eMedicine Specialties > Sports Medicine > Spine

Cervical Spine Acute Bony Injuries

George L Hertner, MD, Consulting Staff, Department of Emergency Medicine, Memorial Hospital of Colorado Springs
Nathaniel Johnson Stewart Jr, MD, FACEP, Director for Education and Professional Services, Chief, Department of Emergency Medicine, Palmetto Richland Memorial Hospital

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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Cervical Disc Disease
Cervical Spine Injuries in Sports

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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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Specialty Site Public Health & Prevention

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

Differential Diagnoses

Other Problems to Be Considered

Burner injury
Cervical dislocations
Cervical ligamentous laxity
Neurapraxia
Spear tackler's spine
Stinger injury

Workup

Laboratory Studies

Laboratory studies are not typically useful in the diagnosis of cervical spine injuries.

Imaging Studies

• Plain radiography
  • Obtain plain radiographs when cervical injury is suspected. Two large studies looked at when radiographs should be obtained. The criteria for radiography differ, and some controversy remains regarding which system is better.^17,18,19
  • According to the National Emergency X-Radiography Utilization Study (NEXUS) study criteria, the patient must exhibit the following criteria in order for the mechanism and dynamics of injury to be considered low risk, and, if any of the below criteria are present, radiographs should be obtained²⁰ :
    • No posterior midline cervical spine tenderness
    • No evidence of intoxication
    • Normal level of alertness
    • No focal neurologic deficit
    • No painful distracting injuries
  • The Canadian C-Spine Rule (CCR) uses more criteria to determine who should undergo radiographs^18,21,22 :
    • Primary criteria – First, take the following into consideration: (1) patient age older than 65 years, (2) mechanism of injury considered dangerous, and (3) numbness or tingling present in the extremities. A dangerous mechanism of injury would be, for example, a fall from an elevation of 3 feet or higher, a bicycle collision, an axial load to the head (eg, resulting from a dive into an empty swimming pool), or a motor vehicle collision involving high speed, rollover, or ejection. If any of these high-risk factors is present, then the patient is at risk for having a cervical spine injury and neck radiography should be performed.
    • Additional criteria: If the patient does not meet any of the above criteria, then the question becomes whether the patient is voluntarily able to actively rotate the neck 45° in each direction. NOTE: Before any neck rotation test is performed, at least one of the following low-risk factors must be present: (1) simple rear-end motor vehicle collision, (2) patient ambulatory at any time since injury, (3) delayed onset of neck pain, (4) patient in sitting position in emergency department, or (5) absence of midline cervical spine tenderness. If none of these criteria is met, radiography should be preformed.
    • Finally, if the athlete is unable to voluntarily rotate to 45° in each direction, radiography should be preformed.
  • The standard radiographs obtained in a cervical spine series vary slightly by facility. Usefulness of some views in routine radiographic screening has been debated. A large patient study indicated that standard 3-view imaging is reliable for screening trauma patients.²³
    • The 3-view series includes cross-table lateral, anteroposterior, and open-mouth odontoid views. Additional radiographic views include oblique views, odontoid tip shots, swimmer's view, and flexion/extension views.^24,25,26
• Computed tomography (CT) scanning
  • Perform CT scanning after plain radiography to further evaluate abnormalities.²⁷ CT scanning is also useful in the evaluation of areas that are difficult to evaluate or see in plain radiographs, such as the lower cervical spine in very large individuals secondary to body habitus.
  • CT scanning provides much greater visualization of fractures and the capability to form 3-dimensional (3-D) reconstructions of the vertebrae, which may be helpful preoperatively.
  • CT scanning is becoming more commonly used in unconscious patients and for those with abnormal plain radiographs. In some institutions, this imaging modality has replaced plain radiographs in many situations.
• Magnetic resonance imaging (MRI)
  • MRI serves best in evaluating the soft structures of the spinal column.
  • MRI is helpful in the evaluation of ligamentous injuries and neural tissue.
  • MRI is helpful in the evaluation of spinal stenosis.
  • MRI assessments after spinal cord injury correlate with patient neurologic status and are predictive of outcome at long-term follow-up.²⁸
• Bone scanning: Bone scanning may be of assistance in the evaluation of stress fractures, infections, and tumors.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Treat the site of injury with spinal precautions, and address the ABCs. Immobilize the athlete's neck in neutral position with a cervical collar, towel rolls, or whatever is available. Immobilize the spinal column on a backboard, with the head secured such that the entire column is in neutral position and can be moved en bloc. Transport the athlete to a facility with the ability to stabilize the athlete and to radiographically evaluate the neck.^4,9,12

