Cervical Spine Fracture


Pathophysiology

History:

Physical Exam

Diagnostics

Diagnostic Tests

Diagnostic Imaging

Acute Treatment

  1. Trauma ABCs
  2. CALL NEUROSURGEON
  3. Immobilization
  4. If intubation required
  5. Continue with primary survey
  6. For spinal cord injury:
  7. Other issues

Disposition

  1. Consultation
  2. Admit all known/ suspected C-spine injuries
  3. OR for reduction, decompression or fusion as needed
TABLE 3.5 Unstable Fractures of the C-Spine
TYPE MECHANISM CLINICAL STORY NOTES
Jefferson fracture
(C1 burst fx)
Axial load with vertical compression Football player spearing another player Seen on odontoid view
Bilateral facet dislocation Flexion Although called locked facets the injury is unstable Anterior displacement > 50% diameter of vertebral body.
Odontoid type II/III Flexion Severe high cervical pain or pain radiating to the occiput Usually due to major forces Consider other C-spine and bodily injuries.
Atlantoaxial or atlanto-occipital dislocations Flexion or extension   Atlanto-occipital dissociation usually results in death.
Hangman's fracture (bilateral C2 pedicle fx) Extension; C2 displaced anteriorly on C3 Judicial hanging with ball of noose in front Not common with suicide hangings
Teardrop fracture Flexion or extension
(an avulsion fracture)
  The teardrop is the anteroinferior portion
of the vertebral body.
Instability increases with multicolumn injuries.
Markers of unstable C-spine injury include damage to anterior 20% of vertebral body and loss of >50% of body height.

 

TABLE 3.6 Stable Fractures of the C-Spine
TYPE MECHANISM NOTES
Wedge Compression Fx Flexion Multiple wedge fxs or loss of >50% of vertebral body height may be unstable
Transverse process fracture Flexion  
Clay shoveler's fracture
(Spinous process avulsion)
Flexion against contracted posterior muscles Most commonly at C7
Unilateral facet Flexion and rotation Anterior displacement <50% of width
Burst Fx Vertical compression Can be unstable if fragments enter canal
Isolated fractures of articular pillar and vertebral body Vertical compression "Double-outline" sign



 

Anatomy

  1. C-spine has 7-cervical vertebrae
    • C1 has no body
    • C2 has dens (odontoid process)
  2. 8-cervical nerves which form the brachial plexus
  3. 3-spinal columns
    • Anterior column: anterior half of vertebrae & anterior longitudinal ligament
    • Middle column: posterior half of the vertebrae, disks and posterior longitudinal ligament
    • Posterior column: pedicles, laminae, articulating facets, synovial joints & spinous processes
    • Stability is lost when two columns are compromised adjacently
  4. Spinal tracts
    • Pain & temperature, light touch: anterior cord spinothalamic tract; cross midline when they enter the cord
    • Position: posterior cord fasciculus gracilis and cuneatus tracts; fibers do not cross
    • Motor: anterior cord corticospinal tract; cross in the lower brainstem
    • Posterior column tracts conduct vibration, proprioception, stereognosis & light touch
  5. Spinal cord ends at L1 
    • Inferior to L1 are the cauda equina

Clinical Criteria to Clear C-Spine

Nexus (US) Criteria: National Emergency X-Radiography Utilization Study (NEXUS) criteria
For TRAUMA patients only

X-RAY NOT NEEDED IF:
(Patient must meet ALL criteria)

  • NO posterior midline C-spine tenderness
    • Palpation of C-spine
    • From nuchal ridge to T-1 vertebral prominence
  • NO evidence of intoxication
    • Consider patient intoxicated if
      • ANY recent history of intoxication or ingestion of intoxicants
        • By patient or witness
      • ANY smell of ETOH
      • ANY slurred speech
      • ANY ataxia, dysmetria or other cerebellar findings
      • ANY behavior consistent with intoxication
      • ANY bodily fluid tests positive for ANY intoxicants
        • Alcohol or drugs
  • Normal level of alertness
    • GCS MUST be > 14
    • NO disorientation (time, place, person, events)
    • MUST be able to remember 3 objects at 5 minutes
    • NO delayed / inappropriate response to external stimuli
    • Any other abnormalities
      • eg: Mental retardation
  • ANY focal neurological:
    • Complaint (history)
    • Finding (exam)
  • NO distracting injury
    • Precise definition impossible
    • Examples:
      • Long bone fracture
      • Visceral injury requiring surgical consultation
      • Large laceration
      • Degloving injury
      • Crush injury
      • Large burns
      • Any injury causing acute functional impairment

