Subaxial Cervical Spine

Trauma

Brian K. Kwon, MD, PhD, FRCSC Abstract

Alexander R. Vaccaro, MD Subaxial cervical spine injuries are common, ranging in severity
Jonathan N. Grauer, MD from minor ligamentous strain or spinous process fracture to
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Charles G. Fisher, MD, MPH, FRCSC complete fracture-dislocation with bone and ligament failure,
Marcel F. Dvorak, MD, FRCSC resulting in severe spinal cord injury. Understanding the
Dr. Kwon is Assistant Professor, epidemiology, anatomy, biomechanics, and classification of
Combined Neurosurgical and subaxial cervical spine injuries is important. Emergent
Orthopaedic Spine Program, management of such injuries is based on obtaining an accurate
Department of Orthopaedics, University
clinical history, careful physical examination, and organized
of British Columbia, Vancouver, BC,
Canada. Dr. Vaccaro is Professor, radiographic evaluation. Attaining a unified approach to the wide
Department of Orthopaedic Surgery, spectrum of subaxial cervical injuries is difficult. In addition,
Thomas Jefferson University and The
controversy exists regarding the safety of closed reduction in
Rothman Institute, and Codirector, The
Delaware Valley Regional Spinal Cord certain injury patterns and the administration of
Injury Center, Thomas Jefferson methylprednisolone for acute spinal cord injury. Definitive
University, Philadelphia, PA. Dr. Grauer management (surgical or nonsurgical) is based on the assessment of
is Assistant Professor, Department of
Orthopaedics, Yale University, New
the mechanical instability of the injury, the presence or absence of
Haven, CT. Dr. Fisher is Assistant neurologic impairment, and various patient factors that may
Professor, Combined Neurosurgical and influence outcome. Several complications, including the
Orthopaedic Spine Program,
deterioration of neurologic status, may occur with either surgical
Department of Orthopaedics, University
of British Columbia. Dr. Dvorak is or nonsurgical management, but the most frequent mistake made
Associate Professor, Combined is missing the injury on initial evaluation.
Neurosurgical and Orthopaedic Spine
Program, Department of Orthopaedics,

A
University of British Columbia. lthough the cervical spine is in- visualize the cervicothoracic junc-
None of the following authors or the jured in only 2% to 3% of pa- tion when evaluating patients with
departments with which they are tients who sustain blunt trauma,1 suspected cervical trauma.
affiliated has received anything of value the potential for instability and cat-
from or owns stock in a commercial astrophic neurologic injury makes
Anatomy and
company or institution related directly or prompt identification and judicious
Biomechanics
indirectly to the subject of this article: management critically important. In
Dr. Kwon, Dr. Vaccaro, Dr. Grauer, a review of 818 patients from the The motion afforded to the cervical
Dr. Fisher, and Dr. Dvorak. National Emergency X-Radiography spine by its unique anatomy also
Utilization Study who had blunt cer- predisposes it to the risk of major in-
Reprint requests: Dr. Kwon, Vancouver
General Hospital, D-6 Heather Pavilion,
vical spine injury identified in the jury and subsequent instability. The
2733 Heather Street, Vancouver, BC,
emergency department, approxi- vertebrae of the subaxial cervical
V5Z 3J5 Canada. mately two thirds of all fractures and spine share similar anatomy with re-
three fourths of all dislocations oc- gard to the anterior and posterior
J Am Acad Orthop Surg 2006;14: curred within the subaxial spine, bony elements, intervertebral disks,
78-89 from C3 to C7.2 Fracture of C7 or joint capsules, ligaments, and sur-
Copyright 2006 by the American dislocation at the C7-T1 junction ac- rounding neurovascular structures.
Academy of Orthopaedic Surgeons. counted for almost 17% of all inju- The transverse process contains the
ries—reinforcing the need to clearly transverse foramen, through which

