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. Include the following in the history:
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The mechanism of the injury defines the possible bony injuries, but this may not be possible to elicit, or it may be multifactorial.
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Determine if the athlete has a history of neck injuries, spinal stenosis, spear tackler's spine, or other abnormalities (see Causes, below).
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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.
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Determine if the patient is experiencing paresthesias or weakness.
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Determine if other distracting injuries are present.
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Determine if the athlete is impaired by a head injury or the use of a legal or illicit drug.
Physical Examination
Address the patient's ABCs (airway, breathing, and circulation) 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. [17] 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, 18, 19]
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Flexion injuries
Simple wedge fracture (see the image below)
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 (see the image below)
Avulsion of spinous process of the lower cervical vertebrae, usually C7
Stable fracture
Atlantooccipital and atlantoaxial dislocation with fracture (see the image below)
High instability
High mortality
Bilateral facet dislocation with fracture (see the image below)
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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.)
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Extension with rotation injuries
Pillar fracture
Vertical or oblique fracture of the articular mass
Stable fracture
Pediculolaminar fracture
Variety of severities
Associated ligamentous injuries
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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 (see the image below)
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 (see the image below)
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
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Lateral flexion injuries – Uncinate process fracture, resulting in transverse fracture of the base of the uncinate process by the superior vertebral body
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Compression injuries
Jefferson fracture (see the image below)
The occipital condyles are driven into C1, forcing the lateral masses apart.
Often associated with rupture of the transverse ligament
Unstable fracture
Burst fracture (see the image below)
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.
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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. See the image below.
Type III – Through the superior portion of C2 at the base of the odontoid. See the images below.
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Anteroposterior view of atlantooccipital dislocation.
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Odontoid view of a Jefferson fracture.
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Lateral view of a C2 fracture dislocation.
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Odontoid type 2 fracture.
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Lateral view of type 3 odontoid fracture.
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Computed tomography scans of odontoid type 3 fracture.
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Lateral view of a C3 spinous fracture.
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Lateral view of hangman's fracture.
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C3 flexion fracture.
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C4 burst fracture.
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Clay shoveler's fracture.
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Unilateral locked facets on C5 and C6.
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Bilateral facet fracture/dislocation at C6/C7.
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Child with C6 flexion wedge fracture.
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C7 lamina fracture.
