Blunt neck trauma
Background
- 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
Atlanto-occipital Disassociation
- Unstable
- Often associated w/ brain injury
- 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
- 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 the dens
- Predental space greater than 3 mm in adults or 5 mm in children is abnormal
- Odontoid xray: Masses of C1 lie lateral to outer margins of articular pillars of C2
- If either of the above findings on xray then obtain CT c-spine
- Lateral x-ray: 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 (superior to transverse ligament)
- Frequently involves other cervical spine injuries
- 25% a/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
- Type I
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)
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
- Displacement of teardrop shaped fragment of antero-inferior portion of sup vertebra
- Leads to 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
- Isolated fracture of one of the spinous processes of the lower cervical vertebrae
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
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
See Also
- Spinal Cord Trauma
- Spinal Cord Compression (Non-Traumatic)
- Neurogenic Shock
- C-spine (NEXUS)
- C-Spine X-Ray
Source
- UpToDate
- Tintinalli's