78 Journal of the American Academy of Orthopaedic Surgeons

 Brian K. Kwon, MD, PhD, FRCSC, et al

the vertebral artery passes (between ability to resist kyphosis—is attrib- strophic, and permanent disability
C1 and C6); the vertebral artery may utable to the posterior capsuloliga- than does unstable cervical spine
be injured in the setting of subaxial mentous structures, which cannot fracture and/or dislocation. Thus,
cervical spine fracture or disloca- be directly visualized radiographi- the importance of a careful, thorough
tion.3 Important soft-tissue struc- cally. Magnetic resonance imaging clinical and radiographic evaluation
tures in the posterior aspect of the (MRI) may play an increasingly im- cannot be overstated. Physical exam-
cervical spine include the facet cap- portant role in our understanding of ination of the patient with a sus-
sules, ligamentum flavum, inter- the extent of spinal disruption and pected cervical spine injury should
spinous ligaments, and supraspinous the potential instability that ensues. begin with the standard trauma re-
ligaments. Their crucial role in pro- suscitation as outlined by the Ad-
viding tensile stability to the cervi- vanced Trauma Life Support proto-
Classification of
cal spine in flexion is demonstrated col. Life-threatening compromise to
Cervical Spine Injury
by the kyphosis that can develop the airway, breathing, and circula-
when they are disrupted, either by The wide variety of causes of subax- tion should be promptly addressed.
force transmission during traumatic ial cervical spine fracture and dislo- Specifically for the cervical spine,
injury or iatrogenically during sur- cation imposes significant challenges the immobilization collar should be
gery.4 in creating a classification system carefully removed and the posterior
that is sufficiently descriptive and cervical spine palpated for tender-
comprehensive but not overly com- ness along the midline or paraspinal
Cervical Spine Stability
plicated. The most widely used clas- tissues. In two recent, large-scale
Spinal stability is arguably the most sification system was proposed in studies, the absence of posterior
important consideration in the de- 1982 by Allen and Ferguson in their midline tenderness in the awake,
finitive management of subaxial cer- retrospective review of 165 subaxial alert patient was used as one of sev-
vical spine trauma. Spinal stability is cervical spine injuries.6 Based solely eral predictors for a low probability
defined by White and Panjabi5 as the on static radiographs and the docu- of significant cervical injury.7,8 The
“ability of the spine under physio- mented and/or inferred mechanisms patient should be carefully log rolled
logic loads to limit patterns of dis- of injury, they devised a classification to enable thorough inspection and
placement so as not to damage or ir- that grouped injuries into phylogenies palpation of the entire spinal axis.
ritate the spinal cord or nerve roots according to their radiographic ap- The examiner should note how the
and, in addition, to prevent incapac- pearance, then arranged them along patient holds his or her head, look-
itating deformity or pain due to a spectrum of anatomic disruption. ing specifically for angular or rota-
structural changes.” Although con- The six phylogenies include (1) flex- tional deformities that may, for
ceptually appealing, establishing the ion-compression, (2) vertical com- example, point to a unilateral facet
stability of a particular cervical pression, (3) flexion-distraction, dislocation. The face and scalp
spine injury is not a yes-or-no issue (4) extension-compression, (5) ex- should be examined for evidence of
but rather a matter of assessing and tension-distraction, and (6) lateral direct trauma, which may not only
determining the extent of instability flexion. Within each phylogeny is a suggest a closed head injury but also
along a continuum. series of stages based on the severity provide insight about the forces dur-
To assist in the estimation of spi- of anatomic disruption. This system ing the accident that were imparted
nal instability, White and Panjabi de- typically is used in research. In the to the head and neck.
veloped a checklist that takes into clinical setting, it is more common to Certain aspects of the history also
consideration the competence of the use a classification and nomenclature should be accounted for because
anterior and posterior spinal ele- based on a combination of radiologic they may provide important clues.
ments, the extent of static and dy- description and mechanistic etiology The physician should review the
namic displacement (including the (ie, compression fracture, burst frac- available details of the accident, the
stretch test), the presence of neuro- tion, flexion-distraction injury). energy and mechanism of injury, the
logic injury, and the anticipated general condition of the patient at
physiologic loads to which the spine the scene, and the presence or ab-
Management in the
subsequently would be subjected. sence of neurologic deficits. A histo-
Emergency Department
Although the White and Panjabi as- ry of a high-energy trauma or tran-
sessment of stability is based largely Acute Resuscitation and sient neurologic symptoms should
on a static radiographic assessment Clinical Evaluation raise the level of suspicion for inju-
of the bone anatomy, it is now recog- Very few injuries, when missed ries that may not be readily evident
nized that much of the stability of at initial evaluation, have the poten- at first glance. The details of the ac-
the cervical spine—particularly its tial to lead to a more sudden, cata- cident may provide insights as to

Volume 14, Number 2, February 2006 79

Subaxial Cervical Spine Trauma

how the injury forces were imparted In the absence of such pain re- setting of a facet dislocation, or the
to the cervical spine and the mecha- sponses, or in distracting or cogni- presence of significant posterior lig-
nism of injury (eg, hyperextension tively altering circumstances (ie, an amentous disruption in the setting of
injury in an elderly person after fall- obtunded or anesthetized, intubated, a modest anterior bony injury, could
ing). multitrauma patient), passive flex- influence subsequent management
In addition to the history relating ion and extension with dynamic flu- of the injury (Figure 2). However, al-
to the actual trauma, it also is im- oroscopic imaging may be helpful to though MRI has the ability to dem-
portant to identify other associated rule out cervical spine injury. How- onstrate even subtle abnormalities
conditions and comorbidities that ever, this must be done with great in the posterior soft tissues, many of
might influence either the nature of caution.12 A grossly obvious injury these findings are clinically insignif-
the injury or the means by which it in the cervical spine should not de- icant.16
is managed. Associated conditions tract from a thorough evaluation of Magnetic resonance and CT an-
that are particularly relevant for pa- the rest of the spine; noncontiguous giography are becoming popular as
tients with suspected cervical spine spinal column injuries have been re- relatively easy methods of evaluating
injury include ankylosing spondyli- ported in 10% to 15% of patients.13 the vertebral artery in the setting of
tis (AS), diffuse idiopathic skeletal The use of computed tomography subaxial cervical trauma. Their abil-
hyperostosis (DISH), previous cervi- (CT) in patients with suspected cer- ity to demonstrate injury of the ver-
cal spine fusion (congenital or ac- vical trauma has become popular be- tebral artery is not questioned. The
quired), and connective tissue disor- cause of the excellent resolution of optimal management of such injuries
ders leading to ligamentous laxity. osseous anatomy that CT provides remains controversial, however, be-
as well as its rapid accessibility in cause most are asymptomatic.3
Imaging Studies most emergency departments (Figure
Numerous imaging modalities 1, A). The regions of the cervical Closed Reduction and
are available for evaluating the cervi- spine most difficult to image ade- Realignment
cal spine after acute trauma. Deter- quately with plain radiographs—spe- Spinal realignment and immobili-
mining the appropriate protocol for cifically, the occipitocervical and zation may be achieved in the emer-
their use, however, remains contro- cervicothoracic junctions—can be gency department with cervical trac-
versial. Each institution should de- easily imaged with CT. Furthermore, tion via skull tongs or a halo ring.
velop a multimodality approach to axial CT images and sagittal recon- The use of cervical traction to re-
clearing the cervical spine in both structions are very helpful for visu- duce a facet fracture or dislocation
awake and unconscious patients, alizing the posterior elements and has been extensively studied be-
based on the contemporary litera- identifying minimally displaced frac- cause of the potential risk of iatro-
ture as well as local capabilities and tures of the lamina and facets, which genic neurologic injury during re-
resources. are difficult to identify on plain ra- duction from pushing back into the
The standard radiographic views diographs. The superior imaging of spinal cord a concomitant disk her-
for evaluating the patient with a sus- bony anatomy and the widespread niation at the level of injury.17 This
pected cervical spine injury include availability of CT scanning have risk has compelled many clinicians
anteroposterior, lateral, and open- compelled some radiologists to sug- to advocate MRI of such injuries be-
mouth odontoid projections to visu- gest that CT be considered before or fore attempting a closed reduction.
alize from the occiput to T1. The in lieu of conventional radiographs.14 There has been no documented re-
importance of visualizing the cer- However, the economic and medi- port of permanent spinal cord injury
vicothoracic junction cannot be colegal implications of recommend- in an awake, cooperative, neurolog-
overstated. The surgeon must be ing CT to identify unstable cervical ically intact patient who underwent
particularly cognizant of subtle spine injuries are considerable. CT of a physician-monitored closed reduc-
abnormalities, such as soft-tissue the cervical spine recently has been tion. In their study of a series of pa-
swelling, hypolordosis, disk-space shown to expose the skin and thy- tients with facet dislocations, Vac-
narrowing or widening, and widen- roid gland to levels of radiation that caro et al18 reported no neurologic
ing of the interspinous distances. are an order of magnitude greater injuries after successful closed re-
Flexion-extension views may pro- than that of plain radiographs.15 duction, even in two awake patients
vide information about ligamentous MRI is able to reveal many trau- known to have disk herniations pri-
integrity, but their utility in awake matic abnormalities in the paraver- or to reduction, and in two others
patients is subject to some contro- tebral soft tissues, particularly of the who had new disk herniations after
versy9,10 because pain and neck intervertebral disk and the posterior the reduction.
spasms may preclude meaningful ligaments (Figure 1, B and C). The However, the fact that the poten-
evaluation of dynamic stability.11 presence of a disk herniation in the tial for a disk protrusion is increased

