eMedicine Specialties > Sports Medicine > Spine

Cervical Spine Acute Bony Injuries

Author: George L Hertner, MD, Consulting Staff, Department of Emergency Medicine, Memorial Hospital of Colorado Springs
Coauthor(s): Nathaniel Johnson Stewart Jr, MD, FACEP, Director for Education and Professional Services, Chief, Department of Emergency Medicine, Palmetto Richland Memorial Hospital
Contributor Information and Disclosures

Updated: May 27, 2008

Introduction

Background

Cervical spine fractures lead to substantial morbidity and mortality. Neck injury in athletes can quickly end or change the future of an athlete. Failure to properly recognize and provide early care in cervical spine fracture cases may lead to devastating complications.^1,2,3,4

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Neck Strain, Vertebral Compression Fracture, and Whiplash.

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Frequency

United States

The incidence of all spinal injuries in the United States has been reported at approximately 10,000 cases per year. Nearly 200,000 people in the United States have a history of spinal injuries. These statistics do not differentiate between injuries with fracture and injuries without fracture.^5,6,7

Sports-related activities represent 10-15% of these injuries, and spinal injuries represent 2-3% of all sports-related injuries. Certain sports (eg, American football, diving, gymnastics, skiing, wrestling, rugby, hang gliding, surfing, equestrian events) are more frequently associated with the risk of spinal trauma.^{2,3,4,6,7,8,9,10,11,12}

The most common spinal injuries cited in the literature are injuries secondary to contact sports such as football. Nearly 1.2 million high school athletes and 200,000 college and professional athletes participate in football. The National Football Head and Neck Injury Registry contains data on cervical spine injuries as a result of participation in football. A trend can be seen over time, as equipment and helmets improved. The incidence of cervical spine injuries increased until 1976. In that year, antispearing rules were established to prevent the athlete from using the helmet as driving force in tackles. Direct collision created higher axial loads than the neck could withstand, leading to high injury rates. This rule, along with better coaching of blocking and tackling techniques, has resulted in a significant decrease in the number of spinal injuries.¹⁰

Diving is often cited as another significant cause of cervical spine injuries. Injuries resulting from diving are often associated with devastating outcomes. Diving rules (eg, depth of starting areas) and proper technique have lowered the probability of injury during supervised athletic events. However, unsupervised swimming and diving into shallow water present significant risks. Public awareness of this problem has led to the development of special awareness programs, but the risk of injury remains high.

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Functional Anatomy

The human spine serves to provide structural support and bony protection of the spinal cord. The cervical spine consists of 7 bony vertebrae separated by flexible intervertebral discs. They are joined together by an intricate network of ligaments, which helps form the normal lordotic curve of the cervical neck.¹³

The spinal column can be divided into 2 separate columns based on function and injury patterns. The anterior column consists of the bodies of the vertebrae, intervertebral discs, and the anterior and posterior longitudinal ligaments. The function of the vertebral body is to support weight. The posterior column contains the spinal canal and consists of the pedicles, laminae, articulating facets, and transverse and spinous processes. These structures form the vertebral arch, which encloses the vertebral foramen and protects the neural tissues.

The arch is formed by bilateral pedicles that are oriented posteriorly and join 2 laminae. The spinous process arises posteriorly from the vertebral arch. The cervical transverse processes and 4 articular processes also arise from the arch. The cervical transverse processes are unique to the vertebral column with an oval foramen transversarium. The vertebral arteries pass through these foramina. The posterior column also includes a group of ligaments including the supraspinous, infraspinous, interspinous, and nuchal ligaments.

The first 2 cervical vertebrae are atypical in form and function. The next 5 vertebrae are all similar in structure and function. The atlas, C1, is a ring-shaped bone that supports the skull. Two concave, superior articular facets articulate with the occipital condyles. The atlas does not have a body or spinous process. The atlas has an anterior and posterior arch, each with a tubercle and lateral mass. The axis, C2, is the strongest cervical vertebrae. The atlas rotates on 2 large articulating surfaces. The odontoid process (dens) projects superiorly from the C2 body and is the bony structure that the atlas rotates on. The odontoid process is held in place by the transverse ligament of the atlas.

Sport-Specific Biomechanics

Contact sports, falls, and diving in sports may lead to vertebral stress and fractures. Sports that involving tackling can increase exposure to mechanisms causing fractures.

