This document provides an overview of cervical trauma and cervical spine injuries. It discusses anatomy, mechanisms of injury, history and examination findings, imaging, classifications of injuries including fractures and spinal cord syndromes, and indications for surgical intervention. The key points are that cervical spine injury must be considered in polytrauma patients, manual stabilization is needed in addition to collars, and imaging such as CT and MRI can help classify fractures and rule out injuries when clinical suspicion remains.

1. Cervical traumaCervical trauma
By
Dr. Hamdy Abdalla

2.  Spine injury must always be considered in any patients with multiple
injuries.
 Any patient with trauma who is not fully conscious should be assumed
to have cervical spine injury until proved otherwise.
 Collars alone are inadequate and they need to be supplemented by
manual stabilization or lateral support with blocks and forehead tape.
 Collars and neck support should not be removed unless cervical spine
injury has been excluded for sure.

3. Anatomy
• 7 Cervical Vertebrae
• C1 (Atlas) is a ring which articulates with the occiput
– C1 has no body
– C1 has no spinous process
• C2 (Axis) so named because it is the pivot on which the Atlas turns to
rotate the head
– The Axis has a vertical extension, the Dens,
which articulates with C1

5. Mechanisms of Injury:
- Hyperflexion - MVA, car comes to sudden stop
- Hyperextension - MVA, car struck from behind
- Compression - Head first dive in shallow water

6. causes
 Motor vehicle accident and falls account for 50% and 20% of
cervical spine injuries, respectively.
 Sports-related activities account for 15%:
Diving
Football
Skiing

8. History
 Common presentations include the following:
- Posterior neck pain on palpation of spinous processes
- Limited range of motion associated with pain
- Weakness, numbness, or paresthesias along affected nerve roots

9. Examination
 The examination should include :
Sensory
Motor
Proprioception
Perianal sensation
Rectal sphincter tone

10. Physical
- Common findings on physical examination in cervical spine injury include the
following:
- Spinal shock
Flaccidity Areflexia
Loss of anal sphincter tone Priapism
- Neurogenic shock
Hypotension Paradoxical bradycardia
Flushed, dry, and warm peripheral skin
- Associated with Paralysis of muscles of respiration
• Diaphragm invervated by C3-5

11. Management
 Diagnosis and management go hand in hand
 Inappropriate movement and examination can change the outcome
for the worse
 Early management
 Airway, Breathing and Circulation
 Exclude other life-threatening injury
 Properly immobilize patient
 Avoid hypothermia

12.  assess the patient’s neurologic status
Neurological level
- Most caudal level of motor / sensory function
- Motor and sensory may not be the same
- Sensory can vary on each side
Bony level
Site of vertebral column damage

15.  Complete injury
No motor or sensory function below injury level
 Incomplete injury
Any motor or sensory preservation below injury level

17. Incomplete Spinal Cord Syndromes
 Anterior Spinal Cord Syndrome
 Corticospinal and spinothalamic tracts
injured
 Preservation of posterior column pathway
 Etiology
Anterior spinal cord trauma
Flexion of cervical spine causing cord
contusion
Thrombosis of anterior spinal artery

19.  Posterior Spinal Cord Syndrome
 Rare condition
 Injury to dorsal column
 Preservation of corticospinal and spinothalamic pathways
 Etiology
Penetrating trauma to posterior aspect of cord
Hyperextension injury with vertebral arch fracture

21. Central Cord Syndrome
 Injury affects central portion of cord
 Loss of function of central fibers of corticospinal and
spinothalamic tracts
 Decreased strength and pain/temperature of upper extremities
compared with lower extremities
 Etiology
Hyperextension injuries
Central spinal stenosis
Disruption of normal blood flow
old age

23.  Brown Sequard Syndrome
 Transverse hemisection of spinal cord
 Ipsilateral loss of motor function, proprioceptive/vibratory
sensation
 Contralateral loss of pain/temperature sensation
 Etiology = Penetrating injury or Lateral cord compression

25. When to get c- spine image

27. Imaging
 X-ray c-spine?
 Flex/ex films?
 CT c-spine?
 MRI c-spine?

28. C-spine Film Interpretation
1. Count Vertebrae
-C1 through C7
-If T1 not seen do Swimmer’s view
2. Assess Curvature
3. Assess Vertebral Alignment (4 lines)
-ant vertebral line
-post vertebral line
-spinolaminal line
-post spinal line

29. C-spine Film Interpretation
4. Assess Bony Integrity
5. Assess Intervertebral Disk Spaces
6. Soft Tissues

31.  Lateral view
Top of T1 visible
Vertebral bodies of uniform height
Odontoid intact and closely applied to C1
 AP view
Spinous processes straight and spaced equally
Intervertebral spaces roughly equal
 Odontoid view
Odontoid intact
Equal spaces on either side of odontoid
Lateral margins of C1 and C2 align

33. Key Things to Identify
 Predental space – should
be 3mm or less

34.  Disc spaces should be the
equal and symmetric

35.  Prevertebral soft tissue
swelling
 May be due to
hematoma from a
fracture
 Soft tissue swelling
may make fracture
diagnosis difficulty

36. AP View
 The height of the cervical
vertebral bodies should be
approximately equal
 The height of each joint space
should be roughly equal at all
levels
 Spinous process should be in
midline and in good alignment

37. Odontoid View
 An adequate film should include
the entire odontoid and the
lateral borders of C1-C2.
 The distance from the dens to
the lateral masses of C1 should
be equal bilaterally.
 The tips of lateral mass of C1
should line up with the lateral
margins of the superior articular
facet of C2.