80 Journal of the American Academy of Orthopaedic Surgeons

 Brian K. Kwon, MD, PhD, FRCSC, et al

Figure 1

A, Computed tomography scan of a patient who sustained a severe flexion-compression injury with coronal and sagittal fractures
through the body (inset). A large anterior fragment has broken off, consistent with a quadrangular fracture. B, Sagittal T2-
weighted magnetic resonance image demonstrating severe cord compression. C, Sagittal T2-weighted magnetic resonance
image demonstrating the opened facet joint and the bright signal that exists within it (arrow).

Figure 2
during a closed reduction warrants with which an MRI may realisti-
use of MRI before any surgical inter- cally be performed.
vention. Closed reduction before
obtaining an MRI should be at-
Use of
tempted only in an incomplete or
Methylprednisolone in
neurologically intact patient when
Acute Spinal Cord Injury
the patient is awake, alert, and able
to cooperate with the neurologic ex- The administration of high-dose
amination. Rapid closed reduction methylprednisolone (30 mg/kg bo-
with no delay (before obtaining an lus followed by a 5.4 mg/kg infu-
MRI) in the awake and alert patient sion), in accordance with the find-
with a complete or high-grade in- ings of the second and third
complete spinal cord injury is prob- National Acute Spinal Cord Injury
ably warranted because such pa- studies (NASCIS), has been standard
tients may be considered to have practice at most North American in-
little to lose even in the presence of stitutions for more than a decade.
a disk herniation.19 The physician The methodology used and interpre- Pre-reduction sagittal T2-weighted
managing a patient with a cervical tation of the data from NASCIS 2 magnetic resonance image demon-
dislocation needs to carefully con- and 3 have come under intense crit- strating a large disk fragment behind
sider the potential benefits and icism in recent years.20 In both of the body of C6 (arrow) in a patient with
hazards of performing a closed re- these prospective randomized stud- bilateral facet dislocation and incom-
plete tetraplegia. The patient had an
duction. The decision may be sig- ies, methylprednisolone failed to
associated disk herniation at C6-C7.
nificantly influenced by factors show significant benefit over pla-
Anterior C6-C7 diskectomy was done
such as a worsening neurologic sta- cebo, conferring a negative result to before intraoperative open reduction.
tus or by the anticipated rapidity the primary outcome measure.

