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9. Cervical Fractures: Who Did Jefferson Bite?
Case
Neck Pain After Trauma
Pertinent History
A 42-year-old female presents to the emergency department after a fall with neck pain. She reports that she was drinking alcohol the night prior, fell down from standing in the bathroom, and woke up with a throbbing headache and pain in the neck. Her pain is worsened with movement and has made it difficult to move around her house or complete her normal activities of daily living today.
Pertinent Physical Exam
Blood pressure 161/99 mm Hg, pulse 105 beats per minute, temperature 97 °F (36.1 °C), temperature source Oral, resp. rate 20 breathes per minute, height, SpO2 99%.
Head: Normocephalic, atraumatic
Eyes: Conjunctivae normal, extraocular muscles intact with full range of motion without pain
Neck: Tenderness in the superior midline cervical spine. Increased pain with range of motion
Neuro: Cranial nerves 2–12 intact, strength normal in bilateral upper and lower extremities, sensation intact to light touch throughout.
PMH
No pertinent past medical history.
SH
Current every-day smoker, drinks vodka approximately 3 times a week until she is “drunk,” has thought about stopping alcohol consumption before and would like to quit.
FH
No pertinent past family history.
Pertinent Test Results
- 1.
3 mm anterior subluxation of C2 on C3 with 15 degrees of forward tilt of C2
- 2.
Asymmetric widening of the atlanto-axial junction
- 3.
No visualized fracture, CT imaging recommended
- 1.
Mildly displaced fracture involving the right lateral mass and bilateral transverse processes/pars interarticularis of C2 with grade 1 anterolisthesis of C2 on C3. These findings are consistent with hangman’s type fracture.
- 2.
Comminuted fracture of the transverse process, articular process, and lamina of C3. There is perched facet on the left contributing to a rotatory component.
- 3.
Small fracture involving the anterior aspect of the transverse process and the superior aspect of the left articular process of C4. Vascular injury not excluded.
- 1.
Cervical fractures as described in CT
- 2.
No evidence of cord compression, contusion, or hemorrhage
- 3.
Disruption of the anterior longitudinal ligament at C2–C3 with 3 mm of anterolisthesis of C2 on C3. Posterior ligamentous injury at C1–C2.
- 4.
Left vertebral artery occlusion
ED Management
On initial physical exam, the patient was identified to have midline cervical pain, approximately 12 hours after what was believed to be a fall from standing in her bathroom. She did not completely remember the event as she was significantly intoxicated at the time. As she had been ambulatory, was thought to have a low-risk mechanism, and had no neuro-deficits; plain films of her neck were obtained. On plain radiographs, no fractures were identified, but there was anterior subluxation of C2 on C3 with anterior tilt of C2, which is concerning for a nonvisualized hangman’s fracture.
The patient was then placed in a cervical collar. As there was no spinal surgery available at the hospital, she was transferred to a tertiary care center while maintaining cervical spine immobilization.
Updates on ED Course
At the tertiary care center, a CT scan of the cervical spine was obtained, which confirmed a type 2 hangman’s fracture and also identified multiple high cervical transverse process fractures. Neurosurgery was consulted, recommending an MRI and MRA. The patient was admitted to the neurosurgical service for considerations of internal immobilization versus halo immobilization.
Learning Points
Priming Questions
- 1.
What is the appropriate screening tool for traumatic neck pain?
- 2.
When should you obtain plain films vs CT for traumatic neck pain?
Introduction/Background
- 1.
Cervical spinal fractures and dislocations rarely present to the emergency department. However, providers must remain always vigilant for cervical spine injuries as misdiagnosis can have grave consequences of progressive neurologic deficit and death. Of the millions of patients who present with potential cervical spine trauma, in stable alert patients, less than 1% will have sustained a cervical spine injury [1, 2]. Rates are likely higher in patients with associated head trauma and in unconscious patients.
- 2.
As with most traumatic injuries, there is a bimodal age distribution, with a peak in young adults between ages 15 and 29 when individuals are more likely to engage in riskier behaviors, and then again in adults over the age of 65 when they have other risk factors for cervical injury [3].
- 3.
Blunt cervical spine injury generally requires a high-force mechanism, such as a motor vehicle accident or fall from a great height. However, patients can certainly sustain these injuries from more benign mechanisms such as a fall from standing [4].
Physiology/Pathophysiology
- 1.
The cervical spine consists of seven vertebrae. C1 (atlas) is the most superior, and with C2 (axis) forms the joint connecting the spine to the skull base. C1 lacks a full vertebral body, and instead this piece is fused to C2 to form the odontoid process. This allows for the rotation of the atlas on the axis. Also of importance, the vertebral artery travels through the transverse foramen of the cervical vertebrae.
Image courtesy of wiki commons – user:debivort (https://commons.wikimedia.org/wiki/File:Cervical_vertebra_english.png), “Cervical vertebra english”, https://creativecommons.org/licenses/by-sa/3.0/legalcode
- 2.
Most commonly, a cervical spine fracture occurs following blunt trauma. In rare cases, patients could experience a pathologic fracture such as with malignant bony metastasis [5]. The most common mechanism of injury is motor vehicle collision.
- 3.
The stability of cervical fractures is perhaps best understood by dividing the cervical vertebrae into two columns. The anterior column includes the vertebral body, the intervertebral disk space, the anterior and posterior longitudinal ligaments, and the disk annulus. The posterior column includes the spinal canal, pedicles, and articulating facets, and the posterior ligament complex, among other structures. In general, if both of these columns are affected, the injury is considered unstable and at high risk for spinal injury. Below are some of the classically described cervical spine fractures that should be recognized. While these are generally considered unstable, there are some exceptions such as Type 1 Jefferson and Odontoid fractures.
C1 – Atlas fracture, also known as a Jefferson’s Fracture. These fractures are more common in the elderly population. Rates and cost of care for atlas fractures are increasing [6].
Type I is isolated to the anterior or posterior arch.
Type II is a burst fracture with bilateral fractures of anterior and posterior arches.
Type III is a unilateral lateral mass fracture.
C2 – Odontoid fracture. Most frequent fracture location in older adults.
Type I odontoid fractures involve avulsion of the tip of the odontoid. There may be associated atlanto-occipital instability.
Type II fractures occur through the waist of the odontoid. This is the most common fracture pattern in older adults.
Type III fractures extend into the body of C2.
A Hangman’s fracture is a traumatic anterior spondylolisthesis with a fracture dislocation of C2 on C3. These fractures are associated with a high-energy mechanism, making them more common in a younger population. They occur from a forceful extension of the neck with rapid deceleration. The name comes from the association with judicial hangings when the knot was placed under the chin in order to cause forceful extension. This is a helpful mechanism to remember as the same mechanics can occur when a patient falls and strikes their chin on a stationary surface or when an unrestrained driver hits their chin on the steering wheel.
Type I – axial loading and hyperextension – minimally displaced. Typically nonoperative.
Type II – Hyperextension with rebound flexion, disruption of C2–C3 disk.
Type IIA – Severe flexion of body fragment with minimal fracture displacement.
Type III – flexion/rebound extension with facet joint dislocations. Least common.
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