38. JEFFERSON FRACTURE
 Compression fracture of the
bony ring of C1, characterized
by lateral masses splitting and
transverse ligament tear
 Mechanism: Diving into shallow
water, RTA
 Best seen on Odontoid view
 Signs: Displacement of the
lateral masses of vertebrae C1
beyond the margins of the body
of vertebra C2

39.  Radiographic features:
the key radiographic view is the AP open mouth, which shows
displacement of the lateral masses of vertebrae C1 beyond the
margins of the body of vertebra C2. A lateral displacement of >2
mm or unilateral displacement may be indicative of a C1
fracture. CT is required to define the extent of fracture and to
detect fragments in the spinal canal.
Stability: unstable

40.  the lateral displacement of C1
indicates a Jefferson fracture.

41. odontoid view, which illustrates the lateral
displacement of C1

42. HANGMAN’S FRACTURE
 Fracture through the pedicle of C2 secondary to hyperextension
 Mechanism: Hanging or hitting a dashboard
 Best seen on lateral view
 Signs:
 Prevertebral soft tissue swelling
 Avulsion of anterior inferior corner of C2 associated with
rupture of the anterior longitudinal ligament
 Anterior dislocation of the C2 vertebral body
 Stability: unstable

45. ODONTOID FRACTURE
 Fracture of the odontoid (dens) process of C2
 Best seen on the lateral view
 Types :
 Type I – Fracture through superior portion of dens (Stable)
 Type II – Fracture through the base of the dens (most common,
most dangerous, prone to non-union; Unstable; requires ORIF
 Type III – Fracture that extends into the body of C2 (Stable)
best prognosis

47. BURST FRACTURE
 Fracture of C3-C7 that results from
axial compression
 CT is required for all patients to
evaluate extent of injury
 Injury to spinal cord, secondary to
displacement of posterior
fragments, is common
 stable

49. WEDGE FRACTURE
 Compression fracture resulting from flexion
 Mechanism: Hyperflexion and compression
 Signs:
 Buckled anterior cortex
 Loss of height of anterior vertebral body
 Anterosuperior fracture of vertebral body
 stable

51. FLEXION TEARDROP FRACTURE
 Posterior ligament disruption and anterior compression fracture
of the vertebral body which results from a severe flexion injury
 Mechanism: hyperflexion and compression (e.g. diving into
shallow water)
 Best seen on lateral view
 Signs:
 Prevertebral swelling associated with anterior longitudinal
ligament tear
 Teardrop fragment from anterior vertebral body avulsion
fracture
 Posterior vertebral body subluxation into the spinal canal
 Fracture of the spinous process
 unstable

54. BILATERAL FACET DISLOCATION
 Complete anterior dislocation of the vertebral body resulting
from extreme hyperflexion injury. It is associated with a very
high risk of cord damage
 Best seen on lateral view
 Signs:
 Complete anterior dislocation of affected vertebral body by
half or more of the vertebral body AP diameter
 Disruption of the posterior ligament complex and the
anterior longitudinal ligament
 unstable

56. UNILATERAL FACET DISLOCATION
 Facet joint dislocation and rupture of the joint ligaments
resulting from rotatory injury of the cervical vertebrae
 Best seen on lateral or oblique views
 Signs:
- Anterior dislocation of affected vertebral body by less than half
of the vertebral body AP diameter
- Discordant rotation above and below involved level
- Widening of the disk space

58. ANTERIOR SUBLUXATION
 Disruption of the posterior
ligamentous complex resulting from
hyperflexion
 Difficult to diagnose because muscle
spasm may result in similar findings
on the radiograph. May be stable
initially, but it associates with 20%-
50% delayed instability
 Flexion and extension views are
helpful in further evaluation.
 Signs:
 Loss of normal cervical lordosis
 Anterior displacement of the
vertebral body
 Fanning of the interspinous
distance

59. SCIWORA
 Significant Cord Injury without obvious radiological abnormality
- Higher incidence in pediatric population (34.8%)
 The relatively large size of the head
 inherent skeletal mobility
 cord vulnerable to damage
- Higher incidence above 60 yo
Posterior vertebral spurs due to spondylosis
Ligamentum flavum bulging due to loss of disc height
Risk of central cord syndrome after hyperextension injury

60. indications for surgical intervention
1. Neurologic deficit,
2. Spinal instability, and
3. Intractable pain.

61. Forget about all of this and
If you are not happy
do not discharge the patient.

62. THANK YOU FOR YOUR
ATTENTION !