Cervical Spine Fracture

Cervical Spine Fracture

David Ray Velez, MD

Table of Contents

General Considerations
C1 (Atlas) Fracture
C2 (Axis) Fracture
C3-C7 (Sub-Axial) Fracture

See Also:
*Spinal Cord Injury (SCI)
*Cervical Collar

General Considerations

High Morbidity and Mortality Injury, Particularly in the Elderly (Mortality > 20%)

The Most Common Cervical Spine Fracture is a C2 Odontoid Fracture

Most Common Cause: Falls

Respiratory Failure

  • Cervical Spine Fractures Have High Risk for Hypoxia and Respiratory Failure
  • Due to Damage to the Nerves Controlling the Muscles of Respiration – Particularly the Phrenic Nerve Controlling the Diaphragm (Origin: C3-C5)
  • Require Frequent Suctioning and Pulmonary Toilet

Blunt Cerebrovascular Injury (BCVI)

  • Overall Risk: 30-70%
  • Specific Risk Factors:
    • High Cervical Spine (C1-C3) Fractures
    • Multi-Level Fractures
    • Fractures Associated with Dislocation/Subluxation
    • Transverse Foramen Fractures
  • *See Blunt Cerebrovascular Injury (BCVI)

Other Associated Injuries

  • Rib Fractures
  • Sternal Fracture
  • Facial Fracture
  • Base of the Skull Fracture

C1 (Atlas) Fracture

C1 Burst (“Jefferson”) Fracture: Fracture of Both the Anterior and Posterior Arches

Jefferson (Landell and Van Peteghem) Classification

  • Type I: Isolated Fracture of Either the Anterior or Posterior Arch
  • Type II: Fractures of Both the Anterior and Posterior Arches (Burst Fracture)
  • Type III: Lateral Mass Fracture

Gehweiler Classification

  • Type I: Isolated Fracture of the Anterior Arch
  • Type II: Isolated Fracture of the Posterior Arch
  • Type III: Fractures of Both the Anterior and Posterior Arches (Burst Fracture)
  • Type IV: Lateral Mass Fracture
  • Type V: Fracture of the Transverse Process

Atlanto-Occipital Dislocation (AOD): Severe Disruption of the Ligaments Between the Base of the Skull and Atlas

  • Also Known as: “Internal Decapitation”
  • High Mortality (70% Suffer Immediate Death)

Stability

  • Determined by Disruption of the Transverse Ligament
  • Jefferson Type I (Gehweiler Type I or II) are Usually Stable
  • Jefferson Type II or III (Gehweiler Type III or IV) are Usually Stable

Treatment

  • Stable: Rigid Collar for 6-12 Weeks
  • Unstable: Debated (Rigid Collar or Surgical Stabilization)

C1 Burst “Jefferson” Fracture

C2 (Axis) Fracture

Traumatic Spondylolisthesis of the Axis (“Hangman’s Fracture”)

  • Definition: Fracture Through the Bilateral Pars Interarticularis of C2
  • Usually From Hyperextension Injuries
  • Unstable but Cord Damage is Often Minimal
    • Anterior-Posterior Diameter is Highest at C2 and Bilateral Fracture Allows Decompression
  • Treatment: Rigid Collar, Halo Immobilization, or Surgical Stabilization Based Upon Displacement and Stability

C2 Hangman’s Fracture

C2 Odontoid/Dens Fracture

  • Anderson and D’Alonzo Classification:
    • Type I: Above the Base – Generally Stable
    • Type II: At the Base
    • Type III: Into the Vertebral Body – Better Healing Rates Than Type II
  • Treatment:
    • Type I: Rigid Collar for 6-12 Weeks
    • Type II: Surgical Stabilization
      • Consider Halo Immobilization if Young and No Risk for Nonunion
      • Consider Rigid Collar Alone for Elderly Patients that are Not Surgical Candidates
    • Type III: Debated (Rigid Collar or Surgical Stabilization)

C2 Odontoid/Dens Fracture

C3-C7 (Sub-Axial) Fracture

Anatomical Columns

  • Anterior Column: Anterior Half of the Vertebral Body and Anterior Longitudinal Ligament
  • Middle Column: Posterior Half of the Vertebral Body and Posterior Longitudinal Ligament
  • Posterior Column: Facets, Lamina, Spinous Process, and Interspinous Ligament

Subaxial Vertebral Body Fracture

  • Compression (Wedge) Fracture
    • Fracture of the Anterior Vertebral Body
    • Caused by Hyperflexion
  • Burst Fracture
    • Fracture of the Anterior and Middle Columns
    • May Have Retropulsion into the Spinal Canal
    • Caused by Compressive Forces
  • Flexion Teardrop Fracture
    • Anterior-Inferior Corner Fracture from Vertebral Body Collision
    • Caused by Hyperflexion
  • Extension Teardrop Fracture
    • Anterior-Inferior Corner Fracture from Anterior Longitudinal Ligament Avulsion
    • Caused by Abrupt Extension
  • Treatment: Rigid Collar or Surgical Stabilization Based Upon Fracture Pattern, Stability, and Neurologic Deficits
    • Early Decompression (< 24 Hours) Has Shown Improved Neurologic Outcomes Compared to Delayed Decompression (> 24 Hours)

Cervical Spinous Process (“Clay-Shoveler’s”) Fracture

  • Usually Occurs in Isolation
  • Most Common Location: C7
    • Can Affect C6-T3
  • Excellent Clinical Outcomes with High Union Rates
  • Treatment: Conservative (NSAIDs and Collar for Comfort)

Subaxial Cervical Vertebrae