29/08/2011

Introduc)on
Approximately 3 % of pa7ents with motor vehicle accident or
fall have a major injury to the cervical spine.
10-20% pa7ents with head injury also have a cervical spine
Cervical Spine Injuries injury.
Up to 17% of pa7ents have a missed or delayed diagnosis of
cervical spine injury, with a risk of permanent neurologic
Mr Adeel Memon decit aIer missed injury of 29%.
Orthopaedic tutor Most cervical spine fractures occur predominantly at two
Waterford Regional-RCSI
2011 levels.
One third of injuries occur at the level of C2, and one half of
injuries occur at the level of C6 or C7.

Injury PaPerns
Flexion injuries Flexion injuries
Anterior subluxa7on
Extension injuries
Simple wedge fracture
Axial compression injuries Unstable wedge fracture
Unilateral interfacet disloca7on
Bilateral interfacet disloca7on
Flexion teardrop fracture
Anterior atlantoaxial disloca7on

Extension injuries Axial compression injuries

Hangman's fracture Jeerson fracture is a burst

Trauma7c spondylolisthesis of fracture of the ring of C1 with
C2. lateral displacement of both
Extension teardrop fracture ar7cular masses .
Hyperextension in preexis)ng Burst fracture at lower cervical
spondylosis level
'Open mouth fracture'.

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Unilateral interfacet disloca)on 20 year old male who had a rollover

motor vehicle accident
Unilateral interfacet disloca7on is due
to a hyperexion injury with rota7on.
The superior facet on one side slides
over the inferior facet and becomes
locked.
This results in an anterior subluxa7on of
the upper vertebral body of about 25%
of the AP diameter of the body.
Simple unilateral facet disloca7on is a
stable injury.
30% of pa7ents have an associated
neurologic defect.
MRI plays an important role in the
diagnosis in order to see if there is disc
extrusion leading to cord compression.

The CT conrms the unilateral disloca7on.

The contralateral facetjoint is only distracted.

Widening of C4-5 interspinous space

Subluxa7on of C4-5 with about 25%
transla7on (i.e. anteroposi7on of 25%
of the AP diameter of the vertebral
body)
Malalignment of the spinous processes
as seen on the AP-view, which can only
be produced by a rotatory injury. The
involved spinous process points to the
involved side
Due to the rota7on the spinous
processes of C4 and C5 seem shorter on
the lateral view

Bilateral Interfacetal Disloca)on

(BID)
Spinal cord injury BID is the result of extreme
Rupture of the spinous hyperexion.
ligaments. Anterior disloca7on of the ar7cular
Rupture of the ligamentum masses with disrup7on of the
avum. posterior ligament complex,
Rupture of the disc with posterior longitudinal ligament,
the disc and usually also the
migra7on of disc material
anterior longitudinal ligament.
on the posterior side of C4
and even on the anterior In a complete disloca7on, the
side of C5. dislocated vertebra is anteriorly
displaced one-half of the AP
diameter of the vertebral body.
BID is unstable and is associated
with a high incidence of cord
damage.

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Bilateral interfacetal CT-images conrm the

disloca7on. bilateral disloca7on.
50% anteroposi7on C5C6 as a
result of the disloca7on. Near one of the facets there is
In unilateral disloca7on the a small eck of bone, but
anteroposi7on is usually only there is no major fracture, so
25%. this is basically just a
Widened space between hyperexion soI 7ssue injury.
spinous processes C5 and C6
due to ligament rupture.
Ruptured disc space.

Flexion tear drop fracture

The MRI-ndings: Fracture of the body
SoI 7ssue swelling of C5 with a small
anteriorly fragment anteriorly
Disrup7on of the Fracture of the
disc spinous processus of
Non-hemorrhagic C4
cord injury Acute angula7on at
the level of C5C6
with displacement of
C5 in posterior
direc7on

Abnormal posi7oning of SoI 7ssue injuries

some of the facet joints due anteriorly and
to distrac7on but no
disloca7on
posteriorly with
Addi7onal fracture of the
avum and
body of C4 interspinous
The ver7cal orienta7on of ligament rupture
the fractures of the bodies of and CSF leakage.
C4 and C5 indicate that there Hemorrhagic spinal
was severe axial loading.
cord injury
Vertebral bodies 'exploded'
with propulsion of a bone
fragment anteriorly
(teardrop) and the larger
part posteriorly against the
spinal cord

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Hangman' s fracture Hangman' s fracture

Classica)on:
Most common cervical spine fracture Type I (65%)
4-7% of all cervical fractures/disloca7ons hair-line fracture
C2-3 disc normal
Classically it is an extension-fracture Type II (28%)
displaced C2
Trauma7c Spondylolisthesis af Axis disrupted C2-3 disc
ligamentous rupture with
Bilateral fracture of pars inter ar7cularis or instability
C3 anterosuperior
isthmus and/or adjacent ar7cular process compression fracture
Type III (7%)
Spinal cord injury is rare displaced C2
C2-3 Bilateral interfacet
High rate of neurological complica7ons if disloca7on
Severe instability
associated with facet disloca7on at C2

Subtle lucent line at the back of the corpus of Fracture line runs through the pars
C2 as seen on the lateral view (arrow). interar7cularis of C2 resul7ng in a trauma7c Hangmans fracture Type I (hair-line fracture and with no
Subtle discon7nuity of the arch of C2 spondylolysis
displacement)

Jeerson fracture Odontoid fracture

Caused by a compressive Commonly seen in elderly
downward force from or children
occipital condyles to the Type I
superior ar7cular surfaces Avulsion of the 7p of the dens
of the lateral masses of C1.
Type II
Fractures of the anterior Fracture through the base of
and posterior arches, and the dens (most common)
possible disrup7on of the High non union rate (upto
transverse ligament. 64%)
Radiographically: bilateral Type III
lateral displacement of the Fracture through body of Axis
ar7cular masses of C1 +/- facets

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Type II odontoid peg fractures NEXUS criteria

The NEXUS criteria state that a pa7ent with suspected
c-spine injury can be cleared providing the following:
No posterior midline cervical spine tenderness is
present.
No evidence of intoxica7on is present.
The pa7ent has a normal level of alertness.
No focal neurologic decit is present.
The pa7ent does not have a painful distrac7ng injury