IF PATIENT DOES NOT MEET ALL CRITERIA

  1. Continue immobilization
  2. Obtain C-spine x-rays
 
Canadian C-spine Criteria
*For alert (GCS = 15) stable trauma patients where C-spine injury is a concern

Rule NOT applicable if:

  1. Non-trauma cases
  2. GCS < 15
  3. Unstable vital signs
  4. Age < 16 years
  5. Acute paralysis
  6. Known vertebral disease
  7. Previous C-spine injury

ANY OF THE FOLLOWING PRESENT?
(High-Risk Factors: Radiography Mandatory)

  1. Age > 65 years
  2. ANY dangerous mechanism
    • Fall from > 3 feet or > 5 stairs
    • Axial load to head
      • Diving, etc
    • High speed MVC
      • (> 100 km/hr)
      • Rollover
      • Ejection
    • Motorized recreational vehicle
    • Bicycle struck or collision
  3. Paresthesias in extremities
    • YES: Radiography
    • NO

ANY OF THE FOLLOWING PRESENT?
(Low-Risk Factors: Allow Self-Assessment of Range of Motion)

  1. Simple rear-end MVC
    • EXCLUDES
      • Pushed into oncoming traffic
      • Hit by bus/ large truck
      • Rollover
      • Hit by high-speed vehicle
  2. Sitting position in ED
  3. Ambulatory at ANY time
  4. Delayed onset of neck pain
    • NOT immediate onset of neck pain
  5. Absence of midline C-spine tenderness
    • NO: Radiography
    • YES

Able to Actively Rotate Neck?
(45° left and right)

  1. UNABLE: Radiography
  2. ABLE: No Radiography
 

C-Spine Imaging

PLAIN X-RAYS

  1. Still the most common imaging used
  2. Initial x-rays DO NOT require the patient to move the neck
  3. Initial views should be performed BEFORE cervical collar removal
  4. Views
    • Usual C-spine series consists of 3 views
      • AP view
      • True lateral view (cross-table lateral)
        • May also get swimmer's view
      • Odontoid (open mouth) view
    • These 3 views together detect 95% of C-spine injuries
    • Most commonly missed injuries are in C1&C2
    • Oblique views may be added for further information
  5. Further X-Ray studies
    • Oblique Views
      • To R/O unilateral facet dislocations
      • R/O posterior laminar fractures
      • R/O subluxation

CT Scanning

  1. General information
    • VERY useful for:
      • Fractures that result in neurologic deficit
      • Fractures of the posterior elements of the cervical canal
    • May become imaging modality of choice for C-spine trauma in adults
      • Especially if moderate to high risk for fracture
    • Advantages of CT
      • Excellent for characterizing fractures / identifying osseous compromise of the vertebral canal
        • Superimposition from the transverse view is absent
      • Higher contrast resolution of CT gives improved visualization of subtle fractures
      • CT provides patient comfort
        • Can reconstruct images in axial, sagittal, coronal, and oblique planes from one patient positioning
    • Limitations of CT
      • Difficult to identify fractures oriented in axial plane (e.g. fractures of dens)
      • UNABLE to show ligamentous injuries
      • High cost
      • Ionizing radiation
  2. Indications (guidelines)
    • Further evaluation of any fracture seen on plain film or atlanto-axial rotation
    • Inadequate plain film survey &/or high clinical suspicion
  3. Common scanning parameters (trauma)
    • Scan from top of vertebral body above fracture to bottom of vertebral body below fracture
    • Slice thickness of 1.5 mm (1.5 mm "cuts")
    • Spacing of 1.5 mm

