High Yield Overview

CERVICAL SPINE FRACTURE

Immobilization | ATLS | Upper vs Subaxial

C-spineImmobilize until cleared

C1/C2Upper cervical

C3-C7Subaxial

SLICSubaxial classification

Key Patterns

C1 (Jefferson)

PatternBurst fracture of atlas

TreatmentUsually conservative (collar)

C2 (Odontoid)

PatternDens fracture

TreatmentType II: Surgery often needed

C2 (Hangman)

PatternBilateral C2 pars fracture

TreatmentHalo or surgery

Subaxial

PatternSLIC scoring

TreatmentScore greater than or equal to 5: Surgery

Critical Must-Knows

ATLS immobilization until cleared clinically and radiologically
Upper cervical (C1-C2) injuries have specific patterns
Subaxial cervical (C3-C7): Use SLIC score to guide treatment
MRI if neurological deficit or to assess ligaments
NEXUS or Canadian C-spine rules for clearance

Examiner's Pearls

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Jefferson fracture: Lateral mass spread greater than 7mm = TAL rupture
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Odontoid Type II (base of dens) has high nonunion rate
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Hangman's is usually stable (paradoxically) unless severe
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SLIC greater than or equal to 5 = surgery, 3-4 = equivocal, less than 3 = conservative

Clinical Imaging

Imaging Gallery

2-panel cervical spine imaging (A,B) in 67-year-old male with C2-C4 fracture after fall: (A) lateral X-ray with arrow indicating fracture, (B) coronal CT reconstruction with arrows showing fracture ex — 2-panel cervical spine imaging (A,B) in 67-year-old male with C2-C4 fracture after fall: (A) lateral X-ray with arrow indicating fracture, (B) coronalCredit: Morita Y et al. - Medicine (Baltimore) via Open-i (NIH) - PMC4616526 (CC-BY 4.0)

2-panel X-rays in ankylosing spondylitis patient with occult cervical fracture: (a) lateral view showing bamboo spine appearance, (b) AP view showing fused spine - illustrates difficulty detecting fra — 2-panel X-rays in ankylosing spondylitis patient with occult cervical fracture: (a) lateral view showing bamboo spine appearance, (b) AP view showing Credit: Yagi M et al. - Case Rep Orthop via Open-i (NIH) - PMC4578748 (CC-BY 4.0)

Critical Cervical Spine Fracture Points

Immobilization

All trauma patients: Assume C-spine injury until cleared. Rigid collar, log-roll, in-line immobilization for intubation. NEXUS/Canadian C-spine rules guide clearance.

Upper Cervical

C1 (Atlas): Jefferson (burst) - TAL integrity key. C2 (Axis): Odontoid (Type I/II/III) and Hangman's (bilateral pars). Require specialized imaging and often halo or surgery.

SLIC Score

Subaxial Injury Classification (C3-C7). Scores morphology, disco-ligamentous complex, neurology. Score greater than or equal to 5 = surgery. 3-4 = equivocal. Less than 3 = conservative.

MRI

Essential if: Neurological deficit, obtunded patient, suspected ligamentous injury. May show disc herniation, cord contusion, ligament disruption.

At a Glance

Cervical spine fractures require immediate immobilization until clinically and radiologically cleared using NEXUS or Canadian C-spine rules. Upper cervical injuries (C1-C2) include Jefferson fracture (C1 burst - lateral mass spread greater than 7mm indicates TAL rupture), odontoid fractures (Type II at dens base has highest nonunion rate requiring surgery), and Hangman's fracture (bilateral C2 pars - paradoxically stable unless severely displaced). Subaxial injuries (C3-C7) are classified using the SLIC score combining morphology, disco-ligamentous complex status, and neurological status; scores ≥5 indicate surgery, ≤2 conservative management, 3-4 equivocal. MRI is essential for neurological deficit or suspected ligamentous injury.

Mnemonic

1-2-3Odontoid Fracture Types

Tip of dens (avulsion)

Stable, conservative

Base of dens (waist)

Unstable, high nonunion, often surgery

III

Into C2 body

Extends into body, usually heals (halo)

Memory Hook:Type II = Trouble (high nonunion)!

