Blunt neck trauma
Pearls
- Suspect vascular damage to the 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 anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted
- If find injury consider CT C-spine, xray rest of spine
Atlanto-occipital Disassociation
- Unstable
- Evaluate with the Powers ratio
- Ratio of BC:OA > 1 suggests anterior subluxation
- BC = distance between basion and midpoint of C2 post laminar line
- OA = Distance between opisthion and ant arch of C2
C1 Fractures
Burst (Jefferson)
- Unstable
- Axial loading transmitted through occipital condyles to the lateral masses
- Results in fx of the ant and post arches
- Stability is determined by whether or not the transverse ligament is disrupted
- Suspect disruption if:
- Lateral xray: Increase in the predental space between C1 and the dens
- Predental space greater than 3 mm in adults or 5 mm in children is abnormal
- Odontoid xray: Masses of C1 to lie lateral to the outer margins of the articular pillars of C2
- If either of the above findings on xray then obtain CT c-spine
- Lateral xray: Increase in the predental space between C1 and the dens
Anterior Arch
- Stable
Posterior Arch
- Stable (b/c 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
Odontoid (dens) Fracture
- Only stable if fx confined to avulsion of the tip (sup to transverse ligament)
- Frequently involves other cervical spine injuries
- 25% a/w neurologic injury
Traumatic Spondylolisthesis ("Hangman's Fx")
- Unstable
- Fracture of both C2 pedicles 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)
Cervical Fractures
Anterior Wedge Fracture
- Only unstable if:
- Loss of over half of vertebral height OR multiple adjacent wedge fractures
Flexion Teardrop Fracture
- Unstable
- Displacement of teardrop shaped fragment of antero-inferior portion of superior vertebra
- Severe flexion > vertebral body colliding with the one below
- Associated with acute anterior cervical cord syndrome due to fx-induced kyphosis
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
- Isolated fracture of one of the spinous processes of the lower cervical vertebrae
Burst Fracture
- Unstable
- Axial compression > nucleus pulposus forced into vertebral body
- Posteriorly displaced fracture fragment may impinge on the cord
- Imaging
- Lateral xray - Comminuted body and loss of vertebral height
- AP xray - 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 xray: vertebral body will be displaced <50% of its width
- Anterior xray: affected spinous process points toward side that is dislocated
- Spinal cord injury rarely occurs
Source
- UpToDate
- Tintinalli's