Medscape is available in 5 Language Editions – Choose your Edition here.


Cervical Spine Fracture Follow-up

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


Spinal shock

Severe spinal cord injury may cause a concussive injury of the spinal cord termed spinal shock syndrome.

Spinal shock manifests as distal areflexia of a transient nature that may last from a few hours to weeks. Initially, the patient experiences a flaccid quadriplegia along with areflexia. Segmental reflexes start to return usually within 24 hours as spinal shock starts to resolve. At that point, flaccid quadriplegia changes to spastic paralysis.

Eventually, total resolution can be expected.

Neurogenic shock

Neurogenic shock is spinal shock that causes vasomotor instability because of loss of sympathetic tone.

Patients with neurogenic shock are hypotensive but have paradoxical bradycardia.

Flushed, dry, and warm peripheral skin, (in contrast to findings with hypovolemic or cardiogenic shock) may be present. Other signs of autonomic dysfunction include ileus, urinary retention, and poikilothermia.

Loss of anal sphincter tone with fecal incontinence and priapism suggest spinal shock. Return of bulbocavernosus reflex heralds resolution of spinal shock.

Complete and incomplete cord syndromes

Besides spinal shock, complete and incomplete spinal cord syndromes may occur.

Spinal shock mimics a complete spinal cord lesion. Emergency physicians should wait until spinal shock resolves to make an accurate estimate of the patient's prognosis.

Incomplete cord syndromes are described and include anterior spinal cord syndrome, central spinal cord syndrome, Brown-Séquard syndrome, and less frequent, cord syndromes at high cervical levels (ie, Horner syndrome, posteroinferior cerebellar artery syndrome).

The prognosis of a patient with a complete lesion, after spinal shock subsides, is permanent paraplegia.

Patients with an incomplete lesion (partial motor or sensory function) can expect to regain some degree of function.

Anterior spinal cord syndrome

Anterior spinal cord syndrome involves complete motor paralysis and loss of temperature and pain perception distal to the lesion. Since posterior columns are spared, light touch, vibration, and proprioceptive input are preserved.

This syndrome is caused by compression of the anterior spinal artery, which results in anterior cord ischemia or direct compression of the anterior cord. It is associated with burst fractures of the spinal column with fragment retropulsion caused by axial compression.

Central spinal cord syndrome

This syndrome is caused by damage to the corticospinal tract.

It is characterized by weakness, greater in the upper extremities than the lower extremities and more pronounced in the distal aspect of extremity.

The syndrome usually is associated with a hyperextension injury in patients with spondylosis or congenital stenosis of the cervical canal.

Extension of the cervical spine, causing buckling of the ligamentum flavum into the spinal cord, is believed to cause central spinal cord syndrome.

Brown-Sequard syndrome

This syndrome involves injury to only 1 side of spinal cord.

It causes paralysis, loss of vibration sensation, and loss of proprioceptive input ipsilaterally, with contralateral loss of pain and temperature perception because of involvement of posterior columns and spinothalamic tracts on the same side.

It is associated with hemisection of the spinal cord from penetrating trauma; however, it also can be caused by a lateral mass fracture of a cervical vertebra.

High cervical spinal cord syndromes

These syndromes are associated with damage to the spinal tract of the trigeminal nerve in the high cervical region.

A characteristic onion-skin pattern of anesthesia in the face may occur.

Horner syndrome

This syndrome manifests as ptosis, miosis, and anhydrosis.

It results from damage to the cervical sympathetic chain.

Posteroinferior cerebellar artery syndrome

A diverse constellation of symptoms, including dysphagia, dysphonia, hiccups, vertigo, vomiting, or cerebellar ataxia, may occur.

Any of the high cervical cord syndromes may result from direct injury to the upper cervical level and/or cervicomedullary junction.

Vertebral artery occlusion from dislocation or hyperextension of the cervical column also can produce them.

Craniofacial injuries

An association between significant craniofacial injuries and cervical spine fractures seems intuitively logical, yet several retrospective series do not support this assumption.

