This document provides information on cervical spine trauma. It discusses: - Common levels of cervical spine injury being C2, C6, and C7. - Classification systems for fractures of the atlas, dens fractures, and subaxial cervical fractures. - Treatment approaches depending on the fracture type, including non-operative treatment with collars or halos and surgical stabilization with techniques like anterior or posterior fusion. - Key anatomy and biomechanics relating to mechanisms of injury for various fracture patterns.

1. CERVICAL SPINE
TRAUMA
Dr Asif Jatoi
Senior Reistrar
CMH Rawalpindi

2.  Cervical spine injuries account for about 1/3 of
all spinal injuries and the most commonly
injured vertebrae are C2, C6 and C7
 A neurological deficit occurs in about 15% of
all spinal injuries.
 A low GCS indicates a high risk for a
concomitant cervical injury

3.  The second cervical vertebra was the most common
(24%) level of injury, one-third of which were odontoid
fractures.
 In the subaxial spine, C6 and C7 were the most
frequently affected levels (40%). The most frequent
fracture site was the vertebral body.
 Nearly two-thirds of all injuries (71%) were considered
clinically significant.

4. Anatomy
 Functionally, the cervical spine is divided into
the upper cervical spine [occiput (C0)–C1–C2]
and the lower (subaxial) cervical spine (C3–C7).
 The C0–C1–C2 complex is responsible for 50%
of all cervical rotation while 80% of all
flexion/extension occurs in the lower cervical
spine.

6. Upper Cervical Spine
 The atlas-occiput (C0-C1) junction primarily allows
flexion/extension and limited rotation.
 The flexion is limited by a skeletal contact between the
anterior margin of the foramen magnum and the tip of
the dens
 Flexion/extension is also limited by the tectorial
membrane, which is the cephalad continuation of the
posterior longitudinal ligament [PLL].
 Axial rotation at the craniocervical junction is restricted

7. Upper Cervical Spine
 The alar ligaments restrain rotation of the upper
cervical spine, whereas transverse ligaments
restrict flexion as well as anterior displacement of
the atlas
 The transverse ligament also protects the
atlantoaxial joints from rotatory dislocation.
 Lateral bending is controlled by both components of
the alar ligaments

9. Lower (Subaxial) Cervical Spine
 The vertebrae of the lower cervical spine have a
superior cortical surface which is concave in the
coronal plane and convex in the sagittal plane.
 This configuration allows flexion, extension, and
lateral tilt by gliding motion of the facets.

10. Lower (Subaxial) Cervical
Spine
 The range of flexion/extension is in part dictated by
the geometry and stiffness of the intervertebral disc.
 the greater the disc height and the smaller the
sagittal diameter, the greater is the motion.
 Conversely, the greater the stiffness of the disc, the
smaller the spinal motion.
 The C5/6 level exhibits the largest ROM , which in
part explains its susceptibility to trauma and

11. Lower (Subaxial) Cervical
Spine
 Besides the intervertebral disc and facet joints,
the muscles and the ligaments, particularly the
yellow ligament, dictate the spinal kinematics.
 The facet joint capsules are stretched in flexion
and therefore limit rotation in this position.

13. Biomechanics of Cervical Spine
Trauma
 The position of the spine at impact determines the
fracture pattern
 Atlas burst fractures (Jefferson fractures) result from
axial compression in slight extension,
 Dens fractures are due to a combination of horizontal
shear and vertical compression.
 Tear-drop fracture result from a flexion/compression
injury with disruption of the posterior ligaments

14.  Traumatic spondylolisthesis of the axial
pedicle (hangman’s fracture) that results in an
extension-distraction injury.
 Similar injuries are observed in motor vehicle
and diving accidents.

15. Biomechanics of Cervical Spine
Trauma
 OS ODONTOIDEUM is considered to be a
result of an early childhood trauma to the dens
that leads to a non-union and subsequent
formation of a loose ossicle.
 This entity usually causes an atlantoaxial
instability.

17. Biomechanics of Cervical Spine
Trauma
 The flexed lower cervical spine is susceptible to
ligamentous injuries without fractures on axial
loading, which can result in bilateral facet
subluxation or dislocation.
 Additional rotation leads to unilateral
dislocations.

