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Cervical Spine Fractures

What type of injuries cause Cervical Spine Fractures?

Here are some of the most common cervical spine fractures from trauma:

1. Motor vehicle accidents

This is the most common reason for fractures in the cervical spine (neck). The head and neck are often violently jerked in different directions, beyond the normal motion. This can result not only in fractures, but dislocations of the neck as well as injuries to the muscles and ligaments making the spine unstable. The spinal cord is at a high risk for injuries from these accidents.

2. Falls

3. Diving into shallow water

4. Gunshot wounds to the neck

5. High Impact Sports. The most likely ages for injuries among these athletes are 18-25 year olds (80%). Males are four times more likely to suffer these injuries than females. The most common cervical spine fractures occur in the following high impact sports:

  1. Diving
  2. Horseback riding
  3. Gymnastics
  4. Football
  5. Skiing

Does the spinal cord get injured with Cervical Spine Fractures?                           

Fractures of the cervical spine can cause trauma to the spinal cord when parts of the spine such as pieces of broken bone get pushed into the spinal cord. This can result in immediate paralysis.

Depending on the spinal level where the spinal cord is injured, the patient could suffer paraplegia or quadriplegia. Injuries above the C-5 Spinal level often result in quadriplegia, while those below C-5 may often cause paraplegia. However this is a continuum where patients may only have a partial loss of function in their arms or legs.

Where in the neck do most Cervical Spine Fractures happen?

Cervical spine fractures most commonly happen at either the highest (C-1, C-2) or lowest levels (C-6, C-7) of the spine.

Fractures at C-2 (axis) represent about 1/3rd of all neck fractures. The danger from a C-2 fracture is that it can cause instability of the spine. This happens when the odontoid part of C-2 breaks. The odontoid bone is a small piece of bone which travels upward into the ring of the C-1 vertebra. The C-1 vertebra rests on it and gets much of its stability from it. A significant fracture to the odontoid of C-2 potentially allows the C-1 vertebrae to shift on C-2, causing a spinal cord injury or death.

Injuries at C6 or C7 account for ½ of all cervical spine fractures. Injuries at these levels can result in paraplegia.

What symptoms do Cervical Spine Fractures cause?

The symptoms from a cervical spine fracture can vary widely depending on where in the neck the injury occurred and the severity of the injury. Here are some examples:

  1. Neck Pain
  2. Neck Stiffness
  3. Pain, numbness or weakness in the chest, abdomen, arms or legs
  4. Problems controlling bowel or bladder
  5. Headaches
  6. Swelling of the spine

How are Cervical Spine Fractures diagnosed?

Spine specialists diagnose these fractures with the help of the patient history, a physical examination and special tests.

A. History

The key to the history from the patient with a suspected spine fracture is knowing how the injury occurred. This is called the “mechanism’ of the injury. This involves knowing the place of the impact (head, neck), speeds involved (i.e. from motor vehicle accidents), loss of consciousness (blackout), and the ability to feel and move all four extremities (arms and legs) normally. Some of these statements can be obtained from witnesses or first responders if the patient is unconscious.

B. Physical Examination

Prior to examining the patient, the head and neck should be immobilized. In conscious patients, pain in the neck during palpation (examining by touch and pressure) can be a sign of a significant injury. This is usually followed by a complete neurological exam.

Some classic signs on the examination that the patient has suffered a spinal cord injury are:

  1. Neurogenic shock: the blood pressure and heart beat will be low
  2. Spinal shock: lack of muscle tone, loss of bowel and bladder control
  3. Loss of bowel and bladder control
  4. Weakness in the arms and legs

Here are some other physical examination tests the doctor may perform:

  1. Sensation testing (sensory) in the arms and legs (spine neurological testing)
  2. Strength testing (motor) in the arms and legs (spine neurological testing)
  3. Reflex testing in the arms and legs (spine neurological testing)
  4. Valsalva Test
  5. Hoffman’s Sign
  6. Babinski Sign
  7. Ankle Clonus Test

 