MRI Scanning

  1. General information
    • MRI provides the best visualization of:
      • Cervical soft tissues
        • Ligaments
        • Intervertebral disks
      • ONLY way to directly evaluate the spinal cord
      • Epidural hematomas
    • Advantages of MRI
      • Excellent soft tissue constrast
        • Study of choice for spinal cord survey, hematoma, and ligamentous injuries
      • Provides good general overview
        • Can show information in different planes (e.g. sagital, coronal, etc.)
      • Can demostrate vertebral arteries
        • Useful for evaluating fractures involving the course of the vertebral arteries
      • No ionizing radiation.
    • Disadvantages of MRI
      • Loss of bony details
      • High cost
  2. Indications
    • Cervical fractures that have spinal canal involvement
    • Clinical neurologic deficits (including radicular pain)
      • Assess disc, look for hematoma in the spinal canal
    • Ligamentous injuries
  3. Common scanning protocols (trauma)
    • Five sequential scans:
      • T1 turbo spin echo (sagittal plane)
      • T1 turbo spin echo (axial plane)
      • Turbo T2 (sagittal plane)
      • 2D flash (sagittal plane)
      • 2D flash (axial plane)

Fluoroscopy

  1. PASSIVE flexion/ extension
    • Can assess ligamentous stability in the unconscious patient

 

Image Evaluation

Cross-table lateral View
  1. Assess the adequacy of the film
    • MUST show
      • All 7 cervical vertebrae AND
      • The top of T1 vertebra
        • NOT seeing C7-T1 junction = DISASTER
  2. If unable to see all vertebrae, obtain a swimmer's view or CT
    • Swimmer's view (transaxillary view)
      • Have SHIELDED person pull down on patients arms
      • Can move shoulder contours out of the way
  3. Follow the ABC'S
    • ALIGNMENT
    • BONY INTERITY
    • CARTILAGE SPACES
    • SOFT TISSUES

A = Alignment

  1. Check 3 imaginary contour lines - all should be smooth curves
    • Anterior contour line
      • Connects anterior margins of all vertebrae
    • Posterior contour line
      • Connects posterior margins of all vertebrae
    • Spinolaminar line
      • Connects bases of spinous processes
  2. Each line should be a smooth lordotic curve
    • Misalignment POSTERIORLY is worse than ANTERIORLY
      • Anterior may be due to rotation on film
    • Any disruption > 3.0 mm is significant ANYWHERE
  3. IF ANY DISRUPTION
    • Suspect bony or ligamentous injury
    • Note: This is not true for children!
    • Facet dislocations
      • 25% subluxation = unilateral facet dislocation
      • 50% subluxation = bilateral facet dislocation
    • Angulation of vertebrae
      • Check for angulation changes at each interspace
      • Any abrupt angulation > 11 degrees: suggests bony injury / possible ligament involvement
  4. Check SPINAL CANAL diameter
    • Distance between posterior contour line and spinolaminar line
    • Should be > 18 mm
    • IF < 14 mm, canal is definitely narrowed

B = Bony Integrity

  1. Bodies should be:
    • Regular cuboids
      • Wedge shaped vertebra = fracture
    • Similar in size and shape to the vertebrae immediately above and below (not C1/C2)
  2. Look for:
    • Cortical breaks
    • Bone density changes
      • Decreased density
        • Osteoporosis / osteomalacia / osteolytic lesions
        • May represent weak areas that can fracture
      • Increased density
        • Osteoblastic lesions
        • ACUTE COMPRESSION FX's
    • Compression fractures
      • Anterior wedging of the vertebral body
        • Wedging of 3 mm or more suggests Fx
      • Height loss in vertebrae
        • Height loss of > 40% suggests burst fracture
      • Teardrop fractures of the antero-inferior portion of the body
        • Compression in flexion

C = Cartilage Spaces

  1. Predental space
    • Distance from dens to body of C1
      • Normal adult = 3 mm
      • Normal child = 5 mm
  2. Disc spaces and intraspinous process spaces should all be approximately equal

S = Soft Tissue Spaces

  1. Normal adult prevertebral space (stripe)
    (anterior border of vertebra to posterior wall of pharynx)
    • Level of C2: < 7 mm
    • Level of C3 - C4: < 5 mm OR < 1/2 width of involved vertebra
      • BELOW C4: limit is width of 1 vertebral body
    • Level of C6: < 22 mm
  2. If prevertebral space widened at ANY level:
    • Assume hematoma from fracture
  3. Interspinous space: should be about equal
    • Widened interspinous space ("fanning" of spinous processes) = posterior ligament disruption
  4. Tracheal air shadow: if displaced anteriorly: = soft tissue swelling
  5. If air is seen in prevertebral space:
    • Usually tracheal or esophageal rupture
    • May also be due to air in esophagus during swallowing (rare)
 
