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Lower Cervical Spine Fractures and Dislocations Workup

  • Author: J Allan Goodrich, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
 
Updated: Mar 03, 2014
 

Laboratory Studies

See the list below:

  • Routine lab studies for trauma patients are included for those with subaxial cervical spine trauma. A complete blood count, urinalysis, and serum electrolyte levels and chemistries are obtained as the individual case dictates.
  • A blood type and screen or crossmatch for packed or whole blood may be necessary, depending on the concomitant injuries and vital sign assessment.
  • When spinal cord injury is present, neurologic impairment may impede evaluation of other injuries, including intra-abdominal trauma to solid organs. Liver and renal function testing may be of benefit in these situations.
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Imaging Studies

See the list below:

  • The cross table lateral radiograph is the criterion standard for evaluating subaxial cervical alignment. This must include visualization of the cervical-thoracic junction. A swimmer's view may be necessary to complete the evaluation of this area, but if body habitus precludes adequate visualization, a CT scan of the area is mandatory to exclude neck injury. Additional views include the anteroposterior (AP) and open mouth odontoid radiographs.[11, 12] See the image below.
    Lateral film of a C5 burst/teardrop fracture. Lateral film of a C5 burst/teardrop fracture.
  • While a CT scan is helpful in imaging the cervicothoracic junction, it is extremely beneficial in identifying posterior column injuries such as lamina or facet fractures.[13] See the images below.
    Sagittal CT scan of C5 burst fracture. Sagittal CT scan of C5 burst fracture.
    Axial CT scan of C5 burst fracture. Axial CT scan of C5 burst fracture.
    Axial CT scan of C7-T1 fracture/dislocation. Axial CT scan of C7-T1 fracture/dislocation.
    Sagittal CT of C7-T1 fracture/dislocation. Sagittal CT of C7-T1 fracture/dislocation.
  • MRI is particularly useful in demonstrating injuries to the neural elements, especially the spinal cord. Traumatic disk herniations are well delineated on MRI, but the routine use of this study may not contribute to the treatment regimen chosen for these injuries. If the neurologic level of injury does not match the area of injury identified by standard radiographs, this is another indication for MRI. Some have found MRI of the cervical spine to be helpful in determining ligamentous injury, but its application to justifying surgical intervention is not clear from available literature. See the image below.
    MRI of C7-T1 fracture/dislocation. MRI of C7-T1 fracture/dislocation.
    See the list below:
    • There is controversy on the management of unilateral and bilateral facet dislocations, because neurologic deterioration has been reported after closed reduction. Eismont suggested that the mechanism of this neurologic decline is cord compression at the time of reduction by large, associated disk herniations.[14] He recommended MRI evaluation prior to reduction, and if a large disk herniation is found, he proposed anterior removal prior to reduction as a means of avoiding a catastrophic event. This, however, remains debatable, as some surgeons believe delay in reduction in a neurologically incomplete or deteriorating patient is contraindicated and that reduction should be performed urgently.
    • If the patient is neurologically intact and alert, it seems reasonable to perform MRI scanning if not otherwise contraindicated. Each clinical situation must be assessed individually. In the patient with multiple injuries, including life-threatening injuries that need stabilization in the operating room, reduction could be performed without the delay necessary to obtain an MRI scan.
  • Magnetic resonance angiography may be indicated when associated vertebral artery injury is suspected. This may occur in the severely degenerative cervical spine or when fractures through the foramina transversarium are present.
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Contributor Information and Disclosures
Author

J Allan Goodrich, MD Staff Physician, Orthopaedic Spine Surgeon, Doctor's Hospital

J Allan Goodrich, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, North American Spine Society, Society of Lateral Access Surgery

Disclosure: Received consulting fee from Nuvasive for speaking and teaching; Received royalty from Globus for consulting.