A retrospective review of 2555 patients with significant facial injuries found that only 1.3% had concomitant cervical spine injury.[23] In a smaller series, 1272 patients with significant craniocerebral injury had only a 1.8% prevalence of cervical injuries.[24] A review of 1050 patients admitted with facial fractures found only a 4% prevalence of an associated cervical injury, even though the prevalence of associated head injuries was 85%.[25] These and other series indicate that closed head injuries and facial fractures may not significantly increase the risk of concomitant cervical spine injury.

A larger retrospective study suggests that there is an increased risk (4.5% vs 1.1%) of cervical spine injury with craniocerebral (but not with facial) injuries.[26]

Regardless of the results, none of these retrospective studies suggests decreasing standard care, such as ordering x-rays to find cervical spine injuries in trauma patients.


Patient Education

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Vertebral Compression Fracture.

Contributor Information and Disclosures

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.


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 (; 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.

  1. Ivancic PC. Odontoid fracture biomechanics. Spine (Phila Pa 1976). 2014 Nov 15. 39 (24):E1403-10. [Medline].

  2. Trafton PG. Spinal cord injuries. Surg Clin North Am. 1982 Feb. 62(1):61-72. [Medline].

  3. Hu J, Yang KH, Chou CC, King AI. A numerical investigation of factors affecting cervical spine injuries during rollover crashes. Spine (Phila Pa 1976). 2008 Nov 1. 33(23):2529-35. [Medline].

  4. Thompson WL, Stiell IG, Clement CM, Brison RJ. Association of injury mechanism with the risk of cervical spine fractures. CJEM. 2009 Jan. 11(1):14-22. [Medline].

  5. Donaldson WF 3rd, Hanks SE, Nassr A, Vogt MT, Lee JY. Cervical spine injuries associated with the incorrect use of airbags in motor vehicle collisions. Spine (Phila Pa 1976). 2008 Mar 15. 33(6):631-4. [Medline].

  6. Wang MC, Pintar F, Yoganandan N, Maiman DJ. The continued burden of spine fractures after motor vehicle crashes. J Neurosurg Spine. 2009 Feb. 10(2):86-92. [Medline].

  7. Stein DM, Kufera JA, Ho SM, Ryb GE, Dischinger PC, O'connor JV, et al. Occupant and crash characteristics for case occupants with cervical spine injuries sustained in motor vehicle collisions. J Trauma. 2011 Feb. 70(2):299-309. [Medline].

  8. Vanderlan WB, Tew BE, Seguin CY, Mata MM, Yang JJ, Horst HM, et al. Neurologic sequelae of penetrating cervical trauma. Spine (Phila Pa 1976). 2009 Nov 15. 34(24):2646-53. [Medline].

  9. Beaty N, Slavin J, Diaz C, Zeleznick K, Ibrahimi D, Sansur CA. Cervical spine injury from gunshot wounds. J Neurosurg Spine. 2014 Sep. 21(3):442-9. [Medline].

  10. Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011 Aug. 58(2):145-55. [Medline].

  11. Kanwar R, Delasobera BE, Hudson K, Frohna W. Emergency department evaluation and treatment of cervical spine injuries. Emerg Med Clin North Am. 2015 May. 33 (2):241-82. [Medline].

  12. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25. 349(26):2510-8. [Medline]. [Full Text].

  13. Darras K, Andrews GT, McLaughlin PD, Khorrami-Arani N, Roston A, Forster BB, et al. Pearls for Interpreting Computed Tomography of the Cervical Spine in Trauma. Radiol Clin North Am. 2015 Jul. 53 (4):657-74, vii. [Medline].

  14. Mulkens TH, Marchal P, Daineffe S, Salgado R, Bellinck P, te Rijdt B, et al. Comparison of low-dose with standard-dose multidetector CT in cervical spine trauma. AJNR Am J Neuroradiol. 2007 Sep. 28(8):1444-50. [Medline].

  15. Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. 2009 Feb. 32(2 Suppl):S117-40. [Medline].

  16. Utz M, Khan S, O'Connor D, Meyers S. MDCT and MRI evaluation of cervical spine trauma. Insights Imaging. 2014 Feb. 5 (1):67-75. [Medline].

  17. Winslow JE 3rd, Hensberry R, Bozeman WP, Hill KD, Miller PR. Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures. J Trauma. 2006 Sep. 61(3):686-7. [Medline].

