Define Cervical Spine Injuries. Describe its investigations, management and complications.

Definition & Importance

Cervical spine injuries follow high-energy trauma (RTA, fall, diving) and, in the elderly, low-energy falls onto a spondylotic spine. They are critical because the cervical cord supplies the diaphragm and limbs — a high lesion is immediately life-threatening — and because a missed unstable injury can convert an intact patient into a quadriplegic one. The upper cervical spine (occiput–C2) and the subaxial spine (C3–C7) have distinct injury patterns.

Upper Cervical Injuries

• Atlanto-occipital dissociation — usually fatal.
• Jefferson fracture — a burst fracture of the C1 ring from axial loading (may be stable if the transverse ligament is intact).
• Odontoid (dens) fractures — classified by Anderson–D’Alonzo (Type II, at the base, is commonest and prone to non-union).
• Hangman’s fracture — traumatic spondylolisthesis of C2 (bilateral pars fracture) from hyperextension.

Subaxial (C3–C7) Injuries

These include flexion injuries (wedge compression, unstable teardrop fractures, uni- and bi-facet dislocations), burst fractures from axial loading, and extension injuries (especially in the spondylotic elderly, causing central cord syndrome). Facet dislocations frequently injure the cord or nerve roots.

Clinical Features & Assessment

Assume a cervical injury in any patient with head/facial trauma, neck pain, or an altered conscious level. Immobilise with a collar, blocks and tape/board. Examine for midline tenderness and a full neurological deficit. The nexus criteria and the Canadian C-spine rule identify low-risk patients who may not need imaging.

Investigations

CT of the cervical spine is the standard imaging in significant trauma (far more sensitive than plain radiographs, which must show the occiput to T1). MRI is added for neurological deficit, or suspected ligamentous, disc or cord injury.

Management

Maintain immobilisation and ATLS priorities, preventing secondary cord injury. Stable injuries (e.g. Many isolated C1 or minor wedge fractures) are treated in a collar or halo/orthosis. Unstable injuries, facet dislocations and those with cord compression require reduction (traction or closed reduction for locked facets) and surgical stabilisation/fusion with decompression. Type II odontoid fractures may be treated by halo immobilisation or anterior screw/posterior C1–C2 fixation depending on displacement and age. Throughout, the priorities are to prevent secondary cord injury and to achieve a stable, painless, well-aligned spine that protects neural function and permits rehabilitation.

Facet Dislocations

A flexion–distraction force can cause the inferior facet of one vertebra to jump over the superior facet of the one below — a unilateral (~25% translation, rotational deformity) or bilateral (~50% translation, high risk of cord injury) facet dislocation. Treatment is prompt reduction (closed reduction with traction, or open reduction) followed by fusion. Many units obtain an MRI before reduction to exclude a herniated disc that could be driven into the cord during manipulation.

Complications

Spinal cord injury (from the initial trauma or secondary displacement) is the feared complication, with quadriplegia and respiratory failure in high lesions. Others include vertebral artery injury, non-union (notably of type-II odontoid fractures), post-traumatic deformity and instability, and chronic pain.

Clearance & Prevention

A cervical spine is only ‘cleared’ when the patient is alert, unintoxicated, has no distracting injury, no midline tenderness and a normal neurological examination (or a normal CT where imaging is indicated). In the obtunded patient, precautions are maintained until adequate imaging is reviewed. Many sporting cervical injuries (diving, rugby, gymnastics) are preventable through technique and rule changes, and ‘spear-tackling’ with a flexed neck is a recognised cause of catastrophic injury.

Assume injury until cleared clinically or radiologically.

• Immobilise every at-risk patient; a missed unstable injury can cause quadriplegia.
• Upper C-spine: Jefferson (C1 burst), odontoid (type II common, non-union), Hangman's (C2).
• Subaxial: flexion (wedge, teardrop, facet dislocation), burst, extension (central cord).
• CT is the imaging standard; add MRI for deficit or ligament/cord injury.
• Stable → collar/halo; unstable/cord compression → reduction + fusion. Always image C7–T1.