Cervical Spine Fracture

Aka: Cervical Spine Fracture, C-Spine Fracture, Clay Shoveler's Fracture, Odontoid Process Fracture, Hangman's fracture, Jefferson Fracture, Cervical Wedge Compression Fracture, C1 Fracture, C2 Fracture, Cervical Teardrop Fracture, Cervical Spinous Process Fracture, Cervical Burst Fracture, Cervical Facet Dislocation, Cervical Fracture

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II. Anatomy

  1. See Cervical Spine Anatomy
  2. Image: Cervical Vertebrae
    1. orthoSpineVertebraeCervicalGrayBB84.gifLewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)
  3. Three-Column Model
    1. Anterior column
      1. Anterior half of Vertebral body
      2. Anterior ligamentous complex
        1. Anterior portion of annulus fibrosus
        2. Anterior longitudinal ligament
    2. Middle column
      1. Posterior half of Vertebral body
      2. Ligaments
        1. Posterior portion of annulus fibrosus
        2. Posterior longitudinal ligament
    3. Posterior Column
      1. Facet joints (superior and inferior articular process)
      2. Laminae
      3. Spinous processes
      4. Posterior ligamentous complex
        1. Facet capsules
        2. Interspinous ligaments

III. Types: C1 Fractures and Dislocations

  1. Mechanism
    1. Axial load or Hyperextension injuries
    2. May occur in diving injury into a shallow pool or being struck on the top of the head by a heavy object
  2. Jefferson Fracture (C1 Burst Fracture)
    1. Bilateral burst Fracture through posterior arch and lateral aspects
    2. Neurologic function is often spared
    3. Unstable Fracture
    4. Most common C1 Fracture
  3. Atlantooccipital Dislocation
    1. Dislocation of the C1 Vertebral body (Atlas) from the skull base
    2. Complex and unstable injury (high associated mortality)
    3. Anterior dislocation is most common
      1. Seen on lateral XRay (often with associated Hematoma) increasing prevertebral soft tissue width

IV. Types: C2 Fractures

  1. Hangman's fracture
    1. Mechanism
      1. Previously most associated with hanging (MVA is most common modern mechanism)
      2. Unstable, hyperextension injury
    2. Findings
      1. Fracture through both arches, pedicles
      2. C2 Vertebral body is displaced forwards from the arches leaving a black vertical Fracture line
      3. C2 Vertebral body subluxes anteriorly on C3
  2. Odontoid Fractures (forced flexion or extension)
    1. Unstable Fracture (esp. types 2-3) secondary to multidirectional injury
    2. Types (Anderson and D'Alonzo Classification)
      1. Type 1 (Tip Fracture, most common)
        1. Avulsion Fracture with injury to the alar ligament
        2. Fracture of the top of the dens (superior, odontoid tip)
        3. Instability is uncommon (but evaluate with flexion and extension films)
        4. Managed with Cervical Collar immobilization
      2. Type 2 (Waist Fracture, most serious/unstable)
        1. Fracture at the mid-dens
        2. High risk for devascularization and nonunion
        3. Types (Grauer Classification)
          1. Type 2A: Nondisplaced or minimally displaced and without comminution
            1. Treated with external immobilization
          2. Type 2B: Displaced Fracture - anterosuperior to posteroinferior
            1. Treated with anterior odontoid screw (requires adequate bone density)
          3. Type 2C: Comminuted, displaced Fracture - anteroinferior to posterosuperior
            1. Treated with posterior stabilization
      3. Type 3 (Base Fracture)
        1. Fracture at the base of the dens, extending into the cancellous Vertebral body of the axis (C2)
    3. References
      1. Ortho Bullets
        1. https://www.orthobullets.com/spine/2016/odontoid-fracture

V. Types: Facet Dislocation

  1. Unilateral facet dislocation
    1. Results from axial load with flexion and rotation
    2. Partial Vertebral subluxation <50% of Vertebral body width
    3. Stable injury
  2. Bilateral facet dislocation
    1. Unstable injury
    2. Mechanism
      1. Severe hyper-flexion force to the middle and Posterior Columns
      2. Disrupts the anterior longutudinal ligament, intervertebral disc and posterior ligaments
    3. Findings
      1. Vertebral subluxation >50% of Vertebral body width
      2. Step deformity
        1. Vertical distance between adjacent Vertebrae (lateral view)
        2. Definitively abnormal at >3 mm
    4. Types (in order of increasing severity)
      1. Subluxed facets
      2. Perched facets
      3. Locked facets

