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

Vertebral fractures and dislocations types

Vertebral anatomy.

Numbering order of vertebrae.

• Cervical fractures and dislocations
  • Atlanto-occipital dissociation
  • C1
    • Jefferson fracture
    • C1 isolated anterior arch fracture
    • C1 isolated posterior arch fracture
  • C2
    • Odontoid fracture
    • Hangman's fracture
  • C3-C7
    • Cervical burst fracture
    • Cervical spinous process fracture
    • Extension cervical teardrop fracture
    • Flexion cervical teardrop fracture
    • Anterior cervical wedge fracture
  • Cervical facet dislocation
  • Isolated transverse process fracture
• Thoracic and lumbar fractures and dislocations
  • Chance fracture
  • Thoracic burst fracture
  • Lumbar burst fracture
  • Isolated transverse process fracture
  • Thoracic and lumbar compression fractures

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

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