Cervical Spine Injury

Majority are seen secondary to road-traffic accidents

2nd largest category  Fall from heights and sporting

Most common in young men

Classification according to mechanism of trauma

Flexion Injuries Simple Wedge Stable
Clay Shoveller’s fracture Stable
Tear-Drop Unstable
Atlanto-occipital & Atlanto-axial dislocation Highly Unstable
Bilateral facet dislocation Highly Unstable
Odontoid fracture
Type I Stable
Type II Unstable
Type III Unstable if fragment separation is
significant (>5 mm)
Uncinate process fracture Stable
Rotational Injuries Unilateral facet dislocation Stable
Extension Injuries Fracture of the posterior arch of the atlas Stable
Tear-Drop Unstable in extension
Hangman’s fracture Unstable
Vertical Compression Injuries Jefferson’s fracture Unstable
Burst fracture May impinge spinal cord, therefore
considered unstable

Clinical features:

 All patients with documented or suspected of trauma above the level of the clavicles should be considered
to have cervical spine injury until proven otherwise
 Cervical spine can be examined while immobilized by palpating the neck for muscle spasm, mid-line bony
tenderness, palpable steps and crepitus

“Complete spinal cord lesion”

 Complete loss of motor and sensory function below the level of spinal cord injury
 If symptoms persist > 24 hours, chances of recovery are slim
 Spinal shock may mimic symptoms but usually recovers < 24 hours

“Incomplete spinal cord lesion”

 Can be grouped into 3 syndromes:

o Central-cord lesions
o Brown-sequard syndrome
o Anterior-cord lesions
Radiological examination

Obtain lateral, AP, & open mouth peg view X-Ray

Lateral view (Examine ABCs)

 A  Adequacy & Alignment

o Look for normal smooth curve of:
 Anterior vertebral line
 Posterior vertebral line
 Spino-laminar line
 B  Bone
o Increased density suggest compression fracture
 C  Cartilage
o Intervertebral space should be uniform
 S  Soft tissues
o Look for retro-pharyngeal swelling

AP view

 Tips of spinous process should appear as a straight line in mid-line

 Assess interspinous distances

Open mouth view

 Distance between odontoid and lateral masses of C1 should be equal; lateral margins should be aligned

Spiral CT  Further evaluate abnormalities when plain X-rays are inadequate

MRI  Used to assess soft tissues, ligaments, and spinal cord

Management:

ABCs, ATLS

Maintain in-line immobilization

CT-scan to further assess stability, and confirm diagnosis

MRI if there’s any abnormal neurology

Aim of treatment:

 Prevent new or further neurological insult

 Decompress potentially reversible neurological deficits
 Reduce spinal deformity
 Hold reduction to allow union (Usually 6-12 weeks)
 Rehabilitate

Treatment:

Most fractures don’t require internal stabilization

Surgery is usually to instrument fusion to bridge unstable segments

Stable fractures

 Firm collar (Philadelphia C-spine brace)

 SOMI (Sterno-Occipito-Mandibular Immobilisation)

Unstable fractures

 Skull tongs & traction

 Halo vest immobilization
SOMI
 Fusion

Repeat CT to assess bony union at 6 weeks

In unstable fractures, consider flexion-extension lateral x-ray

once bony union is obtained to check ligamentous integrity

Halo Vest