Cervical Spine Fracture

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.

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.

Subaxial injuries (C3-C7) are graded with the SLIC score (morphology + disco-ligamentous complex + neurology) and described morphologically with the AOSpine system. The full SLIC and AOSpine tables are in the Classification section below; the summary threshold is: less than 4 conservative, 4 surgeon discretion, greater than 4 operative.

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.

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

Cervical spine injury results from the interaction of applied force vector and host bone/ligament quality. Understanding the mechanism predicts the pattern and the risk to neural structures.

Mechanism to Pattern

• Axial load: Burst patterns - Jefferson (C1) and subaxial burst fractures with retropulsion into the canal
• Hyperextension: Hangman's fracture (C2 pars), anterior tension-band (Type B3) injuries, and central cord syndrome in the spondylotic spine
• Flexion / flexion-distraction: Wedge compression, facet subluxation/dislocation, posterior ligamentous (tension-band) failure
• Flexion-rotation: Unilateral facet dislocation
• Distraction: Atlanto-occipital dissociation and highly unstable distraction injuries

Primary vs Secondary Cord Injury

• Primary injury: immediate mechanical disruption (contusion, laceration, compression) at the moment of impact - irreversible
• Secondary injury: an evolving cascade of oedema, ischaemia, excitotoxicity, free-radical damage and inflammation over hours to days. This is the therapeutic target of immobilisation, MAP augmentation (~85-90 mmHg) and early decompression

Host Factors

• Ankylosing spondylitis / DISH: the rigid, brittle, osteoporotic spine fails like a long bone - low-energy, often transverse, three-column, highly unstable fractures that are easily missed
• Osteoporosis and pre-existing canal stenosis: lower the force threshold for both fracture and cord injury, explaining the elderly fall-related odontoid and central cord patterns

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)

Sensory Assessment

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

1. Any high-risk factor? → Imaging
   • Age ≥65, dangerous mechanism, paresthesias
2. Any low-risk factor allowing ROM? → Can assess ROM
   • Simple rear-end MVC, ambulatory, delayed pain onset
3. 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

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

View larger

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

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)

Immediate

• Neuromonitoring: hourly motor/sensory checks for 24-48h; low threshold for urgent MRI if any deterioration (exclude haematoma)
• Airway: anterior surgery risks airway swelling - consider delayed extubation, swallow assessment for dysphagia
• Haemodynamics: maintain MAP ~85-90 mmHg in SCI; watch for neurogenic shock

Immobilisation & Rehabilitation

• Rigid collar typically 6-12 weeks after fusion (construct-dependent); halo pin care with daily cleaning and torque checks where used
• Early mobilisation when fixation is stable, with physiotherapy and occupational therapy; SCI patients transfer to a specialist unit for multidisciplinary rehabilitation, bladder/bowel and skin programmes

Follow-up

• 2 weeks wound check, 6 weeks clinical review with flexion-extension films, 3 months fusion assessment, 12 months final outcome and CT for fusion

Neurological Recovery

• Complete SCI (ASIA A): poor prognosis for significant motor recovery; rehabilitation focuses on adaptation and ADLs
• Incomplete SCI (ASIA B-D): better prognosis, improved further by early decompression (STASCIS); central cord syndrome characteristically recovers legs before hands
• Root injury: good prognosis, with meaningful improvement in the majority

Fracture-Specific & Functional

• Odontoid Type II: high halo-vest nonunion (see evidence) vs high fusion rates with surgery; Jefferson does well in a collar if TAL intact, otherwise after fusion; Hangman's Types I-II generally excellent
• Subaxial: SLIC-guided treatment with posterior instrumentation achieves high fusion rates
• Long-term: chronic neck pain and reduced ROM (especially after fusion) are common; adjacent-segment disease accrues over years
• Mortality: highest in complete SCI and in elderly odontoid fractures (high regardless of treatment), and when upper-cervical injury is associated with head injury

The key task is distinguishing an unstable bony or ligamentous injury (needing immobilisation and often surgery) from mimics that change management. Neck pain after trauma is never assumed benign until the spine is cleared.

• MRI before closed reduction of facet dislocation: Up to 40-50% of facet dislocations harbour a traumatic disc herniation. Whether to obtain MRI first (to avoid pushing disc into the canal) or to reduce immediately in an awake patient (to decompress the cord sooner) remains debated; many centres reduce awake when MRI would cause significant delay and the patient is deteriorating.
• Elderly Type II odontoid fracture - operative vs non-operative: Surgery improves union rates but carries operative risk, while non-operative care accepts a high rate of stable fibrous nonunion. Mortality is high regardless of treatment, so management is individualised by physiological reserve and patient goals rather than age alone.
• Steroids in acute SCI: Although NASCIS suggested a marginal subgroup benefit, AANS/CNS now recommend against routine methylprednisolone; some clinicians still consider it case-by-case despite the complication signal.
• Timing of decompression: STASCIS supports decompression within 24 hours, but the practical definition of "early" and the benefit in complete injuries or polytrauma remain debated.
• SLIC score of 4: The 3-4 range is deliberately equivocal; treatment is surgeon discretion, and reliability of the disco-ligamentous component is the weakest part of the score.
• Collar vs halo for stable upper-cervical injuries: Halo immobilisation is poorly tolerated in the elderly (pneumonia, pressure sores), and many now favour a rigid collar or early surgery over prolonged halo use.
• MRI clearance of the obtunded patient: With modern multidetector CT, the added value of routine MRI to clear the cervical spine in the obtunded but neurologically intact patient is contested.

Global Epidemiology

• Bimodal age distribution: a young-male peak (high-energy road traffic and sports/diving trauma) and an older peak (low-energy falls, often on osteoporotic or ankylosed spines)
• Cervical spine is the most common level of traumatic spinal cord injury, and the proportion of geriatric, fall-related injury is rising worldwide as populations age
• Odontoid fractures are the single most common cervical fracture in patients over 70, frequently from a simple ground-level fall
• Mechanism shift by setting: high-income/ageing populations are dominated by elderly falls; younger road-traffic and diving injuries predominate in many low- and middle-income settings

Side-by-Side Guidelines

Decision Rules for Imaging

• NEXUS and the Canadian C-Spine Rule are the two validated tools for clinical clearance in alert, stable patients; the Canadian rule is more specific (fewer images) while both have very high sensitivity
• CT is first-line whenever imaging is indicated; MRI is reserved for neurological deficit, obtunded patients, or suspected disco-ligamentous injury

High- vs Limited-Resource Practice Variation

• Well-resourced systems: rapid CT and MRI access, dedicated spinal-injury units, early (within 24h) decompression, and structured multidisciplinary rehabilitation
• Limited-resource settings: greater reliance on plain radiographs and clinical decision rules, prolonged collar/halo immobilisation where surgical capacity is constrained, and longer pre-hospital times that increase the importance of meticulous immobilisation and transfer
• Ankylosing spinal disorders (ankylosing spondylitis, DISH) demand a low threshold for CT (often the whole spine) everywhere, as fractures are frequently occult, highly unstable, and easily missed on plain films