Adult Cervical Spine Fractures

Introduction
Anatomy
Causes
Types
Symptoms
Evaluation
Treatment
Rehabilitation
Complications
Summary

Introduction

There are probably no more scary words to describe an injury than "broken neck". For
hundreds of years it was almost the same as "sudden death". Even today when you, or
someone close to you, has "broken their neck" this event is bound to send anxiety to a new
high. Fractures of the neck are actually quite variable. Some injuries are a great threat to life
and independence; others are much simpler with excellent prospects for full recovery. Today, if
you are alive after a neck fracture you are quite unlikely to die suddenly as long as you
cooperate with the treatment. But, partial or complete paralysis after a neck injury is still a
serious problem and may be permanent.
This guide will help you understand
1

what parts of the neck are involved

what the symptoms are
what can cause these fractures
how doctors diagnose these fractures
what the treatment options are

Anatomy
What structures are most commonly injured?

The neck is the flexible connection between the head and the body. The head is controlled by
muscles that start from the neck or shoulder girdle and attach to the skull. The cervical spine is
made up of seven bones called vertebrae. Between each vertebra are two joints. These joints
allow a little movement between each vertebra forwards and backwards called flexion and
extension, side to side movement, and rotation. Because there are seven segments, the small
movement between each bone is multiplied. The neck as a whole can flex forward 45 degrees
until the chin almost touches the chest and backward 50 degrees, until the chin is level with the
ears.
Normally, you can bend your neck from side to side about 40 degrees. This means that you can
put your ear halfway to the shoulder. Most people can rotate their head about 70 degrees,
placing the chin on the shoulder. Injuries to the neck occur most often when the neck is forced
beyond its normal range of movement - over rotation for example. The momentum of the head
is important in the mechanism of injury. Neck injuries very often result from sudden changes in
acceleration as in falls, motor vehicle accidents (particularly motorcycles), sports injuries, or
diving into shallow water. The head wants to go one way and the body another. The neck in
between becomes strained and is damaged.

The anatomical structure of the neck helps to explain how injuries occur. Each vertebra has a
drum-like vertebral body in front. This is where the weight is transferred. The vertebral body

can be injured when the compression forces on the neck are excessive. This may occur with
little force when the bone itself is weakened by aging processes like osteoporosis.
Between one vertebral body and the next are ligaments. The ligaments prevent excessive
movement. The intervertebral disc is a special type of ligament that sits between each vertebra.
The disc provides some shock absorption and allows some rocking front to back and side to side
movement. Too much compression may rupture the disc. Too much rocking can tear off the
ligaments and cause instability between vertebrae.

Behind the vertebral body is an arch of bone called the lamina which protects the spinal cord,
an extension of the brain that passes down to the level of the waist. At the back of the arch the
spinous process projects backward. You can feel the tips of the spinous processes by pressing
on the back of the neck. The lateral masses and the transverse processes project outwards from
the arch. All these processes act as points of attachment for muscles of the neck. The lateral
masses also act as support for joints with the next vertebra. Pull-off, or avulsion injuries occur
where the muscles and ligaments attach to the spinous process, the transverse processes, and
even sometimes the vertebral bodies.

The vertebrae stack on one another with facet joints between the lateral masses. The joints
allow some movement of the neck. Too much movement can dislocate the joints, tear the
ligaments and fracture the lateral masses and the laminae. These injuries are dangerous
because the spinal cord and the spinal nerves are so close.
Spinal Cord Injury

With certain patterns of neck injury, damage to the spinal cord can cause quadriplegia (also
called tetraplegia). Spinal cord injury affects the legs as well as the arms and usually both sides
of the body are involved. This condition results in partial or complete paralysis below the neck.
There may be no sensation or movement of the arms and legs (complete quadriplegia) or there
3

may be movement and sensation in some areas left unchanged (incomplete quadriplegia). Both
complete and incomplete quadriplegia may partly recover if the pressure from the bone
fragments is relieved before the spinal cord tissue dies. Spinal cord tissue does not re-grow so
any recovery may be partial. A great deal of attention in the management of neck fractures is
paid to preventing spinal cord injuries from occurring or getting worse.
Spinal Nerve Injury

The nerves that leave the spinal cord in the neck pass into the arm and supply sensation and
the control of movement in the arm and hand. The spinal nerves as they leave the spine are
sometimes referred to as the "nerve roots". These spinal nerves travel very close to the bone of
the vertebrae and to the intervertebral disc. As a result, they may be damaged or compressed
by injury to these structures. Injury to the spinal nerves causes loss of sensation or weakness,
often on one side only. The pattern of nerve function loss gives a clue as to which nerve root is
injured.