Volume 14, Number 2, February 2006 81

Subaxial Cervical Spine Trauma

Nonetheless, after a post hoc analy- tous disruption but who is neurolog- injuries.6 A purely axial force sub-
sis, it was determined that a signifi- ically intact. Although the patient jects the posterior capsuloligamen-
cantly better neurologic outcome does not need a surgical decompres- tous structures to compression only;
was achieved when patients were sion of the spinal cord, this injury is in theory, therefore, these posterior
treated within 8 hours of injury likely to be mechanically unstable; soft tissues should remain intact to
(NASCIS 2). During the 8-hour time thus, surgical stabilization would be resist bending forces. In practice,
frame, patients who began treat- a reasonable option. Conversely, sur- however, such injuries frequently in-
ment within 3 hours benefitted gical management for neurologic volve an element of forward flexion
from a prolonged, 48-hour infusion reasons is indicated in an individual that imparts a distractive force on
of methylprednisolone (NASCIS 3). with a C5 burst fracture and incom- the posterior elements.
However, continued criticisms of plete quadriplegia from a retropulsed The controversy regarding opti-
the use of methylprednisolone in bone fragment, even if the surgeon mal management of cervical burst
acute spinal cord injury have thinks that the burst fracture itself fractures is related to the impreci-
prompted some Canadian institu- could achieve sufficient mechanical sion with which their mechanical
tions to discontinue its use. At the stability in a halo brace. stability is defined. With spinal cord
very least, it should be recognized Determining the extent of me- compression from retropulsed frag-
that the use of methylprednisolone chanical instability of a cervical in- ments of bone in the neurologically
was advocated only within an acute jury may be challenging. Although compromised patient, there is a
time frame after injury (≤8 hours) the presence of a neurologic injury clear indication for anterior verte-
and only in adult patients with non- often heralds significant mechanical brectomy, reconstruction, and cer-
penetrating injuries. Regardless of its instability, the mere presence of a vical plating to provide both direct
scientific validity, methylpredniso- neurologic injury should not be tak- decompression and mechanical sta-
lone likely will continue to be ad- en as an absolute indication for sur- bility. Less clear is how best to treat
ministered in the United States be- gery. A good example of this is the the burst fracture in the neurologi-
cause of the medicolegal pressures patient with a hyperextension inju- cally intact patient in whom the sur-
exerted on clinicians managing pa- ry and evidence of a neurologic im- gical decision is based primarily on
tients with spinal cord injury. pairment in the central cord. The mechanical stability. There are no
cervical spine in such patients is typ- well-designed prospective random-
ically not unstable, and it either may ized studies to guide the manage-
Surgical Versus
not warrant surgical decompression ment of such injuries. Increased de-
Nonsurgical
or will achieve significant neurolog- grees of mechanical instability are
Management
ic recovery without decompression suggested by anterior translation or
When deciding between surgical and (Figure 3). Patient factors to be con- kyphosis, loss of vertebral body
nonsurgical management, the broad sidered include concomitant inju- height, fracture of the posterior ele-
spectrum of cervical spine trauma ries, noncontiguous spinal injuries, ments (arch or facets), and inter-
requires an individualized, rational smoking, comorbidities, and the spinous widening or other evidence
treatment strategy. In general, it is ability to realistically treat an injury to suggest distractive failure of the
helpful to consider the following nonsurgically (eg, the morbidly posterior elements.
questions: (1) Is there mechanical obese patient who cannot be fitted Koivikko et al21 reported on a ret-
instability, and does it require sur- adequately for a halo brace). rospective comparison of 69 neuro-
gical treatment? (2) Is there neur- logically intact and injured patients
ologic compromise requiring de- with a combination of burst or tear-
Management of
compression, either indirectly (ie, drop fractures treated either surgical-
Specific Injuries
reduction/realignment) or directly ly with anterior decompression and
(ie, surgical decompression)? (3) Are Cervical Burst Fracture stabilization or nonsurgically with
there patient factors that substan- Burst fractures of the subaxial skull traction and halo bracing. The
tially influence the decision wheth- spine involve fractures of the verte- surgical group had markedly better
er to manage the patient surgically bral body (frequently comminuted), neurologic recovery and overall sag-
or nonsurgically? with bony fragments retropulsed ittal alignment than did the nonsur-
An illustrative application of posteriorly into the spinal canal. gically treated group. These results
these considerations would be that Conceptually, these injuries are were echoed in a retrospective co-
of a young male involved in a diving caused by pure axial loading on the hort study comparing patients with
accident who presents with a ky- injured vertebrae, and thus are clas- cervical burst fractures undergoing
photic C5 vertebral body fracture sified within the Allen and Ferguson either halo bracing or anterior cor-
and significant posterior ligamen- phylogenies as vertical compression pectomy and fusion.22 In that study,

82 Journal of the American Academy of Orthopaedic Surgeons

 Brian K. Kwon, MD, PhD, FRCSC, et al

Figure 3 vided by lateral mass or pedicle

screw-and-rod constructs (particu-
larly when anterior decompression
is not required).23

Flexion-Compression
Injury
The Allen and Ferguson flexion-
compression classification is charac-
terized by compressive failure of the
anterior vertebral body with increas-
ing degrees of posterior ligamentous
disruption, the latter being the se-
quelae of forward-bending forces.
These bending forces distinguish
flexion-compression from vertical
compression injuries produced by
pure axial loading (Figure 5). At one
extreme, these represent the minor
anterior compression fractures of the
anterosuperior end plate that are
generally stable and require no more
than a cervical orthosis to heal. At
the other extreme, these represent
severe injury involving compressive
failure of the vertebral body with as-
sociated posterior ligamentous dis-
ruption and/or dislocation. These in-
juries are often called anterior
teardrop or quadrangular fractures.
The teardrop fracture is an injury in
which the severe forward-bending
forces fracture off a triangular piece
of the anterior lip of the rostral ver-
tebral body, often with retrolisthesis
of the remaining body into the spinal
canal. The quadrangular fracture is
Acute central cord syndrome in a 40-year-old man with incomplete spinal cord injury
distinguished from the teardrop frac-
without significant mechanical instability or compression. The patient was the seat-
belted driver of a vehicle stopped at an intersection; he was rear-ended at high
ture, as an injury in which a large
speed, causing a severe hyperextension/whiplash injury. He had immediate bilateral piece of anterior vertebral lip is frac-
arm weakness and paresthesias and, on presentation, demonstrated MRC grade tured off. It is seen in association
3/5 power in his biceps and wrist extensors. A, Normal-appearing original lateral with retrolisthesis, kyphosis, and
plain radiograph. B, Sagittal T2-weighted magnetic resonance image demonstrating circumferential soft-tissue disrup-
a disk bulge at C5-C6 and signal change within the spinal cord behind the body tion, the combination of which re-
of C5. No significant soft-tissue disruption was apparent. C and D, Post- sponds poorly to posterior fixation
immobilization follow-up flexion-extension lateral radiographs demonstrating no alone.24 Behind the teardrop or qua-
dynamic instability (albeit with only modest excursion secondary to splinting). drangular fragment, the cervical ver-
tebral body is often split in the sag-
surgical fixation was superior to halo ittal alignment and stability, it is ittal plane (Figure 5, B).
bracing for alignment and fusion, al- important to consider, particularly The approach to flexion-com-
though overall patient-reported out- in young patients, the potential con- pression injuries differs little from
comes were not superior to halo sequences of losing motion over two that of burst fractures in that the ex-
bracing22 (Figure 4). disk spaces. Alternatively, cervical tent of mechanical instability re-
Although single-level vertebrec- burst fractures may be treated with quires an evaluation of anterior
tomy and fusion offers reliable sag- posterior segmental fixation pro- height loss, translation, sagittal an-

