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Cervical spine injuries can result from one or a combination of following mechanism of injury

• Axial loading

• Flexion

• Extension

• Lateral bending

• Distraction

ATLAS FRACTURE

• Atlas is a thin, bony ring with broad articular surfaces.

• Fractures of the Atlas represent approximately 5% of acute cervical spine fracture.

• Approximately 40% of atlas fractures are associated with fractures of the axis (C2)

• Most common C1 fracture is burst fracture : Jefferson Fracture.

• Jefferson's fracture is usually produced when the cervical spine is subjected to an axial load.

• The occipital condyles are forced downward and produce a burst fracture by driving the lateral masses of C1 apart.

• Fracture is best seen with open mouth view of C1-C2 region or CT.

• These fractures are unstable and should be treated with cervical collar.

AXIS FRACTURE

• Axis is the largest cervical vertebra and most unusual in shape. Therefore it is susceptible to various fracture.

Odontoid Fracture

• Approximately 60% of C2 fractures involve the odontoid process, a peg shaped bony protuberance that projects upwards and is normally positioned in contact with the anterior arch of C1.

• The odontoid process is held in place primarily by the transverse ligament.

• They are identified with lateral view or open mouth odontoid view.

• There are three types

  • Type I : They typically involve the tip of the odontoid and are relatively uncommon.

  • Type II : Fractures occur through the base of the dens and are the most common odontoid fracture.

  • Type III : Fractures occur at the base of the dens and extend obliquely into the body of the axis.



Hangman's fracture : Fracture at the pedicle of C2

Hangman's Fracture

• The hangman's fracture describes a fracture of both pedicles of C2,leading to displacement of body of C2 anteriorly on C3.

• The fracture is usually caused by extension type injury.

• Suicidal hanging do not usually cause the extreme hyperextension seen in judicial hanging and are not associated with the hangman's fracture.

Flexion Teardrop Fracture

• Extreme flexion can produce flexion tear drop fracture characterized by “tear drop” the anterioinferior portion of the vertebral body is separated and displaced.

• It is a unstable injury and is associated with anterior cord syndrome.

Extension Teardrop Fractures

• Hyperextension may cause the anterior longitudinal ligament to avulse a fragment off anterioinferior corner of the vertebral body.

Clay- Shoveler's Fractures

• Avulsion of the lower cervical spinous processes, classically C7 is known as a clay shoveler's fracture. Isolated fractures are mechanically stable.

ATLANTO- OCCIPITAL DISLOCATION

• Crainiocervical disruption is quiet uncommon and result from severe traumatic flexion and distraction.

• Most of the patients with this injury die of brainstem destruction and apnea or have profound neurologic impairment.

• Atlanto occipital dislocation may be identified in upto 19% of patients with fatal cervical spine injuries and is a common cause of death in cases of shaken bay syndrome in which the infant dies Immediately after shaking.

• Detection of atlanto-occipital dislocation is challenging.

• Powers ratio :

  • Power's ratio is >1 in atlanto-occipital dislocation.

  • Powers ratio = BC/OA; Where BC is the distance between basion and posterior arch of C1 & OA is the distance between opisthion and anterior arch of C1.

• Wackenheim's line drawn along the clivus, doesnot intersect the dens on a normal lateral cervical spine radiograph.

How to asses C-Spine X-ray ???

1. Identify the presence of all 7 cervical vertebrae and superior aspect of T1.

2. Identify the

   1. Anterior vertebral line

   2. Anterior spinal lime

   3. Posterior spinal line

   4. Spinous process

3. Asses the bone

   1. Examine all vertebrae for preservation of the height and integrity of the bony cortex.

   2. Examine facets

   3. Examine spinous process

4. Asses the cartilage, including cartilaginous disk space for narrowing or widening

5. Asses the dens

   1. Examine the outline of the dens

   2. Examine the predental space (3mm)

   3. Examine the clivus; it should point to the dens

6. Asses extra axial soft tissue

   1. Examine the extraaxial space and soft tissue : 7 mm at C3 ; 3cm at C7

   2. Examine the distance between the spinous process.

MANAGEMENT

Updated on 8/10/2014

• ATLS

• Tintinalli