Clinical

History

• Initially approach every injured athlete with the suspicion of a cervical spine injury. Consider ABCs (ie, airway, breathing, circulation) from the beginning.
• Obtain the history before the physical examination or movement of the patient.
• The mechanism of the injury defines the possible bony injuries, but this may not be possible to elicit, or it may be multifactorial.
• Determine if the athlete has a history of neck injuries, spinal stenosis, spear tackler's spine, or other abnormalities (see Causes, below).
• Ask the athlete if neck pain is present. Determine location and quality of any pain. Ask if the pain radiates distally or to the extremities.
• Determine if the patient is experiencing paresthesias or weakness.
• Determine if other distracting injuries are present.
• Determine if the athlete is impaired by a head injury or the use of a legal or illicit drug.

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Physical

• Address the patient's ABCs while protecting the cervical spine.
• Palpate the neck, and specifically feel for midline bony pain, muscle spasm, step-off, and crepitus.
• Determine if extremity sensation is intact.
• Determine if the athlete can move all extremities without deficits.
• Determine if the athlete can perform range of motion (ROM) in all directions without pain or symptoms. NOTE: Do not perform passive ROM of the neck.
• Determine if head compression elicits pain or symptoms.
• Before performing the Spurling maneuver to determine whether pain or symptoms are elicited, exclude the presence of any bony injury or instability first.
  • The Spurling maneuver is performed by passively forcing the athlete into cervical extension with lateral flexion toward the side of the symptoms. The maneuver reproduces symptoms of recurrent brachial plexus injuries by nerve root compression in the intervertebral foramen.¹⁴ NOTE: This is an office-based examination to be performed after other injuries have been excluded.

Causes

Collision sports are often associated with fractures. The occurrence of fractures increases with poor technique (eg, improper tackling techniques), poor conditioning, and substandard equipment. Previous injury may also predispose the athlete to new injury. The mechanism of injury determines the type of bony injury, and, historically, cervical spine fractures have been categorized by the mechanism of injury.^8,12,15,16

• Flexion injuries
  • Simple wedge fracture
    • Fracture of the anterosuperior end plate of the vertebral body
    • Associated with posterior ligament disruption, which makes the injury unstable
    • Differs from a burst fracture because no vertical element to the fracture is present
  • Anterior teardrop fracture
    • Teardrop fracture with an anteroinferior vertebral body fragment
    • Unstable fracture associated with complete disruption of ligaments
    • Associated with anterior cord syndrome
  • Clay shoveler's fracture
    • Avulsion of spinous process of the lower cervical vertebrae, usually C7
    • Stable fracture
  • Atlantooccipital and atlantoaxial dislocation with fracture
    • High instability
    • High mortality
  • Bilateral facet dislocation with fracture
• Flexion with rotation injuries – Unilateral facet dislocation with fracture (The dislocation alone is stable. The fracture may occur at the base of the superior articular mass of the inferior cervical vertebrae, or the fracture may occur at the base of the inferior mass of the superior dislocated vertebrae.)
• Extension with rotation injuries
  • Pillar fracture
    • Vertical or oblique fracture of the articular mass
    • Stable fracture
  • Pediculolaminar fracture
    • Variety of severities
    • Associated ligamentous injuries
• Extension injuries
  • Anterior arch of the atlas (avulsion fracture) – Unstable fracture
  • Posterior arch of the atlas fracture
    • Compression between the axis and occiput
    • High association with other fractures
  • Hangman's fracture
    • C2 pedicles with anterior displacement
    • Common in diving accidents
    • NOTE: The patient may be without neurologic deficit, but this is an unstable fracture
  • Laminar fracture
    • Subtle fracture associated with spinous process fractures
    • Stable fracture
  • Extension teardrop fracture
    • Anteroinferior vertebral body fracture from an avulsion by the anterior longitudinal ligament
    • Most common at C2
    • Unstable fracture
• Lateral flexion injuries – Uncinate process fracture, resulting in transverse fracture of the base of the uncinate process by the superior vertebral body
• Compression injuries
  • Jefferson fracture
    • The occipital condyles are driven into C1, forcing the lateral masses apart.
    • Often associated with rupture of the transverse ligament
    • Unstable fracture
  • Burst fracture
    • Axial lode causes the vertebral body to burst.
    • Involves both end plates and may intrude into the spinal canal
    • Unstable fracture
  •  Spear tackler's spine
    • Associated with use of the head as the initial contact in football
    • Over time, athletes develop cervical stenosis, posttraumatic changes, and loss of cervical lordosis.
    • Traumatic axial compression can cause compression of the anterior column, followed by flexion, resulting in a fracture.
• Other injuries
  • Odontoid fracture
    • Associated with other cervical fractures
    • Type I – At the tip superiorly. The transverse ligament remains intact, and the fracture is stable.
    • Type II – At the junction of the odontoid and the body. This is the most common type of odontoid fracture.
    • Type III – Through the superior portion of C2 at the base of the odontoid

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