  18. Hagedorn JC 2nd, Emery SE, France JC, Daffner SD. Does CT Angiography Matter for Patients with Cervical Spine Injuries?. J Bone Joint Surg Am. 2014 Jun 4. 96(11):951-955. [Medline].

  19. Goode T, Young A, Wilson SP, Katzen J, Wolfe LG, Duane TM. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination?. Am Surg. 2014 Feb. 80(2):182-4. [Medline].

  20. Kill C, Risse J, Wallot P, Seidl P, Steinfeldt T, Wulf H. Videolaryngoscopy with Glidescope Reduces Cervical Spine Movement in Patients with Unsecured Cervical Spine. J Emerg Med. 2013 Jan 22. [Medline].

  21. Aziz M. Use of video-assisted intubation devices in the management of patients with trauma. Anesthesiol Clin. 2013 Mar. 31(1):157-66. [Medline].

  22. Yue JK, Chan AK, Winkler EA, Upadhyayula P, Readdy WJ, Dhall SS. A review and update on the guidelines for the acute management of cervical Spinal Cord Injury (SCI) - part II. J Neurosurg Sci. 2015 Sep 9. [Medline].

  23. Davidson JSD, Birdsell DC. Cervical spine injury in patients with facial skeletal trauma. J Trauma. 1989. 29:1276-1278. [Medline].

  24. O'Malley KF, Ross SE. The incidence of injury to the cervical spine in patients with craniocerebral injury. J Trauma. 1988 Oct. 28(10):1476-8. [Medline].

  25. Sinclair D, Schwartz M, Gruss J, McLellan B. A retrospective review of the relationship between facial fractures, head injuries, and cervical spine injuries. J Emerg Med. 1988 Mar-Apr. 6(2):109-12. [Medline].

  26. Hills MW, Deane SA. Head injury and facial injury: is there an increased risk of cervical spine injury?. J Trauma. 1993 Apr. 34(4):549-53; discussion 553-4. [Medline].

  27. Duane TM, Dechert T, Wolfe LG, Aboutanos MB, Malhotra AK, Ivatury RR. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma. 2007 Jun. 62(6):1405-8; discussion 1408-10. [Medline].

  28. Ellis GL. Imaging of the atlas (C1) and axis (C2). Emerg Med Clin North Am. 1991 Nov. 9(4):719-32. [Medline].

  29. Hockberger RS, Kirshebaum KJ, Doris PE. Spinal injuries. Rosen P, Barkin R, Danzl DF, et al, eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby-Year Book; 1998. 462-503.

  30. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000 Jul 13. 343(2):94-9. [Medline].

  31. Ivy ME, Cohn SM. Addressing the myths of cervical spine injury management. Am J Emerg Med. 1997 Oct. 15(6):591-5. [Medline].

  32. Jacobs LM, Schwartz R. Prospective analysis of acute cervical spine injury: a methodology to predict injury. Ann Emerg Med. 1986 Jan. 15(1):44-9. [Medline].

  33. Mahoney BD. Spinal injuries. Tintinalli JE, Krone RL, Ruiz E, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw Hill Text; 1996. 1147-1153.

  34. National Spinal Cord Injury Statistical Center (NSCISC). Spinal Cord Injury. Facts and Figures at a Glance. Birmingham, Ala: NSCISC; July 1996.

  35. Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15. 33(4 Suppl):S101-22. [Medline].

  36. Proudfoot J, Pollack E, Friedland LR. Pediatric cervical spine injury: navigating the nuances and minimizing complications. Pediatr Emerg Med Rep. 1996. 1(9):83-94.

  37. Roberge RJ, Wears RC, Kelly M, et al. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. J Trauma. 1988 Jun. 28(6):784-8. [Medline].

  38. Stassen NA, Williams VA, Gestring ML, et al. Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient. J Trauma. 2006 Jan. 60(1):171-7. [Medline].

  39. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17. 286(15):1841-8. [Medline].

  40. Velmahos GC, Theodorou D, Tatevossian R, et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing. J Trauma. 1996 May. 40(5):768-74. [Medline].

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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.