Definition
• Injury to the bony/ligamentous structure of the cervical spine (C2 24%, C6 20%, C7 19%)
Approach
• Maintain C-spine immobilization until cleared clinically w/o imaging (see table) or radiographically
Palpation
• Midline cervical tenderness, step-offs, neurologic deficits
Radiology
• Plain c-spine x-rays: 52% sens (limited use), C-spine CT: 98% sens → persistent midline tenderness/obtunded → Flex/ex films: 94% sens for ligamentous injury if adequate ROM (30° flexion/extension), MRI: 98% sens for ligamentous injury (J Trauma 58(5):902) (J Trauma 53(3):426)
C1 Burst Fracture (Jefferson Fracture)
Definition
• Unstable burst fracture of atlas (C1) causing widening of lateral masses (33% a/w C2 fracture)
History
• Axial load
Physical Findings
• C1 tenderness, neurologic deficit rare (wide canal at C1)
Evaluation
• CT/CTA, MRI for ligamentous injury
Treatment
• C-spine immobilization, spine consult for operative management
Disposition
• Admit
C2 Hangman’s Fracture
Definition
• Unstable fracture of bilateral C2 pedicles (↑ risk of C2 anterior subluxation/C2–C3 disk rupture → high mortality)
History
• Hyperextension
• Named due to judicial hangings in which knot is in front of pt & “height of drop” is at least as long as victim
Physical Findings
• C2 tenderness, high-impact trauma, neurologic deficits
Evaluation
• CT/CTA, MRI for ligamentous injury
Treatment
• C-spine immobilization, spine consult for operative management
Disposition
• Admit
Odontoid Fracture (C2 Dens)
Definition
• Fracture through the dens w/ variable stability (see table)
History
• Flexion injury
Physical Findings
• C2 tenderness
Evaluation
• CT scan, MRI for ligamentous injury
Treatment
• C-spine immobilization, spine consult
Disposition
• Likely admit
Tear Drop Fracture
Definition
• Unstable avulsion of cervical vertebral body at insertion of anterior ligament in extension injury (C2 common) or posterior in flexion injury (C5–C6)
History
• Flexion (MVC, diving in pool) or extension (elderly fall on chin)
Physical Findings
• C-spine tenderness, anterior cord syndrome (flexion), central cord syndrome (extension)
Evaluation
• CT/CTA, MRI for ligamentous injury
Treatment
• C-spine immobilization, spine consult
Disposition
• Admit
Clay Shoveler’s Fracture
Definition
• Stable avulsion fracture of spinous process (most common in low C-spine, >C7)
History
• Forceful flexion (as when clay sticks to a shovel when trying to throw it)
Physical Findings
• C-spine tenderness, no neurologic deficits
Evaluation
• CT scan
Treatment
• C-spine immobilization, spine consult
Disposition
• D/c
Subluxation/Ligamentous Injury
Definition
• Unstable rupture of ligaments w/o bony injury, anterior slipping of vertebrae one over the other
History
• Flexion
Physical Findings
• C-spine tenderness, no neurologic deficits
Evaluation
• CT/CTA scan, MRI
Treatment
• C-spine immobilization, spine consult
Disposition
• May require admission