Overview

Cervical spine fractures are potentially devastating injuries. The priority is to protect the spinal cord while evaluating and treating the bony and ligamentous injury.

ATLS Approach

Immobilize in rigid collar
Log-roll for turns
In-line immobilization for airway management
Do NOT remove collar until cleared

Imaging

X-rays: Less commonly used now (CT is standard).

CT: Primary imaging for bony injury.

MRI: For neurological deficit, to assess ligaments, disc, and cord.

Upper Cervical (C1-C2)

Jefferson Fracture: Burst fracture of C1 (atlas) - typically 4-part fracture of both arches.

Mechanism: Axial load (e.g., diving).

Key: Assess transverse atlantal ligament (TAL) integrity.

Rule of Spence: Combined lateral mass overhang greater than 7mm on open-mouth X-ray suggests TAL rupture → unstable.

Treatment:

TAL intact: Rigid collar or halo
TAL ruptured: Surgical stabilization (C1-C2 fusion)

Axial CT scan showing Jefferson fracture of the C1 atlas — Jefferson fracture: Axial CT demonstrating a burst fracture of the C1 ring (atlas). Note the fractures through both the anterior and posterior arches. The Rule of Spence applies when measuring lateral mass overhang on coronal images - combined overhang greater than 7mm indicates TAL rupture and instability.Credit: Utz M, Khan S, O'Connor D, Meyers S. Insights into Imaging 2013 - CC-BY 4.0

Subaxial Cervical (C3-C7)

SLIC Score (Subaxial Injury Classification)

Feature	Points
Morphology
Compression	1
Burst	2
Distraction	3
Rotation/Translation	4
DLC (Disco-Ligamentous)
Intact	0
Indeterminate	1
Disrupted	2
Neurology
Intact	0
Root injury	1
Incomplete cord	3
Complete cord	2
Ongoing compression + neuro	+1

Total Score:

Less than 3: Conservative (collar)
3-4: Equivocal (surgeon discretion)
Greater than or equal to 5: Surgery

Common Patterns

Facet Dislocation: Unilateral or bilateral. Rotational/translational injury. Usually requires reduction and fusion.

Compression Fracture: Anterior wedging. May be stable if posterior elements intact.

Burst Fracture: Retropulsion into canal. May need surgery if cord compression.

Spinal Cord Protection

The primary goal in cervical spine trauma is to protect the spinal cord from further injury. Maintain immobilization until fully assessed. Any neurological deterioration requires urgent MRI and surgical consultation.

Anatomy

Upper Cervical Spine (C0-C2)

Atlantooccipital Joint (C0-C1)

Allows 50% of cervical flexion-extension
Stabilized by tectorial membrane, alar ligaments, cruciate ligament

Atlas (C1)

Ring structure without vertebral body
Anterior and posterior arches with lateral masses
Articulates with occipital condyles superiorly, C2 inferiorly

Axis (C2)

Contains odontoid process (dens) projecting superiorly
Dens articulates with anterior arch of C1
Transverse atlantal ligament (TAL) holds dens against C1 anterior arch
Large spinous process and pars interarticularis

Key Ligaments

Transverse Atlantal Ligament (TAL): Primary stabilizer of C1-C2; prevents anterior translation of C1
Alar Ligaments: Limit rotation
Tectorial Membrane: Continuation of PLL to occiput
Cruciate Ligament: TAL + vertical bands

Subaxial Cervical Spine (C3-C7)

Vertebral Structure

Anterior column: Vertebral body, intervertebral disc
Posterior column: Pedicles, lateral masses, facet joints, laminae, spinous processes
Uncovertebral joints (joints of Luschka): Unique to cervical spine

Disco-Ligamentous Complex (DLC)

Anterior longitudinal ligament (ALL)
Posterior longitudinal ligament (PLL)
Intervertebral disc
Facet joint capsules
Ligamentum flavum
Interspinous ligament

Neural Structures

Spinal cord: Terminates as conus at L1-L2
Cervical roots exit above same-numbered vertebra (C6 root exits at C5-C6)
Vertebral arteries traverse foramen transversarium C6-C1