Volume 14, Number 2, February 2006 83

Subaxial Cervical Spine Trauma

Figure 4

A, Sagittally reconstructed computed tomography scan demonstrating kyphosis and slight retropulsion (inset) in a 30-year-old
man who sustained a cervical burst fracture in a high-speed motor vehicle accident. The patient was neurologically intact and
exhibited no obvious clinical or radiographic evidence of significant posterior ligamentous injury. The decision to operate was
made based on an estimation of mechanical stability. Lateral (B) and anteroposterior (C) radiographic views taken after the
cervical burst fracture was managed surgically with corpectomy, titanium cage reconstruction, and anterior cervical plating. An
allograft or prosthesis, such as the titanium cage, may be used with autogenous bone graft taken from the corpectomy bone,
thus avoiding the need to harvest bone from the iliac crest.

Figure 5

A, Lateral cervical spine radiograph demonstrating a large teardrop fragment in a patient who sustained a flexion-compression
injury with complete tetraplegia. B, Sagittal computed tomography scan demonstrating osseous detail showing canal
encroachment and sagittal alignment. Severe retropulsion and fractures of the posterior arch are evident (insets). C, The sagittal
T2-weighted magnetic resonance image demonstrates no significant posterior disruption.

84 Journal of the American Academy of Orthopaedic Surgeons

 Brian K. Kwon, MD, PhD, FRCSC, et al

Figure 6

Unilateral facet injury at C5-C6 and C6-C7 demonstrating both facet fracture and dislocation in a 25-year-old man who plunged
headfirst into a snowbank while skiing. He reported immediate neck pain and right arm paresthesias and weakness, and was
found to have MRC grade 4/5 strength in his right wrist extensors and triceps. A, Sagittal computed tomography scan through
the midline demonstrating the typical amount of anterior translation found with unilateral facet injuries. B, Sagittal computed
tomography scan through the facets demonstrating facet fracture (asterisk) of C5 (top inset) with perching of the remaining
lateral mass as well as the dislocation of C6 on C7 (bottom inset). C, Postoperative lateral radiograph. After magnetic resonance
imaging was performed to rule out disk herniation, the patient was treated with posterior open reduction and C5-C7 fusion.

gulation, and, most important, the Ferguson categorized these injuries tured, subluxated, or dislocated
competence of the posterior ele- in the flexion-distraction phylogeny (“locked”), either unilaterally or bi-
ments. Posterior element disruption and assigned them varying levels of laterally. The unilateral injury pro-
may make these flexion-compres- severity: facet subluxation (stage 1), duces a so-called double-sail sign on
sion injuries extremely unstable. unilateral facet dislocation (stage 2), the lateral view. CT is invaluable for
Although treatment options are not bilateral facet dislocation with 50% defining the bony anatomy of the in-
dissimilar to those for cervical burst displacement (stage 3), and complete jury, demonstrating malalignment
fractures, such instability may favor dislocation (stage 4).6 Facet fracture of the facet as well as fracture of the
surgical stabilization over halo im- and dislocation injuries represent a pedicle or lamina on axial images,
mobilization. The pronounced in- spectrum of osteoligamentous pa- and fracture of the facets (which typ-
stability of some flexion-compres- thology ranging from pure ligamen- ically occur in the axial plane) on
sion injuries also may warrant tous dislocation to osseous fracture sagittal reconstruction (Figure 6). In
circumferential stabilization. Mi- of the facet and/or lateral mass. Fail- addition to demonstrating disk her-
nor anterior column injuries may be ure of the posterior musculature, in- niations and the extent of posterior
sufficiently immobilized in a cervi- terspinous ligament, ligamentum ligamentous injury, MRI also may
cal orthosis or halo vest. flavum, and facet capsules has been demonstrate signal change within
demonstrated on MRI in patients the spinal cord.
Facet Fracture and with both unilateral and bilateral Definitive management of unilat-
Dislocation facet dislocation.25 eral or bilateral facet dislocation be-
Facet dislocation or fracture- The radiographic appearance of gins with considering a closed reduc-
dislocation is caused by flexion and facet injuries reflects differing de- tion with skull traction, while
distraction forces, with or without grees of soft-tissue and bony dis- recognizing the risks of disk hernia-
an element of rotation. Allen and ruption. The facets may be frac- tion. Closed reduction with skull