18. Clinical Presentation
 History
 type of trauma (high vs. low-energy)
 mechanism of injury (compression, flexion/distraction,
hyperextension,rotation, shear injury)
 The cardinal symptoms of an acute cervical injury
are:
 pain
 loss of function (inability to move the head)
 numbness and weakness
 bowel and bladder dysfunction

19.  In patients with evidence for neurological
deficits, the history should include:
 time of onset (immediate, secondary)
 course (unchanged, progressive, or improving

20. Physical Findings
 The initial focus is on
 Vital functions and
 Neurological deficits
 The inspection and palpation of the spine should
include the search for:
 skin bruises, lacerations, ecchymoses, open wounds
 swellings, hematoma
 painful structures (spinous, transverse, and mastoid processes;
facet joints)
 spinal (mal)alignment (torticollis)
 gaps/steps

21. Criteria for C0-C1-C2 instability
 >8° axial rotation C0–C1 to one side
 >1mm translation of basion to dens top (normal 4–5
mm) on flexion/extension
 >7mm bilateral overhang C1–C2
 >45° axial rotation (C1–C2) to one side
 >4mm C1–C2 translation measurement
 <13mm posterior body C2 – posterior ring C1
 avulsion fracture of transverse ligament

23. Imaging Studies
 STANDARD RADIOGRAPHS
 anteroposterior view
 cross-table lateral view
 open-mouth dens view
 Dynamic views. Flexion/ extension views
 Swimmer’s view

24. RADIOGRAPHIC SIGNS OF
CERVICAL SPINE TRAUMA
 Soft tissue
 retropharyngeal space >7 mm in adults or children
 retrotracheal space >14 mm in adults or >22 mm in children
 displaced prevertebral fat stripe
 tracheal and laryngeal deviation.
 Vertebral alignment
 loss of lordosis
 acute kyphotic angulation
 torticollis
 widened intraspinous space
 axial rotation of vertebra

25. COMPUTED TOMOGRAPHY
 CT is the first choice for unconscious or
polytraumatized patients
 Helpful in fracture charcterization and surgical
planning

26. MAGNETIC RESONANCE
IMAGING
 discoligamentous lesions
 vertebral artery injuries
 neural encroachment and spinal cord
contusion
 traumatic meningoceles or CSF leaks
 non-contiguous vertebral fractures
 injury sequelae (e.g., myelomalacia, cysts,
syrinx)

27. GENERAL TREATMENT
PRINCIPLES
 The general objectives of the treatment are:
 restoration of spinal alignment
 preservation or improvement of neurological
function
 restoration of spinal stability
 avoidance of collateral damage
 restoration of spinal function
 resolution of pain

28. NON-OPERATIVE TREATMENT
MODALITIES
 Soft collar
 useful for the acute (short-term) treatment of minor cervical
muscle strains and sprains
 The Philadelphia collar
 better control neck motion, especially in the
flexion/extension plane
 Scalp ulcer in comatose patients
 Minerva Brace/Cast
 This brace provides adequate immobilization between C1
and C7

30. TRACTION
 The Gardner-Wells tongs
 rule out an atlanto-occipital dislocation or
complete discoligamentous injuries before
applying traction because of the inherent risk of
rapid neurological deterioration, which can be
irreversible.
 Halo vest
 The halo vest is the first conservative choice for
unstable lesions.
 most rigid and effective method of cervical spine
immobilization

32. ATLANTO-OCCIPITAL
DISLOCATION
 Atlanto-occipital dislocation is a rare and often fatal condition
 Prevertebral soft tissue swelling on a lateral cervical
radiograph or
 craniocervical subarachnoid hemorrhage on axial CT has
been associated with AOD and should increase the suspicion
of this lesion.
 Patients who survive often have neurological impairment,
such as
 unilateral or bilateral weakness,

33.  lateral cervical radiograph is recommended for the
diagnosis of AOD to calculate the ratio of
basion/posterior arch of C1 to anterior arch of
C1/opisthion
 CT with 3D image reformation, MRI and angiography
are the imaging modalities that will allow the diagnosis
of AOD and to exclude additional concomitant injuries

35.  Therapeutic options aim to
stabilize the cervico-
occipital junction and to
avoid secondary
neurological deterioration
 craniocervical fusion with
internal fixation with Y-
plate

36. FRACTURES OF THE ATLAS
 Classification
 five types
 Burst fractures of the atlas are caused by
massive axial loads and often occur at the sulcus
vertebralis, the weakest site of the arch.
 These fractures are very frequently associated
with other fractures of the craniocervical
junctions.

37. ATLAS TYPE I
 Anterior arch injuries
are in general
hyperflexion injuries.
These are normally
stable and treated
with a soft collar

38. ATLAS TYPE II
 Posterior arch
injuries are
hyperextension
injuries. These are
normally stable and
normally treated with
a soft collar under
close observation.

