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Cervical Spine Injuries 

The cervical spinal column is extremely vulnerable to injury. Many cervical spine injuries are caused by hyperextension or congenitally narrowed spinal canals whiplash and paralysis.

C1 to C2 and C5 to C7. C2 and C5 are the two most common areas of cervical spine injury. Injuries of the cervical spine produce neurological damage in approximately 40% of patients. Approximately 10% of traumatic cord injuries have no obvious roentgenographic evidence.


Instability may be caused by trauma, neoplastic or infectious disorders, or iatrogenic causes. Instability may be acute or chronic. Acute instability is caused by bone or ligament disruption that places the neural elements in danger of injury with any subsequent loading or deformity. Chronic instability is the result of progressive deformity that may cause neurological deterioration, prevent recovery of injured neural tissue, or cause increasing pain.

In a series of cadaver studies, White and Panjabi systematically cut the various supporting structures and noted the resulting instabilities of the spine. The supporting structures of the lower cervical spine can be divided into two groups: anterior and posterior (Fig. 56-8) (Figure Not Available) . A motion segment is made up of two adjacent vertebrae.

If a motion segment has all the anterior elements and one posterior element intact, or all the posterior elements and one anterior element intact, it will remain stable under physiological loads. White and Panjabi suggest that a motion segment should be considered unstable if all the anterior or posterior elements are not functional. They developed a checklist for the diagnosis of clinical instability of the lower cervical spine (Table 56-6) (Table Not Available) , in which a score of 5 or more.

Roentgenographically, cervical spine instability is indicated by the horizontal translation of one vertebra relative to an adjacent vertebra in excess of 3.5 mm on the lateral flexion-extension view. Instability also is indicated by more than 11 degrees of angulation of one vertebra relative to another.  


The goals of treatment of cervical spine injuries are (1) to realign the spine, (2) to prevent loss of function of undamaged neurological tissue, (3) to improve neurological recovery, (4) to obtain and maintain spinal stability, and (5) to obtain early functional recovery. After initial medical stabilization and documentation of neurological function, spinal alignment.

Nonoperative treatment.

Many cervical spine injuries can be treated without surgery. Immobilization in a rigid cervical orthosis for 8 to 12 weeks may be sufficient. For a stable cervical spine injury with no compression of the neural elements, a rigid cervical brace or halo for 8 to 12 weeks usually produces a stable, painless spine without residual deformity. Stable compression fractures of the vertebral bodies and undisplaced fractures of the laminae, lateral masses, or spinous processes also can be treated with immobilization in a

Halo vest immobilization.

The halo orthosis was first used by Perry and Nickels in 1959 for stabilization after cervical spine fusion in patients with poliomyelitis. Use of the halo vest has expanded considerably since then, and it is used in the treatment of many cervical spine injuries.

Complications of halo immobilization have been reported to occur in as many as 30% of 

Surgical treatment.

Unstable injuries of the cervical spine, with or without neurological deficit, generally require operative treatment. In most patients early open reduction and internal fixation are indicated to obtain stability and allow early functional rehabilitation. Cervical spine fractures may be stabilized through an anterior, a posterior, or a combined approach. This allows rapid mobilization of the patient in a cervical orthosis, and healing usually occurs within 8 to 12 weeks. If the spinal cord or nerve roots have been compressed by retropulsed bone fragments or disc material, anterior decompression, with or without internal fixation, may be indicated to

Stauffer and Kelly, however, reported instability and recurrent deformity after anterior decompression and strut grafting in posteriorly unstable fractures. The addition of anterior internal fixation appears to prevent some of the complications of anterior strut grafting in highly unstable cervical spine injuries. In general, posterior stability should be obtained first, followed by anterior decompression and fusion if indicated. Arena et al. and other authors emphasize the importance of documenting the presence or

Imaging studies such as MRI, myelography, and postmyelogram CT scanning should be performed to determine if a disc is herniated. Iatrogenic neurological injuries have been documented in patients in whom reduction and posterior stabilization were carried out before anterior decompression. These authors recommend discectomy and interbody fusion with anterior internal fixation, followed by posterior stabilization, as

Injuries to upper cervical spine (occiput to C2)
Dislocations of atlantooccipital joint.

Dislocations of the atlantooccipital joint are uncommon. The injury may be either anterior or posterior and usually is fatal. Davis et al., in an extensive study of fatal cranial spinal injuries, demonstrated that many spinal injuries occurred between the occiput and C3. For this injury to occur, the alar and apical ligaments, the tectorial membrane, and the posterior atlantooccipital ligaments must be disrupted. Fractures of the atlantooccipital joint may accompany the dislocation. Although many patients die immediately of complete respiratory arrest caused by

Atlas fractures.