Volume 14, Number 2, February 2006 85

Subaxial Cervical Spine Trauma

tongs should be performed only in Reduction following anterior dis- stability is high, and patient out-
the awake, cooperative patient kectomy may be performed with a comes (in the absence of spinal cord
whose neurologic status can be distractor placed within the disk injury) are generally good.34
monitored during the reduction. Be- space or, alternatively, with distrac-
cause weight is sequentially added tion pins inserted into the vertebral Extension-Distraction
to the skull tongs, neurologic exam- bodies.28,29 The anteriorly dislocated Injury
ination should be performed and ra- vertebral body is then pushed or le- Hyperextension injuries are par-
diography used to demonstrate the vered back into position once suffi- ticularly common in the elderly,
relationship between facets and en- cient distraction is achieved to dis- who, upon falling forward, strike
sure that the cervical spine is not be- engage the facets. their heads and force their often
ing overdistracted. Great disparity Posterior reduction may be per- spondylotic and kyphotic cervical
exists in the literature as to what formed by applying distraction spines into extension. The posterior
constitutes a safe weight limit for a across the spinous processes or infolding of the ligamentum flavum
closed reduction.26 Although many across the lamina using a modified on a spinal canal already narrowed
authors advocate applying 10 to 15 laminar spreader.30 Although burring by posterior vertebral osteophytes
pounds for the weight of the head, away part of the superior facet may may cause a severe spinal cord injury
then adding 5 to 10 pounds of weight help disengage the locked facets, it even in the absence of bony or liga-
per level of injury, safe closed reduc- may increase the instability once re- mentous disruption. In such injuries,
tions have been reported with duction has been achieved. spinal instability often is not a signif-
weights up to 140 pounds.27 A mild Choices for definitive stabiliza- icant concern. The primary consider-
degree of neck flexion and rotation tion of facet injury include external ation is whether decompression of
may be necessary to disengage the immobilization or internal fixation. the spinal cord is necessary, and, if
locked facet. A cervical orthosis or halo brace so, whether it should be performed
Open reduction of facet injury is may provide sufficient stability for early or be delayed. Although no pro-
indicated when closed reduction fails facet fracture with minimal dis- spective randomized studies cur-
because of the presence of a facet frac- placement (≤1 mm), in which long- rently exist to resolve the issue of
ture or a lateral mass dissociation, or term stability will be achieved on timing of decompression in patients
in the presence of neurologic worsen- osseous union.31 Upright radiographs with central cord injury, a retrospec-
ing. Open reduction also is indicated taken at frequent intervals during tive study by Guest et al35 reported
when closed reduction is deemed un- follow-up should be carefully scruti- no neurologic benefit to early de-
likely to succeed because of delayed nized for loss of reduction. For pure- compression (within 24 hours of in-
presentation. Several techniques have ly ligamentous injuries, however, jury) in elderly patients with spon-
been described for achieving open re- the ability of external immobiliza- dylosis. Younger patients with
duction either anteriorly or posteri- tion to provide sufficient stability in fractures or acute disk herniations
orly. Although anterior open reduc- both the short and long term is less did achieve better motor recovery
tion is technically more demanding, predictable. Several reports have with early decompression.
its primary advantage is the ability to demonstrated persistent pain and in- It is extremely important to rec-
remove an extruded disk herniation stability, particularly when the re- ognize that an extension injury in
before spine realignment. duction is either not obtained or is the elderly patient with cervical
Difference of opinion exists as to lost during brace treatment.31-33 spondylosis is a distinct entity from
what constitutes a disk herniation in For this reason, facet dislocations that of the patient with a fused cer-
the setting of facet dislocation. In are more commonly managed with vical spine secondary to AS or DISH.
their study using MRI before and af- anterior or posterior arthrodesis, or In the patient with AS or DISH, the
ter reduction of facet dislocations, both. Anterior stabilization involves circumferentially fused cervical
Vaccaro et al18 defined disk herniation diskectomy and fusion with a struc- spine behaves more like a long bone
as material with signal consistent tural graft (usually tricortical iliac when fractured; hence, such injuries
with nucleus pulposus protruding crest autograft) and plate fixation. are extremely unstable, even when
posterior to the cortical wall of the For posterior arthrodesis, several fix- minimally displaced.36 The major
subjacent vertebral body. In principle, ation choices exist, including inter- pitfall in managing such patients is
however, any disk material that may spinous wiring, oblique wiring (be- the failure to identify the cervical in-
be pushed into the spinal cord on re- tween the lateral mass and spinous jury; the surgeon may be misled by
duction by virtue of lying posterior to process), lateral mass plates, and in- the low-energy injury mechanism,
either the dislocated or subjacent ver- terlaminar clamps. With these tech- lack of significant discomfort or neu-
tebral body warrants consideration for niques, the rate of solid arthrodesis rologic injury, and subtle radiograph-
anterior diskectomy. and the achievement of long-term ic features. Reports are not infre-

86 Journal of the American Academy of Orthopaedic Surgeons

 Brian K. Kwon, MD, PhD, FRCSC, et al

quent of patients with AS and DISH Figure 7

whose cervical fractures were
missed because of their benign orig-
inal presentation; the neurologic
consequences can be devastating,
even fatal. During triage of a patient
with AS suspected of having a cervi-
cal spine fracture, the surgeon
should be particularly cautious with
the position in which the head is sta-
bilized. The head should be propped
up with bolsters or gentle halo trac-
tion into a position that reproduces
the patient’s native alignment, rath-
er than forcing it into extension with
a standard hard collar (Figure 7).
The definitive stabilization for AS
patients with cervical fractures has
traditionally been nonsurgical appli-
cation of a halo vest; however, halo
immobilization is not without risks
(eg, pin-site problems, swallowing
difficulties, pulmonary problems).
The long lever arms created by the
rigidly fused spinal column above
and below the fracture impose a
challenging biomechanical environ-
ment to healing and may provide a
compelling rationale for surgical fix-
ation anteriorly, posteriorly, or cir-
cumferentially.