39. ATLAS TYPE IIIA
(JEFFERSON)
 Burst fractures are axial load
injuries resulting in both
anterior and posterior ring
fractures. The fractures can
be unilateral or bilateral.
 Undisplaced burst fractures
are normally treated non-
operatively with close
observation.

40. ATLAS TYPE IIIB
 Displaced fractures with
widening >6.9 mm
suggests injury of the
transverse atlantal
ligament.
 associated with transverse
atlantal ligament injury
which can be either:
 Pure ligament rupture
(Dickman type 1)
 Avulsion (Dickman type 2).

41. ATLAS Type IIIb
 In the presence of ligament rupture, open reduction and
C1-C2 fusion is required.
 Avulsion fractures of the transverse ligament (the
ligament pulls off a piece of bone from the lateral mass)
will usually heal if the patient is immobilized with a halo
vest.
 The diagnosis is made on an axial CT image.

42. Lateral mass screw fixation for
Dickamn type 2 Dickman type 1

43. ATLAS TYPE IV
 These fractures
comminuted or lateral
mass fracture
 Minimally displaced can be
treated conservatively with
a soft cervical collar.
 In more severe
dislocations reduction is
performed with a halo vest.

44. ATLAS TYPE IV
 In case of persistent
displacement after 6
weeks of halo vest,
an occipitocervical
fusion is performed.

45. ATLAS Type V
 Transverse process
fractures are stable
fractures and treated
nonoperatively with soft
collar and observation.
 If it involves the vertebral
foramen, check for
arterial injury.

46. C1-C2 ROTATORY
SUBLUXATION
 Occur in adolescents
after minor trauma or
after throat inflammatory
processes.
 The transverse ligament
may be ruptured or
intact.
 The treatment may be
conservative in acute
cases with cervical
traction. If reduction
cannot be achieved,
then C1-C2 fusion would

47. C1-C2 DISLOCATION
 C1-C2 dislocations may
occur in traumatic
accidents, congenital
anomalies or in
rheumatoid patients.
 Axial X-ray will show
narrowing of the spinal
canal due to the anterior
dislocation.
 The treatment is in
general surgical with C1-
C2 fusion.

48. Posterior C1-C2
Anterior C1-C2 fusion with
Trans-articular screws

49. DENS FRACTURES
 ANDERSON D'ALONZO
CLASSIFICATION:
 Type I: oblique fractures through the upper
portion of the odontoid process.
 Type II: across the base of the odontoid
process at the junction with the axis
body.
 Type III: through the odontoid that extends
into the C2 body

50. ANDERSON D'ALONZO TYPE
I

51. ANDERSON D'ALONZO TYPE
II
 The fracture line is
located in the odontoid
peg itself, above C2
vertebral body.
 Has up to 21% nonunion
rate when treated
conservatively.
 surgical treatment is
indicated due to the high
nonunion rate.

52. ANDERSON D'ALONZO TYPE
III
 The fracture line in the
C2 vertebral body
 The fracture often enters
the lateral atlantoaxial
joint on one or both
sides creates an
intraarticular step.

53. INDICATIONS FOR SURGERY
 dens displacement of 5 mm or more
 dens fracture (Type IIA)
 inability to achieve fracture reduction
 inability to achieve main fracture reduction
with external immobilization

54. Treatment
 Odontoid screw fixation
 Posterior C1-C2 fixation in Unstable or dislocated
fractures combined with C2 injuries.

56. HANGMAN’S FRACTURE

57. LEVINE AND EDWARDS
CLASSIFICATION (BASED ON
MECHANISM OF INJURY)

58. NON-OPERATIVE
 Rigid cervical collar x 4-6 weeks
 Indications:
 Type I fractures (< 3mm horizontal displacement)
 Closed reduction followed by halo immobilization
for 8-12 weeks
 indications
 Type II with 3-5 mm displacement
 Type IIA
 Reduction technique
 Type II use axial traction combined + extension
 Type IIA use hyperextension (avoid axial traction in
Type IIA)

59. OPERATIVE
 Reduction with surgical stabilization
 indications
 Type II with > 5 mm displacement and severe
angulation
 Type III (facet dislocations)
 Technique
 anterior C2-3 interbody fusion
 posterior C1-3 fusion
 bilateral C2 pars screw osteosynthesis

60. SUBAXIAL CERVICAL
TRAUMA
 80% all cervical spine injuries affect the lower
cervical spine.
 are often associated with neurological deficits.
 require accurate characterization of the
mechanism and types of injury to enable
efficacy of operative and non-operative
treatment strategies.