Coauthor(s)

Thad Andrew Riddle, MD Orthopedic Surgeon and Partner, Georgia Bone and Joint Surgeons

Thad Andrew Riddle, MD is a member of the following medical societies: AO Foundation, American Academy of Orthopaedic Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, North American Spine Society, Scoliosis Research Society, Cervical Spine Research Society, International Society for the Study of the Lumbar Spine, AOSpine, Society of Lateral Access Surgery, International Society for the Advancement of Spine Surgery, Lumbar Spine Research Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Samuel Hu, MD, to the development and writing of this article.

References
  1. Uhrenholt L, Charles AV, Hauge E, Gregersen M. Pathoanatomy of the lower cervical spine facet joints in motor vehicle crash fatalities. J Forensic Leg Med. 2009 Jul. 16(5):253-60. [Medline].

  2. Kouyoumdjian P, Guerin P, Schaelderle C, Asencio G, Gille O. Fracture of the lower cervical spine in patients with ankylosing spondylitis: Retrospective study of 19 cases. Orthop Traumatol Surg Res. 2012 Sep. 98(5):543-51. [Medline].

  3. Hubbard ME, Jewell RP, Dumont TM, Rughani AI. Spinal injury patterns among skiers and snowboarders. Neurosurg Focus. 2011 Nov. 31(5):E8. [Medline].

  4. Allen BL, Ferguson RL, Lehmann TR et al. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine. 1982. 7:1-27.

  5. Zehnder SW, Lenarz CJ, Place HM. Teachability and reliability of a new classification system for lower cervical spinal injuries. Spine (Phila Pa 1976). 2009 Sep 1. 34(19):2039-43. [Medline].

  6. Toh E, Nomura T, Watanabe M, Mochida J. Surgical treatment for injuries of the middle and lower cervical spine. Int Orthop. 2006 Feb. 30(1):54-8. [Medline].

  7. Marco RA, Meyer BC, Kushwaha VP. Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction. Surgical technique. J Bone Joint Surg Am. 2010 Mar. 92 Suppl 1 Pt 1:67-76. [Medline].

  8. Kim HJ, Lee KY, Kim WC. Treatment outcome of cervical tear drop fracture. Asian Spine J. 2009 Dec. 3(2):73-9. [Medline]. [Full Text].

  9. Dvorak MF, Fisher CG, Aarabi B, Harris MB, Hurbert RJ, Rampersaud YR, et al. Clinical outcomes of 90 isolated unilateral facet fractures, subluxations, and dislocations treated surgically and nonoperatively. Spine. 2007 Dec 15. 32(26):3007-13. [Medline].

  10. Milligram MA, Rand N. Cervical Spine Anatomy. Spine State of the Art Reviews. 2000. 14(3):521-532.

  11. Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. Delayed or missed diagnosis of cervical spine injuries. J Trauma. 2006 Jul. 61(1):150-5. [Medline].

  12. Silva CT, Doria AS, Traubici J, Moineddin R, Davila J, Shroff M. Do additional views improve the diagnostic performance of cervical spine radiography in pediatric trauma?. AJR Am J Roentgenol. 2010 Feb. 194(2):500-8. [Medline].

  13. Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?. J Trauma. 2006 Aug. 61(2):382-7. [Medline].

  14. Eismont FJ, Arena MJ, Green BA. Extrusion of an Intervertebral Disc associated with Traumatic Subluxation or Dislocation of Cervical Facets. J Bone Joint Surg AM. 1991. 73:1555-1560.

  15. Tsutsumi S, Ueta T, Shiba K, Yamamoto S, Takagishi K. Effects of the Second National Acute Spinal Cord Injury Study of high-dose methylprednisolone therapy on acute cervical spinal cord injury-results in spinal injuries center. Spine. 2006 Dec 15. 31(26):2992-6; discussion 2997. [Medline].

  16. Bracken MB, Holford TR. Neurological and functional status 1 year after acute spinal cord injury: estimates of functional recovery in National Acute Spinal Cord Injury Study II from results modeled in National Acute Spinal Cord Injury Study III. J Neurosurg. 2002 Apr. 96(3 Suppl):259-66. [Medline].