Complications A, Lateral radiograph of a C5-C6 extension-distraction injury in a man with

The most significant mistake relat- ankylosing spondylitis who fell backward from a height of approximately 3 feet and
ed to subaxial cervical spine injury is landed on his back. The emergency personnel did not initially recognize that he had
ankylosing spondylitis. B, Lateral radiograph taken after the head was flexed and
missing the diagnosis. Because the
supported on bolsters in an attempt to reproduce his native alignment. C,
neurologic stakes are high, vigilance
Subsequent sagittal computed tomography scan demonstrating that even on the
is required when evaluating patients bolsters, the patient remains in extension, but the spinal canal appears to be patent.
suspected of having such an injury. D, Sagittal computed tomography scan demonstrating another extension-
Vertebral artery injuries are asso- distraction injury at T10-T11 (asterisk). The patient underwent posterior fixation of
ciated with blunt cervical trauma both injuries simultaneously, followed by anterior C5-C6 stabilization.
with alarming frequency. In a sys-
tematic review of the literature on
vertebral artery injury, the incidence prolonged immobilization should be potension, ascending spinal cord
was estimated to be as high as 11% anticoagulated unless this is medi- necrosis, epidural hematoma (partic-
in patients with cervical injury.3 The cally contraindicated. ularly in patients with AS), and ver-
management of such injuries is con- Neurologic deterioration of either tebral artery injury. The treatment of
troversial; many go unnoticed and the neurologically intact or the spi- acute deterioration includes rapidly
untreated without sequelae. For pa- nal cord–injured patient can occur, identifying and reversing systemic
tients symptomatic from one or and it has been reported in as many hypotension, optimizing oxygen-
more vertebral artery injuries, con- as 6% of patients with spinal cord ation, and using imaging studies to
sideration should be given to antico- injury.37 Potential mechanisms for determine a structural cause. Plain
agulation therapy.3 Also, patients such deterioration include inade- radiographs may identify problems
with neurologic deficit or those with quate immobilization, sustained hy- with alignment that can be rectified

Volume 14, Number 2, February 2006 87

Subaxial Cervical Spine Trauma

with rapid reduction and/or traction. Citation numbers printed in bold ries of the neck. Radiol Clin North
MRI is invaluable in such situations, type indicate references published Am 1999;37:515-532.
15. Rybicki F, Nawfel RD, Judy PF, et al:
and CT myelography may be useful within the past 5 years.
Skin and thyroid dosimetry in cervi-
when extensive spinal instrumenta- cal spine screening: Two methods for
tion precludes adequate MR visual- 1. Lowery DW, Wald MM, Browne BJ, evaluation and a comparison between
Tigges S, Hoffman JR, Mower WR: Ep-
ization. Administration of cortico- a helical CT and radiographic trauma
idemiology of cervical spine injury
steroid should be considered. series. AJR Am J Roentgenol 2002;
victims. Ann Emerg Med 2001;38:12-
179:933-937.
Managing subaxial cervical spine 16.
16. Benzel EC, Hart BL, Ball PA, Baldwin
injuries with halo immobilization 2. Goldberg W, Mueller C, Panacek E,
Tigges S, Hoffman JR, Mower WR: NG, Orrison WW, Espinosa MC: Mag-
involves several potential complica- netic resonance imaging for the eval-
Distribution and patterns of blunt
tions, including pin loosening, infec- traumatic cervical spine injury. Ann uation of patients with occult cervical
tion, pain, and intracranial intru- Emerg Med 2001;38:17-21. spine injury. J Neurosurg 1996;85:
sion; nerve injury; pressure sores 3. Management of vertebral artery inju- 824-829.
ries after nonpenetrating cervical 17. Eismont FJ, Arena MJ, Green BA: Ex-
from the vest; and an inability to suf-
trauma. Neurosurgery 2002;50(3 trusion of an intervertebral disc asso-
ficiently immobilize particularly un- ciated with traumatic subluxation or
suppl);S173-S178.
stable cervical spine injuries. Surgi- 4. Albert TJ, Vacarro A: Postlaminecto- dislocation of cervical facets: Case re-
cal management is accompanied by my kyphosis. Spine 1998;23:2738- port. J Bone Joint Surg Am 1991;73:
all of the potential complications as- 2745. 1555-1560.
sociated with anterior or posterior 5. White AA III, Panjabi MM: Clinical 18. Vaccaro AR, Falatyn SP, Flanders AE,
Biomechanics of the Spine, ed 2. Phil- Balderston RA, Northrup BE, Cotler
surgery and fixation to the cervical
adelphia, PA: JB Lippincott, 1990. JM: Magnetic resonance evaluation of
spine, including vascular injury, 6. Allen BL Jr, Ferguson RL, Lehmann the intervertebral disc, spinal liga-
neurologic injury, dural tears, esoph- TR, O’Brien RP: A mechanistic classi- ments, and spinal cord before and af-
ageal tears, infection, and hardware fication of closed, indirect fractures ter closed traction reduction of cervi-
loosening. and dislocations of the lower cervical cal spine dislocations. Spine 1999;24:
spine. Spine 1982;7:1-27. 1210-1217.
7. Hoffman JR, Mower WR, Wolfson AB, 19. Hart RA, Vaccaro AR, Nachwalter RS:
Summary Todd KH, Zucker MI: Validity of a set Cervical facet dislocation: When is
of clinical criteria to rule out injury to magnetic resonance imaging indicat-
Subaxial cervical spine injury re- the cervical spine in patients with ed? Spine 2002;27:116-117.
quires careful clinical and radio- blunt trauma. National Emergency 20. Kwon BK, Tetzlaff W, Grauer JN,
X-Radiography Utilization Study Beiner J, Vaccaro AR: Pathophysiolo-
graphic evaluation and a high index
Group. N Engl J Med 2000;343:94-99. gy and pharmacologic treatment of
of suspicion because failure to iden- 8. Stiell IG, Wells GA, Vandemheen KL, acute spinal cord injury. Spine J 2004;
tify such injury can lead to progres- et al: The Canadian C-spine rule for 4:451-464.
sive deformity and catastrophic radiography in alert and stable trauma 21. Koivikko MP, Myllynen P, Karjalain-
neurologic consequences. Under- patients. JAMA 2001;286:1841-1848. en M, Vornanen M, Santavirta S: Con-
9. Brady WJ, Moghtader J, Cutcher D, servative and operative treatment in
standing the epidemiology, anat-
Exline C, Young J: ED use of flexion- cervical burst fractures. Arch Orthop
omy, biomechanics, and classifica- extension cervical spine radiography Trauma Surg 2000;120:448-451.
tion of subaxial cervical spine in the evaluation of blunt trauma. 22. Fisher CG, Dvorak MF, Leith J, Wing
injuries is important. They may Am J Emerg Med 1999;17:504-508. PC: Comparison of outcomes for un-
present with a breadth of pathology, 10. Pollack CV Jr, Hendey GW, Martin stable lower cervical flexion teardrop
DR, Hoffman JR, Mower WR: Use of fractures managed with halo thoracic
but a sound treatment approach that
flexion-extension radiographs of the vest versus anterior corpectomy and
takes into consideration the me- cervical spine in blunt trauma. Ann plating. Spine 2002;27:160-166.
chanical stability of the injury, the Emerg Med 2001;38:8-11. 23. Brodke DS, Anderson PA, Newell
neurologic status, and other patient- 11. Wang JC, Hatch JD, Sandhu HS, DW, Grady MS, Chapman JR: Com-
related factors (eg, AS, DISH) can aid Delamarter RB: Cervical flexion and parison of anterior and posterior ap-
extension radiographs in acutely in- proaches in cervical spinal cord inju-
in selecting a reasonable plan for de-
jured patients. Clin Orthop 1999; ries. J Spinal Disord Tech 2003;16:
finitive management. Several com- 365:111-116. 229-235.
plications can occur, but the most 12. Cox MW, McCarthy M, Lemmon G, 24. Favero KJ, Van Peteghem PK: The qua-
frequent is missing the injury on ini- Wenker J: Cervical spine instability: drangular fragment fracture: Roent-
tial evaluation. Clearance using dynamic fluorosco- genographic features and treatment
py. Curr Surg 2001;58:96-100. protocol. Clin Orthop 1989;239:40-
13. Vaccaro AR, An HS, Lin S, Sun S, 46.
References Balderston RA, Cotler JM: Noncontig- 25. Vaccaro AR, Madigan L, Schweitzer
uous injuries of the spine. J Spinal ME, Flanders AE, Hilibrand AS, Al-
Evidence-based Medicine: There are Disord 1992;5:320-329. bert TJ: Magnetic resonance imaging
no level I or II evidence-based stud- 14. LeBlang SD, Nunez DB Jr: Helical CT analysis of soft tissue disruption after
ies referenced in this review. of cervical spine and soft tissue inju- flexion-distraction injuries of the sub-