If a fracture is detected, immediately consult a spinal orthopedic surgeon or neurosurgeon. The consultant should make the recommendations regarding the further stabilization of the fracture if needed. This may include Gardner-Wells tongs, surgical intervention, halo immobilization, a cervical collar, or no intervention. The consultant should be a part of all further decisions regarding rehabilitation, return to play, and long-term prognosis.

The patient should rest and remain immobilized, as directed by the consultant. Some patients with very stable fractures may be able to enter an early strengthening and exercise program.^12,29

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Occupational Therapy

Early occupational therapy may help increase function in those with neurologic deficits.

Medical Issues/Complications

• The cervical spine must always be considered injured until proven otherwise by history and physical or radiologic evaluation.
• Establishing the ABCs and searching for other injuries are priorities.
• Early consultation of a spinal expert is mandatory for patients with fractures.

Surgical Intervention

Surgery may very well be necessary, especially in cases of unstable fractures. The consulting surgeon determines whether surgical intervention is necessary.

Consultations

Consult an orthopedic surgeon or neurosurgeon. Other consultants may be contacted, as determined by the patient's injuries. Early psychologic counseling may also be warranted because these injuries may be devastating to the athlete.

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Other Treatment

• Do not remove helmets and shoulder pads on the field if the athlete has a potential unstable cervical injury or if the patient is unconscious. Remove the face guard with a screwdriver or cutters. Athletes with respiratory compromise should be intubated with the helmet on.^2,30
• Transport the athlete with helmet and pads in place. The chinstrap should remain attached if possible. No cervical collar should be placed, but the athlete and helmet should be secured to a backboard.
• Unless the patient can be clinically cleared, obtain plain radiographs while the protective gear is in place. If the radiographs are inadequate, consider CT scanning with the helmet and pads in place. Caution: The helmet and shoulder pads should be removed by individuals who are trained and qualified in their removal.³¹

Recovery Phase

Rehabilitation Program

Physical Therapy

Treatment is determined by the patient's injuries. An exercise and strengthening program may be initiated, as well as a maintenance program for uninvolved areas. At this time, all involved physicians should discuss the type of sports and activities that the athlete will be able to participate in. If a change in sports or activity is needed, plans to encourage the athlete should begin.

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Occupational Therapy

Occupational therapy is initiated as determined by the injury and neurologic involvement.

Medical Issues/Complications

• Monitor the athlete for signs of depression.
• If the athlete is immobilized, monitor for problems such as skin breakdown or deep venous thrombosis (DVT).

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Surgical Intervention

The consulting surgeon addresses any potential surgical intervention issues (eg, delayed surgical repair, revisions).

Maintenance Phase

Rehabilitation Program

Physical Therapy

Treatment is determined by the patient's injuries. Continue exercise and strengthening program, as well as the maintenance program for uninvolved areas. Continue to evaluate the type of sports and level of activity that the athlete will be able to participate in. If a change in sports or activity is needed, plans to encourage the athlete should begin.

Occupational Therapy

Occupational therapy is initiated as determined by the patient's injury and neurologic involvement.

Medical Issues/Complications

• Monitor the athlete for signs of depression.
• If the athlete is immobilized, monitor for potential problems such as skin breakdown or DVT.

Surgical Intervention

The consulting surgeon addresses any potential surgical intervention issues (eg, delayed surgical repair, revisions).

Medication

As with all fractures, pain management should be a primary concern. Often acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) is prescribed for the acute pain of a fracture. However, additional pain relief may be indicated if the patient does not have relief with acetaminophen or NSAIDs alone. In this case, an opiate may be required, particularly for breakthrough pain. Adjustment of pain medications may be necessary, especially in the acute phase.

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Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained injuries.