Jefferson first described burst fractures of the atlas in 1920, attributing the fracture to axial loading to the top of the head. Levine and Edwards, in a review of 144 patients with 163 injuries of the C1-2 complex, found that 53% of patients with fractures of the atlas also had other cervical spinal fractures, most commonly type I traumatic spondylolisthesis of the axis and posteriorly displaced type II and type III dens fractures. They also emphasize the difficulty of accurate roentgenographic diagnosis of these 

Rupture of transverse ligament.

This injury is a purely ligamentous injury and is different from other injuries involving the C1-2 complex. It most commonly results from a fall with a blow to the back of the head. The transverse ligament may be avulsed with a bony fragment from the lateral mass on either side, or it may rupture in its mid substance. Usually the anterior subluxation of the ring of C1 can be detected on flexion films, and the instability can be reduced in extension. Lateral views should be carefully checked for retropharyngeal hematoma, which suggests an acute injury, and for small flecks of bone avulsed off the lateral masses of C1, which may indicate avulsion of 

Rotary subluxation of C1 on C2.

This injury is uncommon in adults and is a different entity from rotary subluxation in children (Fig. 56-22) (Figure Not Available) . The injury in adults usually is caused by motor vehicle accidents and often is not recognized at initial evaluation because the patient presents with torticollis and restricted neck motion. An open-mouth odontoid roentgenogram may reveal the "wink sign" caused by overriding of the C1-2 joint on one side and a normal configuration on the other side. CT and routine anteroposterior tomography are helpful in clearly defining the osseous injury. Acute rotary subluxation of C1-2 can be reduced by closed means once the

Occipital condyle fractures.

Occipital condylar fractures are rare and are frequently missed on initial evaluation. These injuries usually result from axial loading and lateral bending during which force is applied to the head and neck. Recently Anderson and Montesano described three types of occipital condylar fractures 

Dens fracture.

Anderson and D'Alonzo classified odontoid fractures into three types (Fig. 56-25) (Figure Not Available) . Type I fractures are uncommon, and even if nonunion occurs after inadequate immobilization, no instability results. Type II fractures are the most common and in the study of Anderson and D'Alonzo had a 36% nonunion rate for both displaced and nondisplaced fractures. Type III fractures have a large cancellous base and heal without surgery in 90% of patients. It also is helpful to consider the amount of displacement and

Traumatic spondylolisthesis of the axis (hangman fractures)

Hangman fractures were originally those neck injuries incurred during hanging of criminals. Their most common cause now is motor vehicle accidents with hyperextension of the head on the neck. The occiput is forced down against the posterior arch of the atlas, which in turn is forced against the pedicles of C2. Levine and Edwards reviewed 52 traumatic spondylolistheses of the axis and classified these fractures into four types. Type I fractures are minimally displaced and are believed to be caused by hyperextension and axial loading with failure of the neural arch in tension. Because ligamentous injury is minimal, these fractures 

Injuries to lower cervical spine (C3-7).

Injuries to the lower cervical spine are different from those involving the upper cervical region. Patients with these injuries may have isolated minor compression and avulsion fractures or severe fractures and fracture-dislocations and profound neurological 

Posterior ligamentous injury.

Failure of the posterior ligamentous complex is caused by distraction and flexion forces and is manifested by widening of the interspinous process space during flexion. These injuries may be difficult to diagnose. Disruption of the posterior ligamentous complex may cause unilateral or bilateral facet dislocation and can occur with or without neurological deficits. Because it is a

Unilateral facet dislocation.

Unilateral facet dislocations usually result from flexion and rotation of the cervical spine. They are considered stage 2 distractive flexion injuries. The most common site of dislocation is at C5-6. Patients may present with an isolated nerve root injury or an incomplete neurological deficit. The injury may be purely ligamentous or may involve a facet fracture in addition to the dislocation. Unilateral facet dislocations may be difficult to reduce in skeletal traction. Closed reduction may be attempted to unlock the dislocated facet joint; however, this is successful in less than 50% of patients and we do not routinely use manipulation of the

Fractures of vertebral body.

Vertebral body fractures may range from stable compression fractures without neurological involvement to highly unstable burst fractures with significant neurological injury. Many mechanisms of injury are possible, but most vertebral body fractures result from axial loading and flexion. Eismont et al. have shown that the sagittal dimension of the cervical spinal canal plays an important role in determining the degree of neurological deficit with these injuries. Mild compression fractures with minimal displacement and without posterior element fracture, ligament disruption, facet dislocation, or neurological injury are stable fractures that will heal with 8 to 12 weeks of external cervical orthotic immobilization. The stability of the posterior ligamentous structures should be verified by the criteria of White and Panjabi (p. 2712) or by the stretch test previously described (p. 2713). More significant

Triple-wire procedure for posterior fusion.

This procedure may be done safely with the patient under general or local anesthesia. In patients with high cervical quadriplegia, local anesthesia may be preferred to avoid the respiratory complications that may be encountered with general anesthesia. Usually, the patient is intubated with an atraumatic, fiberoptic intubation technique and is then positioned prone on a