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Cervical Spine Fracture Clinical Presentation

  • Author: Moira Davenport, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Sep 14, 2015
 

History

Common presentations of cervical spine fracture include the following:

  • Posterior neck pain on palpation of spinous processes
  • Limited range of motion associated with pain
  • Weakness, numbness, or paresthesias along affected nerve roots
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Physical

Clinical evaluation of the cervical spine in a patient with blunt trauma is unreliable. In a study of surgical residents' ability to predict cervical injuries on the basis of clinical examination alone, sensitivity and specificity were 46% and 94%, respectively. Because of these limitations and potential for catastrophic morbidity if injury is missed, most patients with complex blunt trauma seen in the ED undergo radiographic evaluation before clearance, with some exceptions.

Common findings on physical examination in cervical spine injury include the following:

  • Spinal shock
    • Flaccidity
    • Areflexia
    • Loss of anal sphincter tone
    • Fecal incontinence
    • Priapism
    • Loss of bulbocavernosus reflex
  • Neurogenic shock
    • Hypotension
    • Paradoxical bradycardia
    • Flushed, dry, and warm peripheral skin
  • Autonomic dysfunction
    • Ileus
    • Urinary retention
    • Poikilothermia
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Causes

Motor vehicle collisions and falls account for 50% and 20% of cervical spine injuries, respectively. Recent studies have shown that the impact velocity at the time of a motor vehicle collision[3, 4] , airbag deployment on unrestrained drivers[5, 6] , drivers aged 65 years or older, and rollover mechanisms[7] all significantly increase the likelihood of a cervical spine injury.

Sports-related activities account for 15%. The remaining injuries are attributed to interpersonal violence. The following athletic activities have the highest incidence of associated cervical spine injuries. Participants in these events should be considered at high risk.

  • Diving
  • Equestrian activities
  • Football
  • Gymnastics
  • Skiing
  • Hang gliding

Penetrating trauma rarely causes cervical spine fractures but may result in significant neurologic deficits.[8] In one study of 144 cervical gunshot wounds, 40 were associated with neurologic deficits.[9]

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Contributor Information and Disclosures
Author

Moira Davenport, MD Attending Physician, Departments of Emergency Medicine and Orthopedic Surgery, Allegheny General Hospital

Moira Davenport, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

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.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Emilio Belaval, MD Medical Director, Department of Emergency Medicine, Our Lady Of Fatima Hospital

Disclosure: Nothing to disclose.

Jorma B Mueller, MD Staff Physician, Department of Emergency Medicine, New York University Medical Center and Bellevue Medical Center

Disclosure: Nothing to disclose.

Simon Roy, MD Consulting Staff, Department of Emergency Medicine, South Shore Hospital

Disclosure: Nothing to disclose.

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

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Odontoid fractures. (A) Type I odontoid fracture represents an avulsion of the tip of the dens at the insertion site of the alar ligament. Although mechanically stable, it is associated with life-threatening atlanto-occipital dislocation. (B) Type II odontoid fracture is a fracture at the base of the dens. This is the most common type of odontoid fracture. (C) With type III odontoid fracture, the fracture line extends into the body of the axis.
(A) Simple wedge fracture with a flexion mechanism of injury is stable. (B) Flexion teardrop fracture with a flexion mechanism is unstable.
Anterior subluxation with a flexion mechanism is stable in extension but potentially unstable in flexion.
Bilateral facet dislocation with a flexion mechanism is extremely unstable and can have an associated disk herniation that impinges on the spinal cord during reduction.
Clay shoveler fracture. (A) Lateral view of this fracture caused by a flexion mechanism shows that it is stable and represents an avulsion fracture of the base of the spinous process near the supraspinous ligament. (B) Anteroposterior view shows the vertically split appearance of the spinous process.
Unilateral facet dislocation. (A) Lateral view of this fracture caused by a flexion-rotation mechanism shows that it is stable. Anterior displacement of spine is less than one half of the diameter of a vertebral body. (B) Anteroposterior view shows disruption of a line connecting spinous processes at the level of the dislocation. (C) Oblique view shows that the expected tiling of the laminae is disrupted, and the dislocated superior articulating facet of the lower vertebra is seen projecting within the neural foramina.
Hangman fracture caused by an extension mechanism is unstable. Fracture line is evident in the lateral projection extending through pedicles of C2, along with disruption of the spinolaminar line. Sometimes, this fracture is associated with unilateral or bilateral facet dislocation, which makes it highly unstable.
(A) Fracture of the posterior arch of C1 fracture caused by an extension mechanism is stable. Lateral projection shows a fracture line through the posterior neural arch without widening predental space. An odontoid view must be obtained to differentiate this benign fracture from a Jefferson fracture. (B) Jefferson fracture caused by a vertical (axial) compression mechanism is unstable. This fracture of all aspects of the C1 ring is associated with possible disruption of the transverse ligament of the atlas. Lateral projection may show a widened predental space and a fracture through the posterior arch of C1. Odontoid view shows displacement of the lateral masses of C1, allowing distinction of this fracture from a simple fracture of the posterior neural arch of C1.
Burst fracture of vertebral body caused by a vertical (axial) compression mechanism is stable mechanically and involves disruption of the anterior and middle columns, with variable degree of protrusion of the latter. This middle column posterior protrusion may extend into the spinal canal and be associated with an anterior cord syndrome.
(A) Normal lateral projection shows the relationships of anterior, posterior, and spinolaminar lines and prevertebral spaces. (B) Normal oblique projection shows the normal appearance of the laminae as shingles on a roof forming a regular elliptical curve with equal interlaminar spaces.
 
 
 
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