C. Imaging

      a. X-Rays

The initial trauma X-Ray is a plain X-Ray from the front (AP) and side (Lateral). If the patient is conscious, a 5 view, or a Flexion/Extension X-Ray can be taken. Flexion/Extension X-Rays should only be done after a CT scan confirms it is safe to do so.

      b. CT scans

CT scans for cervical spine trauma are commonly done when a fracture is suspected. It is an excellent tool to see the bone anatomy and alignment of the vertebrae. It is also the best test to rule out a spine fracture.

      c. MRI scans

MRI technology is usually used when spinal cord trauma is suspected as MRI scans are better at showing the actual tissue of the spinal cord. The bones of the neck can be seen but CT scans are better at showing them in detail.

How are Cervical Spine Fractures classified?

Here is the classification (by Allen) of spine fractures

A. Compression/Flexion (downward force while spine is bent forward)

  1. Stage I

The front of the vertebrae is slightly indented (blunted) but no other injuries are present.

       2. Stage II

Stage I injury plus center of vertebrae pay be pushed in or fractured vertically

       3. Stage III

Stage II injury plus fracture extending from the front of the vertebrae through its center and bottom part (endplate) of the vertebrae.

        4. Stage IV

Stage III injury plus part of the bottom back portion of the vertebrae is pushed into the spinal canal

B. Vertical Compression (straight downward force on the spine)

  1. Stage I

Fracture of the top or bottom (endplates) of the vertebrae

       2. Stage II

Fracture of both the top and bottom (endplates) of the vertebrae

      3. Stage III

Stage II injury plus fracture of the center of the vertebrae

C. Distraction Flexion (spine pulled apart in forward bending)

  1. Stage I

Failure of the ligaments in the back of the spine (posterior elements)

       2. Stage II

Dislocation of a facet joint on one side (small joins on the back of the spine)

       3. Stage III

Dislocation of both facet joints with 50% forward slippage of the vertebrae

       4. Stage IV

Vertebrae is slipped forward by its whole length

D. Compression Extension (downward force on the spine while bent backward)

  1. Stage I

Fracture of one side of the back part of the vertebrae (vertebral arch)

      2. Stage II

Fracture of both lamina (bone shelves on the back of the spine)

      3. Stage III

Fracture of more of the back part of the vertebrae than just the lamina

      4. Stage IV

Stage III fracture plus the vertebrae is slipped forward by less than its width

      5. Stage V

Stage IV fractures plus the vertebrae is slipped forward by more than its width

E. Distraction/Extension (spine pulled apart while bent backward)

  1. Stage I

Failure of the ligaments in the front of the spine

      2. Stage II

Stage I injury plus ligament failure in the back of the spine, allowing the vertebrae to slip partially into the spinal canal

F. Lateral Flexion (sidebending)

  1. Stage I

Symmetrical fracture of the center of the vertebrae plus the back part of the vertebrae (vertebral arch) on the same side

      2. Stage 2

Asymmetrical fracture of the center of the vertebrae plus the back of the vertebrae (vertebral arch) or ligament failure on the opposite side of the spine

How are Cervical Spine Fractures treated?

If the spine is found to be fractured and/or dislocated, often the first treatment is to place the spine into traction. This is done by attaching a traction device to the skull. This includes placing metal pins into the skull (tongs) which provide the best fixation for traction. Weights are attached to the tongs and are often increased in steps.

Spine fractures do frequently require surgery for correction. This is dependent on the type of fracture, location, overall stability of the spine as well as the presence of a neurological injury. The surgical correction often means that parts of the fractured vertebra are removed, followed by a surgical fusion for stability.

Steroid medications are often given intravenously (IV) for spinal cord injuries in hopes of reducing the swelling and inflammation of the spinal cord which often follows the trauma.

The following surgeries are sometimes done for Cervical Spine Fractures:

  1. Anterior Cervical Decompression and Fusion (ACDF)
  2. Cervical Corpectomy
  3. Cervical Laminectomy and Fusion
  4. Posterior Cervical Fusion
  5. Occipito-Cervical Fusion