Classification

Occipital Condyle Fractures (Anderson & Montesano)

Type	Description	Stability
I	Impaction from axial load	Stable
II	Basilar skull fracture extension	Stable
III	Avulsion by alar ligament	Potentially unstable

Atlantooccipital Dissociation (Traynelis)

Type	Direction	Treatment
I	Anterior	Fusion
II	Longitudinal (distraction)	Fusion
III	Posterior	Fusion

C1 Ring Fractures (Jefferson)

Burst fracture from axial load
Typically 4-part (both arches)
Rule of Spence: Lateral mass overhang greater than 7mm = TAL rupture = unstable

Odontoid Fractures (Anderson & D'Alonzo)

Type	Location	Nonunion Risk	Treatment
I	Tip (avulsion)	Low	Collar
II	Base (waist)	High (40%)	Surgery often
III	Into C2 body	Low	Halo

Hangman's Fracture (Levine-Edwards)

Type	Displacement	Angulation	Treatment
I	Less than 3mm	Minimal	Collar
II	Greater than 3mm	Present	Halo or surgery
IIA	Minimal	Severe	Surgery (traction contraindicated)
III	Facet dislocation	Severe	Surgery

Clinical Assessment

Primary Survey (ATLS)

Airway with C-spine protection

In-line stabilization for intubation
Avoid neck extension
Consider awake fiberoptic intubation if time permits

Breathing and Circulation

Neurogenic shock: Hypotension + bradycardia (loss of sympathetic tone)
Differentiate from hypovolemic shock

Disability

GCS and pupillary response
Spinal cord injury level

Neurological Examination

Motor Assessment (ASIA/ISNCSCI)

Level	Key Muscle	Action
C5	Biceps	Elbow flexion
C6	Wrist extensors	Wrist extension
C7	Triceps	Elbow extension
C8	FDP (middle finger)	Finger flexion
T1	Interossei	Finger abduction

Sensory Assessment

Level	Key Dermatome
C4	Top of shoulders
C5	Lateral arm
C6	Thumb
C7	Middle finger
C8	Little finger
T1	Medial arm

ASIA Impairment Scale

A: Complete - No motor/sensory function in S4-S5
B: Sensory incomplete - Sensory but no motor below level, including S4-S5
C: Motor incomplete - Motor function preserved, majority of key muscles less than 3/5
D: Motor incomplete - Motor function preserved, majority ≥3/5
E: Normal

Clearance Criteria

Canadian C-Spine Rules

Any high-risk factor? → Imaging
- Age ≥65, dangerous mechanism, paresthesias
Any low-risk factor allowing ROM? → Can assess ROM
- Simple rear-end MVC, ambulatory, delayed pain onset
Can actively rotate 45° each direction? → No imaging needed

NEXUS Criteria (all must be present)

No midline tenderness
No focal neurological deficit
Normal alertness
No intoxication
No distracting injury

Investigations

Imaging Algorithm

CT Cervical Spine (First-line)

Indicated for all significant trauma
Skull base to T1 (include C7-T1 junction)
100% sensitivity for fractures
Assess: Alignment, fracture pattern, canal compromise

Multiplanar CT reconstruction of cervical spine fracture — Comprehensive CT assessment of cervical spine trauma: (a) Coronal reconstruction showing vertebral body alignment and lateral mass integrity. (b) Sagittal reconstruction demonstrating overall cervical lordosis, vertebral body heights, and facet alignment. (c) Coronal view of cervicothoracic junction - critical to include C7-T1 in all trauma imaging. (d) Sagittal view showing fracture detail. Multiplanar CT reconstruction is the gold standard for cervical spine trauma assessment with 100% sensitivity for fractures.Credit: Open-i/PMC - CC BY 4.0

MRI Cervical Spine

Indications:
- Neurological deficit
- Obtunded patient (cannot clinically clear)
- Suspected ligamentous injury (DLC)
- Suspected disc herniation
Findings: Cord edema/contusion, disc herniation, ligament rupture (bright T2 signal)
Timing: Within 24-72 hours for acute injury