Acetaminophen (Tylenol, Feverall, Tempera, Aspirin Free Anacin, Tylenol-3)

Indicated for mild to moderate pain. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d

>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Interactions

Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.

Contraindications

Documented hypersensitivity; known G6PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed the recommended maximum dose.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

400-600 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established

6 months to 12 years: 4-10 mg/kg/dose PO tid/qid

>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy

Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR, Tylox, Roxiprin)

Indicated for moderate to severe pain.

Dosing

Adult

5-30 mg PO q4h prn

Pediatric

0.05-0.15 mg/kg/dose; not to exceed 5 mg/dose of q4-6h PO prn

Interactions

Phenothiazines may decrease the analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly patients; be aware of the total daily dose of acetaminophen the patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity; high association of abuse and addiction with OxyContin

Hydrocodone and acetaminophen (Vicodin, Margesic, Lortab, Norcet, Lorcet-HD)

Indicated for moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn pain

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen

>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg/dose hydrocodone bitartrate or 5 doses/24 h

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; high-altitude cerebral edema (HACE); elevated intracranial pressure (ICP)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction

Codeine

Indicated for moderate to severe pain. Binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering perception and response to pain.

Dosing

Adult

10-20 mg/dose PO q4-6h prn for cough; not to exceed 120 mg/d

Pediatric

<2 years: Not established

2-6 years: Not to exceed 30 mg/d

6-12 years: Not to exceed 60 mg/d

Interactions

Toxicity increases with concurrent administration of tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics

Contraindications

Documented hypersensitivity; HACE diagnosis; elevated ICP

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Use to treat cough in patients diagnosed with HACE only if absolutely necessary; may depress hypoxic ventilatory rate and respiratory drive during sleep

Corticosteroids

Corticosteroid agents have anti-inflammatory properties that may be protective in acute spinal cord injuries with neurologic deficits.

Methylprednisolone (Solu-Medrol, Depo-Medrol)

Decrease inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Indicated for known or suspected spinal cord injury. To be administered within 8 h of injury.

Dosing

Adult

30 mg/kg IV as a bolus; followed by continuous IV drip 5.4 mg/kg q1h for 1 d

Pediatric

Administer as in adults

Interactions

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase the levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease the levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when they are taking medication concurrently with diuretics.

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use.

Follow-up

Return to Play

The absolute decision of when to return to play after a cervical spine fracture is dependent on the injury.^12,16,29 The consulting surgeon should play a large role in determining what type of activity can be performed and when it may begin. Failure to respect the severity of an injury may place the athlete in a position for further injury and possible disability. An athlete with persistent pain or neurologic symptoms certainly should be held from play. This may be frustrating to an athlete. An athlete does not want to be needlessly held from play, but proper evaluation and stabilization is paramount. Various sources indicating contraindications for play are available.

• Absolute contraindications for contact and high-risk sports include the following:
  • Neurologic symptoms or deficits
  • Loss of ROM or pain with ROM
  • Acute cervical fracture
  • Spear tackler's spine
  • Atlantoaxial instability, with or without fracture
  • Atlantooccipital instability, with or without fracture
  • Limited ROM
  • Ligamentous laxity
  • Vertebral body fracture with a sagittal segment
  • Anterior teardrop fracture
  • Fusion of 3 or more vertebrae
  • Healed fractures with associated neurologic symptoms
  • Fracture with canal involvement
  • Odontoid fracture
• Relative contraindications for contact and high-risk sports include the following:
  • Developmental canal stenosis with history of symptoms
  • Healed, nondisplaced Jefferson fracture
  • Stable 2-level surgical fusion
  • Healed, stable, mildly displaced body fracture without neural ring or sagittal components
  • Healed stable neural ring fractures
• Indicators that the patient is safe for participation (when asymptomatic with normal findings and pain-free examination) include the following:
  • Developmental canal stenosis
  • Healed stable compression fracture of body
  • Healed spinous process fracture (clay-shoveler's fracture)
  • Stable, one-level surgical fusion
  • Healed, stable end-plate fracture

Complications

An extensive list of complications to cervical fractures exists. Neurologic impairment is the most obvious and severe. The neurologic complications may range from paresthesias to complete loss of function. Cervical spinal cord injuries can be devastating because they may involve respiratory function and death. Spinal shock is also challenging to care for in the initial phase of injury. Long-term complications are related to immobilization and loss of function. These complications include skin breakdown, infections, loss of muscle mass, depression, and increased risk of suicide. Halo immobilization is associated with pin-site infections and osteomyelitis. Long-term collar immobilization is associated with skin breakdown.