  17. Young W, Bracken MB. The Second National Acute Spinal Cord Injury Study. J Neurotrauma. 1992 Mar. 9 Suppl 1:S397-405. [Medline].

  18. Young W, Bracken MB. The Second National Acute Spinal Cord Injury Study. J Neurotrauma. 1992 Mar. 9 Suppl 1:S397-405. [Medline].

  19. Bracken MB, Shepard MJ, Hellenbrand KG, Collins WF, Leo LS, Freeman DF, et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg. 1985 Nov. 63(5):704-13. [Medline].

  20. Fehlings MG. Summary statement: the use of methylprednisolone in acute spinal cord injury. Spine. 2001 Dec 15. 26(24 Suppl):S55. [Medline].

  21. Hugenholtz H, Cass DE, Dvorak MF, et al. High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option. Can J Neurol Sci. 2002 Aug. 29(3):227-35. [Medline].

  22. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar. 72 Suppl 2:93-105. [Medline].

  23. Fehlings MG, Bracken MB. Summary Statement: The Sygen(R) (GM-1 Ganglioside) Clinical Trial in Acute Spinal Cord Injury. Spine. 2001 Dec 15. 26(24 Suppl):S99-S100. [Medline].

  24. Sapkas GS, Papadakis SA. Neurological outcome following early versus delayed lower cervical spine surgery. J Orthop Surg (Hong Kong). 2007 Aug. 15(2):183-6. [Medline].

  25. Apple DF. Spinal cord injury rehabilitation. In: Garfin SR, Vaccaro AR, eds. Orthopaedic Knowledge Update: Spine. Vol 2. American Academy of Orthopaedic Surgeons. 2002:239-244.

  26. Levine AM. Facet fractures and dislocations. In: Lampert R, ed. Spine Trauma. WB Saunders Co. 1998:331-365.

  27. Segal JL, Pathak MS, Hernandez JP, et al. Safety and efficacy of 4-aminopyridine in humans with spinal cord injury: a long-term, controlled trial. Pharmacotherapy. 1999 Jun. 19(6):713-23. [Medline].

  28. Furlan JC, Noonan V, Cadotte DW, Fehlings MG. Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma. 2011 Aug. 28(8):1371-99. [Medline]. [Full Text].

  29. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012. 7(2):e32037. [Medline]. [Full Text].

  30. Fehlings MG, Sekhon LHS. Restoration of spinal cord function. In: Garfin SR, Vaccaro AR, eds. Orthopaedic Knowledge Update: Spine. Vol 2. American Academy of Orthopaedic Surgeons. 2002:483-488.

  31. Rang M. Spine Fractures and Traumatic Paraplegia. The Story of Orthopaedics. 2000. 411-422.

  32. Vaccaro AR, Zlotolow DA, Blam OG. The Lower Cervical Spine in Spinal Cord Injury. Spine State of the Art Reviews. 1999. 13(3):489-506.

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Cross-sectional anatomy of the cervical cord.
Normal anatomy of the lower cervical spine.
Lateral film of a C5 burst/teardrop fracture.
Sagittal CT scan of C5 burst fracture.
Axial CT scan of C5 burst fracture.
Reduction of C5 burst fracture after tongs traction.
Postoperative image of C5 burst fracture; note anterior and posterior fixation.
Postoperative image of C5 burst fracture.
Standard lateral cervical spine of an 80-year-old patient after a motor vehicle accident; patient has no neurologic deficits and no neck pain.
Swimmer's view of the same 80-year-old patient as in Image 9; note the C7-T1 fracture/dislocation.
Axial CT scan of C7-T1 fracture/dislocation.
Sagittal CT of C7-T1 fracture/dislocation.
MRI of C7-T1 fracture/dislocation.
Reduction of C7-T1 fracture/dislocation.
Postoperative anteroposterior view of C7-T1 fracture/dislocation.
Postoperative lateral view of C7-T1 fracture/dislocation.
 
 
 
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