Flexion-extension views: 
(Limited use if MRI available)
  1. Can help if:
    • Suspicious films
    • Neck pain with normal films
  2. Done with cervical collar removed
  3. ONLY for alert, cooperative pt with MD guidance
    • Flexion / extension MUST be voluntary
  4. ABSOLUTELY CONTRAINDICATED:
    • DOCUMENTED UNSTABLE INJURIES
  5. X-rays are taken with neck in flexion and extension
    • Pt slowly flexes neck to 15 degrees
    • Pt then slowly extends neck to 15 degrees
    • Stop flexion/ extesion IMMEDIATELY if:
      • Patient complains of any pain
      • Patient complains of any paresthesias
  6. Same ABC's rule applies to reading
  7. If still suspect bony injury despite plain films:
    • CT Scan
 
AP View

Alignment (AP View)

  1. MUST see all spinous processes from C2 to T1
  2. Straight line should connect the tips of all spinous processes
    • Lateral displacement: = unilateral facet disruption
  3. Laryngeal and tracheal air shadows should be midline
  4. Lateral cortical margin
    • Should be smooth, undulating, apparently intact density

Bony Integrity (AP View)

  1. Vertebrae should have:
    • Concave superior surface
    • Convex inferior surface
  2. Vertebral bodies should be intact
    • Look CAREFULLY for fracture lines
      • Look in body AND lamina
    • Fracture lines can be very hard to see
  3. Spinous processes should be intact
    • Split or bifid-looking: = probable fracture of spinous process
  4. Examine pillars carefully
    • Look for fracture lines

Cartilage Spaces (AP View)

  1. Intravertebral disc spaces should look approximately equal
  2. Widened spaces are consistent with facet dislocation

Soft Tissue Spaces (AP VIEW)

  1. Minimal usefulness in this projection
Odontoid View (Open Mouth View)

Alignment (Odontoid View)

  1. MUST see ENTIRE odontoid and lateral borders of C1-C2
  2. Check lateral masses of C1- C2 in relation to odontoid process
    • Lateral borders of C1 and C2 should line up
      • Should match within 1 mm
    • If landmarks shifted IN on one side:
      • Should be shifted OUT same amount on other side

Bony Integrity

  1. Odontoid should have uninterrupted cortex
    • Dens should have NO fracture lines
      • Type I dens Fx
        • UNSTABLE
      • Type II dens Fx
        • UNSTABLE
      • Type III dens Fx
        • STABLE

Cartilage Spaces

  1. Interspace between C1 and C2 should be symmetrical

Soft Tissue Spaces

  1. Minimal / no utility in this view

 

Oblique View (Laminar View)

Alignment

  1. Vertebral laminae usually overlap smoothly
    • "Shingles on a roof" appearance
      • Regular elliptical curve
      • Equal interlaminar spaces
    • If "tiling is disrupted:
      • Suspect unilateral facet dislocation

Bony Integrity

  1. Look for undisrupted "shingle" bodies
    • Disruption: suspect laminar fracture

Cartilage Spaces

  1. Interlaminar spaces should be equal
    • If space between 2 contiguous lamina is increased:
      • Suspect unilateral facet dislocation

Soft Tissue Spaces

  1. A neural foramina may be obliterated by facet dislocations
 
Swimmer's View
  • Swimmer's view (transaxillary view)
    • Have SHIELDED person pull down on patients arms
    • Can move shoulder contours out of the way
Flexion-/ Extension View
(Limited use if MRI available)
  1. Can help if:
    • Suspicious films
    • Neck pain with normal films
  2. Done with cervical collar removed
  3. ONLY for alert, cooperative pt with MD guidance
    • Flexion / extension MUST be voluntary
  4. ABSOLUTELY CONTRAINDICATED:
    • DOCUMENTED UNSTABLE INJURIES
  5. X-rays are taken with neck in flexion and extension
    • Pt slowly flexes neck to 15 degrees
    • Pt then slowly extends neck to 15 degrees
    • Stop flexion/ extesion IMMEDIATELY if:
      • Patient complains of any pain
      • Patient complains of any paresthesias
  6. Same ABC's rule applies to reading
  7. If still suspect bony injury despite plain films:
    • CT Scan