61. AO CLASSIFICATION
 Related to specific injury pattern
 TYPE A: injuries of the anterior elements
induced by compression
 TYPE B: injuries of the posterior and anterior
elements induced by distraction
 TYPE C: injuries of the anterior and posterior
elements induced by rotation

62. AO- NONSTRUCTURAL FRACTURES
 Involve isolated
fracture of the
spinous process, the
transverse process
or the lamina.

63. A1- Compression fracture single
endplate
 Type A1 injuries are
compression
fractures involving a
single endplate
without involvement
of the posterior wall
of the vertebral body.

64. A2- CORONAL SPLIT/PINCER
FRACTURE
 Type A2 is a coronal
split or pincer
fracture involving
both endplates
without involvement
of the posterior wall
of the vertebral
body.

65. A3- BURST FRACTURE OF SINGLE
ENDPLATE
 Type A3 is a burst
fracture involving a
single endplate
(superior or inferior)
with involvement of the
posterior vertebral
wall.

66. A4 BURST FRACTURE OR
SAGITTAL SPLIT
 These injuries are similar to
A3 injuries but involve both
endplates.
 Fractures that split the
vertebral body in the sagittal
plane involving the posterior
vertebral wall are also
included in this group.

67. B1 POSTERIOR TENSION BAND INJURY
(BONY)
 Type B1 is a posterior
tension band injury
where the fracture line
only goes through the
bony structure.
 In the cervical spine
this is a very
uncommon injury

68. B2 POSTERIOR TENSION BAND INJURY
 complete disruption of the
posterior capsulo-
ligamentous or bony
capsulo-ligamentous
structures together with a
vertebral body, disk, and/or
facet injury.
 This always involves a
motion segment and

69. B3 ANTERIOR TENSION BAND
INJURY
 There is physical
disruption or separation
of the anterior structures
(bone/disk) with
tethering of the posterior
elements.
 may pass through either
the intervertebral disk or
vertebral body itself (as
in the ankylosed spine).
 An intact posterior hinge
will prevent gross
displacement

70. C TRANSLATIONAL INJURY
 C-type injuries are in
general failure of anterior
and posterior elements
leading to displacement.
 includes injuries with
displacement or translation
of one vertebral body
relative to another in any
direction.

71. FACET INJURY
 NON DISPLACED
FACET FRACTURE
 non-displaced facet
fracture (either
superior or inferior
facets). Fracture
fragments are smaller
than 1 cm and
comprise less than
40% of the lateral
mass

72. FACET INJURY
 FACET FRACTURE
WITH POTENTIAL
FOR INSTABILITY
 Fracture fragments
are either larger
than 1 cm, comprise
more than 40% of
the lateral mass, or
there are signs of
displacement.

73. FACET INJURY
 FLOATING
LATERAL MASS
 a disruption of the
pedicle and lamina
resulting in
disconnection of
superior and inferior
articular processes at
a given level or set of
levels.
 might lead to
instability of the facet
joint of two motion
segments.

74. FLEXION TEARDROP
FRACTURE
 characterized by
anterior column failure
in flexion/compression
 posterior portion of
vertebra retropulsed
posteriorly
 posterior column failure
in tension
 larger anterior lip
fragments may be
called 'quadrangular
fractures'

75. EXTENSION TEARDROP AVULSION
FRACTURE
 characterized by
 small fleck of bone is
avulsed of anterior
endplate
 usually occur at C2
 must differentiate from a
true teardrop fracture
 mechanism
 extension

76. NONOPERATIVE
 collar immobilization for 6 to 12 weeks
 indications
 stable mild compression fractures (intact posterior
ligaments & no significant kyphosis)
 anterior teardrop avulsion fracture
 external halo immobilization
 indications
 only if stable fracture pattern (intact posterior
ligaments & no significant kyphosis)

77. OPERATIVE
 Anterior decompression, corpectomy, strut
graft, & fusion with instrumentation
 INDICATIONS:
 compression fracture with 11 degrees of angulation or
25% loss of vertebral body height
 unstable burst fracture with cord compression
 unstable tear-drop fracture with cord compression
 minimal injury to posterior elements
 early decompression (< 24 hours) has been
shown to improve neurologic outcomes compared
with delayed (>/ 24 hours) decompression

78. OPERATIVE
 Posterior decompression, & fusion with
instrumentation
 Indications:
 significant injury to posterior elements
 anterior decompression not required