Prevention

Athletes, especially those in contact sports, should participate in neck-strengthening exercises. Encourage education on proper technique and coaching. Rules of play to avoid tackling while leading with the head should be enforced. Additional education for the public should be supported. This should include prevention of diving injuries from shallow pools and natural water sources and avoidance of drinking alcohol while swimming. After the occurence of a cervical fracture, a change of sports or activity modification may be needed to prevent reinjury. Proper rehabilitation may also be necessary.

Prognosis

The prognosis for the athlete is completely dependent on the type and extent of his or her injuries as well as associated problems.

Education

A strong educational program should be included in all sports, especially contact and high-risk sports. Proper tackling must be taught from the beginning. A community education program should also be encouraged to prevent unsupervised sports injuries. Water and pool safety must be widely encouraged, including emphasis on feet-first water entry and avoidance of chemical impairment while engaging in water sports.

Everyone exposed to athletes (eg, physicians, coaches, trainers, referees, parents) should aid in providing this education. The rules of play for sports should reflect an effort to prevent injury and promote safe play. Paramedics and hospital personnel should be educated in proper care of a patient wearing equipment such as helmets and pads.

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Miscellaneous

Medicolegal Pitfalls

• Failure to recognize spinal injuries is a significant medicolegal pitfall.
• Failure to recognize spinal injuries is the source of a copious amount of litigation and, many times, results in the loss of suits.

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Multimedia

Media file 1: Anteroposterior view of atlantooccipital dislocation.

Media file 2: Odontoid view of a Jefferson fracture.

Media file 3: Lateral view of a C2 fracture dislocation.

Media file 4: Odontoid type 2 fracture.

Media file 5: Lateral view of type 3 odontoid fracture.

Media file 6: Computed tomography scans of odontoid type 3 fracture.

Media file 7: Lateral view of a C3 spinous fracture.

Media file 8: Lateral view of hangman's fracture.

Media file 9: C3 flexion fracture.

Media file 10: C4 burst fracture.

Media file 11: Clay shoveler's fracture.

Media file 12: Unilateral locked facets on C5 and C6.

Media file 13: Bilateral facet fracture/dislocation at C6/C7.

Media file 14: Child with C6 flexion wedge fracture.

Media file 15: C7 lamina fracture.

References

1. Langer PR, Fadale PD, Palumbo MA. Catastrophic neck injuries in the collision sport athlete. Sports Med Arthrosc. Mar 2008;16(1):7-15. [Medline].

2. Bell K. On-field issues of the C-spine-injured helmeted athlete. Curr Sports Med Rep. Jan 2007;6(1):32-5. [Medline].

3. Dec KL, Cole SL, Dec SL. Screening for catastrophic neck injuries in sports. Curr Sports Med Rep. Jan 2007;6(1):16-9. [Medline].

4. Bailes JE, Petschauer M, Guskiewicz KM, Marano G. Management of cervical spine injuries in athletes. J Athl Train. Jan-Mar 2007;42(1):126-34. [Medline]. [Full Text].

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Keywords

cervical spine fracture, C-spine trauma / injury, spinal injury, spinal trauma, neck fracture, neck injury

Contributor Information and Disclosures

Author

George L Hertner, MD, Consulting Staff, Department of Emergency Medicine, Memorial Hospital of Colorado Springs
George L Hertner, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Colorado Medical Society, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Nathaniel Johnson Stewart Jr, MD, FACEP, Director for Education and Professional Services, Chief, Department of Emergency Medicine, Palmetto Richland Memorial Hospital
Nathaniel Johnson Stewart Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of California at Davis; Director of Amputee Clinic, Chief of Orthopedic Trauma, Kaiser Hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author coauthor Mark Leski, MD, to the development and writing of this article.

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