CT Angiography

Indications:
- Fracture through foramen transversarium
- Facet subluxation/dislocation
- High-energy mechanism
Screens for vertebral artery injury (dissection, occlusion)

Key Imaging Findings

Upper Cervical

Jefferson: Open-mouth (odontoid) view - lateral mass overhang
Odontoid: Sagittal CT - fracture line location
Hangman: Bilateral C2 pars fractures

Subaxial

Facet dislocation: Perched or locked facets on sagittal CT
DLC disruption on MRI: Bright signal in ligaments/disc
Canal compromise: Measure for surgical planning

Laboratory Studies

FBC, coagulation profile (pre-operative)
Group and screen
Consider arterial blood gas if respiratory compromise

Management

Immediate Management

Immobilization

Rigid cervical collar (properly sized)
Log-roll precautions
In-line stabilization for all procedures

Hemodynamic Support

Target MAP 85-90 mmHg for spinal cord injury
Differentiate neurogenic from hypovolemic shock
Vasopressors if needed (norepinephrine)

Steroids

Methylprednisolone NO LONGER recommended
AANS/CNS guidelines: Risks outweigh benefits
May increase infection, GI bleeding risk

Thromboprophylaxis

High risk for VTE
Mechanical prophylaxis immediately
Chemical prophylaxis within 72 hours (if no active bleeding)

Surgical Technique

C1-C2 Fusion Techniques

Posterior C1-C2 Fusion (Harms Technique)

C1 lateral mass screws + C2 pedicle screws
Rod fixation
Bone graft between C1-C2
Advantages: Direct visualization, high fusion rate
Risks: Vertebral artery injury (C2 pedicle)

Gallie Fusion

Sublaminar wire around C1 and C2
Structural bone graft
Older technique, less rigid than screw fixation

Brooks Fusion

Bilateral sublaminar wires around C1-C2
Two bone blocks

Anterior Odontoid Screw

Indications:

Type II odontoid fracture (favorable pattern)
Non-comminuted, not too oblique
Preserved transverse ligament

Technique:

Anterior Smith-Robinson approach to C2-C3
Cannulated screw from C2 body into dens
Preserves C1-C2 rotation

Contraindications:

Transverse fracture line (screw parallel to fracture)
Oblique fracture (from anterosuperior to posteroinferior)
Pathological bone

Lateral cervical spine X-ray showing anterior odontoid screw fixation — Anterior odontoid screw fixation: Postoperative lateral radiograph demonstrating a single anterior lag screw traversing a Type II odontoid fracture. This technique allows direct compression across the fracture site and preserves C1-C2 rotation. Patient selection is crucial - the fracture line must be suitable (not too transverse or posteriorly oblique) for screw purchase.Credit: James Heilman MD, Wikimedia Commons - CC-BY-SA 4.0

Complications

Neurological Complications

Spinal Cord Injury Progression

Secondary injury from edema, ischemia
Prevented by: Immobilization, MAP support, early decompression

Iatrogenic Injury

Screw malposition (cord, nerve root, vertebral artery)
Excessive retraction
Decompression injury

Surgical Complications

Anterior Approach

Dysphagia: 2-60% (usually transient)
Recurrent laryngeal nerve palsy: 2-11% (hoarseness)
Esophageal injury: Rare but serious
Vascular injury: Carotid, vertebral artery

Posterior Approach

Vertebral artery injury: 0.1-4% (C2 pedicle screws highest risk)
C5 palsy: 2-16% (deltoid weakness)
Wound infection: 1-3%

Hardware Complications

Screw pullout
Rod fracture
Cage subsidence
Plate migration

Fusion Complications

Nonunion (Pseudarthrosis)

Risk factors: Smoking, multilevel, osteoporosis
Higher in upper cervical injuries

Adjacent Segment Disease

Increased stress on adjacent levels
May require extension of fusion

Medical Complications

DVT/PE (high risk in SCI)
Pneumonia (especially high cervical SCI)
Pressure ulcers
Autonomic dysreflexia (injuries above T6)

Postoperative Care