VI. Types: Wedge Compression Fracture

  1. Mechanism
    1. Hyperflexion loading of the spine (even minor forces, esp. in Osteoporosis)
    2. More often affects the thoracolumbar spine
  2. Anterior Vertebral body compression (with or without posterior compression)
    1. Posterior Vertebral height maintained (<25% wedge compression)
      1. Typically stable Fracture
      2. Evaluate with flexion-extension views for subluxation
    2. Posterior Vertebral height compressed more than 25%
      1. Associated with posterior ligamentous complex disruption

VII. Types: Flexion Teardrop Fracture

  1. Mechanism
    1. Flexion and compression injury (e.g. diving)
    2. Disrupts all supportive ligaments and the intervertebral disc
    3. Associated with anterior Spinal Cord Compression (Anterior Cord Syndrome)
  2. Fracture dislocation which is highly unstable
    1. Small anteroinferior teardrop Fracture fragment
    2. Posterior displacement of the Vertebral body
    3. Facet subluxation or spine angulation may be present
    4. Contrast with the more benign, extension tear drop injury
  3. References
    1. Flexion Teardrop Fracture (Radiopaedia)
      1. https://radiopaedia.org/articles/flexion-teardrop-fracture-1?lang=us

VIII. Types: Translation-Rotation Fracture

  1. Severe, unstable injury almost always requiring Spine Surgery
  2. Mechanism
    1. Displacement of a Fracture in the horizontal plane (left-right, anterior-posterior or rotational)
  3. Findings
    1. Vertebral subluxation
    2. Unilateral or bilateral facet dislocation if rotational injury
    3. Associated rib or transverse process Fractures
    4. Posterior ligamentous complex disruption in all cases

IX. Types: Burst Fracture

  1. Mechanism
    1. Flexion and compression injury (e.g. diving)
    2. Compression of both the anterior and posterior Vertebral body height
    3. Most commonly affects the mid-Cervical Spine
  2. Comminuted, unstable Vertebral Fracture
    1. Disrupts anterior and middle columns
    2. Typically involves middle and lower Cervical Vertebrae
    3. Spinal Cord Injury may result from bone fragments displaced into the spinal canal
  3. Findings
    1. Vertebral height loss
    2. Posterior Ligamentous Complex Injury

X. Types: Spinous Process Fracture

  1. Mechanisms
    1. Direct spinous process Trauma
    2. Sudden deceleration
    3. High velocity Trauma with neck flexion
    4. Severe Muscle Contraction with secondary avulsion
  2. Clay Shoveler's Fracture (Spinous process tip avulsion)
    1. Occurs at C6 or C7
    2. Flexion injury
      1. Related to strong pull from neck and ShoulderMuscles with heavy physical work
    3. Stable Fracture (but confirm with flexion-extension XRay views)
    4. Differential Diagnosis
      1. Fracture of base of spinous process (disrupts posterior ligamentous complex)
      2. Nonfused, spinous process apophysis

XI. Imaging

  1. See Acute Cervical Spine Imaging

XII. Management

  1. See Cervical Spine Injury
  2. See Cervical Spine Immobilization
  3. Vertebral Fracture Stability
    1. Consider any cervical Vertebral Fracture unstable with the exception of those listed below
    2. Subaxial Injury Classification and Severity Scale (SLICS)
      1. https://www.mdcalc.com/calc/10085/subaxial-injury-classification-severity-scale-slics
    3. Unstable Cervical Spine Fracture (Mnemonic - "Jefferson Bit Off A Hangman's Tit")
      1. J - Jefferson Fracture (C1 Burst Fracture, axial loading injury)
      2. B - Bifacet dislocation or Fracture (flexion injury)
      3. O - Odontoid Fracture (Types 2 and 3, flexion injury)
      4. A - Any Fracture-dislocation, Atlantoaxial dislocation or atlanto-occipital dislocation (flexion injury)
      5. H - Hangman's fracture or bilateral C2 Pedicle Fracture (posterior C2 Fracture, extension injury)
      6. T - Flexion Teardrop Fracture
    4. Stable Fractures
      1. Spinous process Fracture
      2. Transverse process Fracture
      3. Unilateral facet dislocation
      4. Wedge Fracture (unless posterior Vertebral height compressed more than 25%)
      5. Vertebral burst Fracture (except C1 Jefferson Fracture, or if fragments are retropulsed into spinal canal)
      6. Extension teardrop Fracture
        1. Extension injury avulses anteriorinferior fragment of Vertebra (esp at C2)
        2. Contrast with the very unstable flexion teardrop Fracture

XIII. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Eiff and Hatch (2018) Fracture Management for Primary Care, p. 187-96
  3. Ouellette and Tetreault (2015) Clinical Radiology, Medmaster, Miami, p. 42-50

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