88 Journal of the American Academy of Orthopaedic Surgeons

 Brian K. Kwon, MD, PhD, FRCSC, et al

axial cervical spine. Spine 2001;26: ative reduction of locked facets in J Neurosurg 1999;91:19-24.
1866-1872. the cervical spine by use of a modi- 34. Wiseman DB, Bellabarba C, Mirza SK,
26. Initial closed reduction of cervical fied interlaminar spreader: Techni- Chapman J: Anterior versus posterior
spine fracture-dislocation injuries. cal note. Neurosurgery 2001;48:444- surgical treatment for traumatic cer-
Neurosurgery 2002;50:S44-S50. 445. vical spine dislocation. Curr Opin
27. Cotler JM, Herbison GJ, Nasuti JF, 31. Hadley MN, Fitzpatrick BC, Sonntag Orthop 2003;14:174-181.
Ditunno JF Jr, An H, Wolff BE: Closed VK, Browner CM: Facet fracture-dis- 35. Guest J, Eleraky MA, Apostolides PJ,
reduction of traumatic cervical spine location injuries of the cervical spine. Dickman CA, Sonntag VK: Traumatic
dislocation using traction weights up Neurosurgery 1992;30:661-666. central cord syndrome: Results of sur-
to 140 pounds. Spine 1993;18:386- 32. Rorabeck CH, Rock MG, Hawkins RJ, gical management. J Neurosurg 2002;
390. Bourne RB: Unilateral facet disloca- 97:25-32.
28. de Oliveira JC: Anterior reduction of tion of the cervical spine: An analysis 36. Kwon BK, Hilibrand AS: Cervical frac-
interlocking facets in the lower cervi- of the results of treatment in 26 pa- tures in patients with diffuse idio-
cal spine. Spine 1979;4:195-202. tients. Spine 1987;12:23-27. pathic skeletal hyperostosis. Curr
29. Ordonez BJ, Benzel EC, Naderi S, 33. Shapiro S, Snyder W, Kaufman K, Abel Opin Orthop 2003;14:187-192.
Weller SJ: Cervical facet dislocation: T: Outcome of 51 cases of unilateral 37. Harrop JS, Sharan AD, Vaccaro AR,
Techniques for ventral reduction and locked cervical facets: Interspinous Przybylski GJ: The cause of neurolog-
stabilization. J Neurosurg 2000;92: braided cable for lateral mass plate fu- ic deterioration after acute cervical
18-23. sion compared with interspinous wire spinal cord injury. Spine 2001;26:
30. Fazl M, Pirouzmand F: Intraoper- and facet wiring with iliac crest. 340-346.

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