Introduction

The cervical spine is a dynamic structure tasked with protecting nervous innervation to the entire body while also maintaining a range of motion for the head and neck. Fractures of the cervical spine are a leading cause of mobility and mortality in trauma patients, and a bone fracture is associated with 56% of cervical spinal cord injuries. Fractures of the cervical spine can be described based on the level involved and typically divided into three groups: C1, C2 and the sub-axial spine (C3 to C7).[1][2][3]

Etiology

Fractures of the cervical spine result from abnormal movement or a combination of movements including hyperflexion, hyperextension, rotation, axial loading, and lateral bending of the spinal column.[4]

Epidemiology

Cervical spine fractures may occur in all age groups but are more common in males. Falls account for the most common cause followed by motor vehicle accidents, biking, and diving. Mortality ranges from 5-10%. [5][6]

Pathophysiology

C1 fractures typically result from axial loading. C2 fractures typically occur due to a combination of compression, hyperflexion, and hyperextension. Subaxial cervical spine fracture is commonly seen with high impact accidents such as motor vehicle accidents.[7]

History and Physical

Examination of a patient with cervical spine fractures should begin with a thorough trauma examination of ABCs (check of the airway, breathing, and circulation). Injury to the cervical spine has the potential to compromise respiratory and cardiovascular function and even once stabilized these patients must be closely monitored for the ongoing possibility of changes in the respiratory and cardiovascular function. Next, formal strength and sensation testing of the upper and lower extremities, as well as rectal tone and palpation of the cervical spine should be performed. This is most commonly done following the ASIA scoring system. Acute spinal cord injury is important to identify as early decompression within 24 hours can increase the chance of neurological recovery.

Evaluation

Indications for cervical spine imaging include localized neck pain, deformity, edema, altered mental status, head injury, or neurological deficit. Computed tomography is the preferred imaging in acute spine trauma as it is more sensitive for detection of bony cervical spine injury when compared to plain radiographs (sensitivity of 98% versus 52%). Further evaluation of ligamentous structures of the spinal cord with MRI is important for determining spinal stability and in planning surgical treatment. Scoring systems in dealing with cervical spinal cord injury that includes ligamentous, bony and neurologic injury exist, a common one is called SLICS (Subaxial Cervical Spine Injury Classification System), and this can be used to help with evaluation and guidance of surgical or nonsurgical management. A SLICS score of 1 to 3 is nonsurgical, a score of 4 is not specified, and a score of 5 or greater is a surgical indication. [8][9][10]The scoring system is as follows: 

Fracture Morphology

• No abnormality - 0
• Compression endplate disruption or vertebral body fracture - 1
• Burst - 2
• Distraction - 3
• Rotation or translocation - 4

Discoligamentous Complex

• Intact - 0
• Indeterminate - 1
• Disrupted - 2

Neurologic Status

• Intact - 0
• Root injury - 1
• Complete spinal cord injury - 2
• Incomplete spinal cord injury - 3

Continuous Cord Compression

• With neuro deficit - 1

Differential Diagnosis

• Acute torticollis

• Cauda Equina

• Cervical strain

• Hanging injuries

• Neck trauma

• Septic shocks

• Spinal cord infections

• Spinal cord injuries

• Spinal cord neoplasms

• Vertebral artery dissection

Pearls and Other Issues

Cervical spine fractures are high-risk injuries with the potential for devastating neurological sequelae. Hence, a trained spine specialist should carry out subsequent evaluation and treatment. All patients with cervical fractures should be closely monitored with a follow-up to ensure continued cervical stability and healing. Any fracture extending into the foramina transversarium from C2 to C6 should be evaluated for the possibility of co-occurring vertebral artery injury. This is most often done with computed tomogram (CT) angiogram.

Enhancing Healthcare Team Outcomes

The diagnosis and management of cervical spine fractures usually require an interprofessional team that includes an emergency department physician, radiologist, neurosurgeon/orthopedic surgeon, EMS, and nurses.

Cervical spine fractures are high-risk injuries with the potential for devastating neurological sequelae. Hence, a trained spine specialist should carry out subsequent evaluation and treatment. All patients with cervical fractures should be closely monitored with a follow-up to ensure continued cervical stability and healing. Any fracture extending into the foramina transversarium from C2 to C6 should be evaluated for the possibility of co-occurring vertebral artery injury. This is most often done with a CT angiogram.

Each fracture described should warrant cervical collar placement with surgery indicated for restoration of cervical lordosis, decompression of the spinal cord, or fixation as determined by the instability of ligamentous components.

The outcome of cervical spine fractures depends on the neurological deficit at the time of presentation and concomitant head injury.[15][16]