6>T1 avulsion fx; ; caused by extreme muscle flexion where spinous process is ‘pulled off’
• Isolated fracture of the spinous processes of the lower cervical vertebrae

• Management
  • nonop
  • collar for 10 days with ortho f/u
  • r/o lamina and facet fx, r/o jumped facet

Cervical burst fracture

• Unstable if:
  • Associated neurologic deficits
  • 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

Cervical facet dislocation

• determine if more than 1 spinal column affected
  • 1 column = generally stable
  • 2 or more columns = unstable
• generally superior facet fx
• abnormal xray? -> get CT

Bilateral

• Unstable as whole column can sublux
• high risk for significant spinal cord injury
• Disruption of annulus fibrosus and ant longitudinal ligament > ant displacement of spine
• Imaging
  • Lateral xray: vertebral body will be displaced ~50% of its width
• Management
  • spinal precautions
  • operative management: nsg vs ortho

Unilateral

• Relatively Stable
• Presentation
  • C5/C6: C6 radiculopathy with weakness to wrist extension numbness and tingling in the thumb
  • C6/C7: C7 radiculopathy with weakness to triceps and wrist flexion and numbness in index and middle finger
• Imaging
  • Lateral x-ray: vertebral body will be displaced ~25% of its width
  • Anterior x-ray: affected spinous process points toward side that is dislocated
• Spinal cord injury rarely occurs

Vascular Injuries

• Carotid and vertebral artery injuries can occur with blunt c-spine trauma
  • 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)
• Unstable spine fractures‎

Source

• National Spinal Cord Injury Statistical Center (NSCISC). Spinal Cord Injury. Facts and Figures at a Glance. Birmingham, Ala: NSCISC; July 1996
• 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