Causes
How do fractures of the cervical spine commonly happen?

The complexity of the bone shapes and the various different ways that the neck may be
stressed means that there are a large number of fracture patterns. These patterns are
recognized and classified by the doctors to help with the treatment plan. This level of detail is
not needed here but the fractures will be grouped according to mechanism of injury.
One important concept to understand about spine fractures is the stability of the injury. A
stable fracture is one in which the broken pieces are not likely to move further out of position.
The deformity seen on the initial X-rays will likely remain after healing. The critical aspect of
4

stability is that damage or further damage to nerves or the spinal cord is unlikely in a stable
fracture.
An unstable fracture is more dangerous. An unstable fracture carries the risk that the bone
fragments may shift further out of position. The alignment of an unstable fracture may actually
get worse over time. This can cause spinal cord or spinal nerve injury.

Types
Burst Fractures

Flexion Fractures
Atlantoaxial, Anterior Wedge fracture, Burst :

Teardrop Fracture, Odontoid, Spinous Process Fracture, Facet Dislocation:

Subluxation Injury

Symptoms
What symptoms do cervical spine fractures cause?

Many people with a broken neck have sustained multiple injuries. They may be unconscious or
unable to cooperate and describe their symptoms. If there is any suspicion of a neck injury it is
common practice to x-ray the neck to "clear" the cervical spine before moving or examining a
patient. Emergency health care workers are very careful to protect the neck until the stability of
the cervical spine is confirmed.
The most common symptom of a broken neck is pain. It may be localized to the neck or
experienced in the shoulders or arms if the nerves are injured. The pain may be increased by
moving the neck. Absence of pain does not rule out serious injury. The neck region is likely to
be tender but the injured parts are so deep that feeling the broken parts is not possible and
deep pressure not advisable.
Paralysis, loss of voluntary motor power, or numbness in the arms, trunk, or legs is an
indication of spinal cord injury. One-sided neurological loss may be an indication of nerve root
injury. The patterns and combinations of nerve and spinal cord injuries may be quite
complicated. Some patients complain of a feeling of instability and even hold their head to
"prevent it falling off" to alleviate this sensation. This is a very good indication of an unstable
neck injury.

Evaluation
How will my fracture be evaluated?

Different types of fracture patterns relate both to the mechanism of injury and to the stability
of the injury and therefore the prognosis. Evaluation of a neck injury begins with getting an
account of the accident that caused it and reconstructing the forces that acted on the neck. This
information may help to understand what type of injury to the cervical spine may have
occurred.
A series of x-rays are taken. It is now common to do a CT scan of the spine if there has been a
fracture or if there is a high index of suspicion for fracture. THE CT scan is more sensitive and

may show fractures no seen on plain x-rays. If there is neurological injury or suspicion of
intervertebral disc injury then an MRI is often done.
A careful physical examination is done to find any neurological problems. This helps to establish
the completeness and level of the Spinal Cord Injury (SCI) if there is one. If the exam does not
correlate well with the x-rays then further x-rays may be needed to rule out spine injuries at
more than one level. If the patient has sustained multiple injuries, these must be evaluated and
treated as well.

reatment
What treatments should I consider?

The goal of treatment for a fractured neck is to protect the spinal cord and nerves. The broken
bones themselves heal well. Once they do, the injury becomes much more stable and less
dangerous. Treatment is aimed at keeping the bones in good position, preventing instability
and holding everything still until bone healing occurs. The spectrum of treatment runs from
symptom relief and a soft collar - to surgery to reduce the fractures and stabilize the neck with
wires, plates and screws.
Nonsurgical Treatment

Soft Collar

Stable fractures, such as the simple anterior compression fractures and spinous process
fractures may only require symptomatic support. The soft collar is commonly used. The soft
collars are made of foam rubber. They fit snugly round the neck and improve comfort, but they
do not support the head or protect the neck from further injury.
Hard Collar

For more significant, but stable fractures, a hard collar may be a better choice. It is not possible
to completely immobilize the neck with a hard collar, but you can limit flexion, extension and
rotation. Stable patterns of C1 and C2 fractures (Type I Odontoid, C2 Pedicle fracture, Extension
Teardrop Fracture) can often be treated in this fashion. These devices are made of rigid
materials and are adjustable to fit against the back of the head and under the chin. They
essentially prevent major movements of the neck. They may also be used after surgery.
Traction
Traction is commonly used immediately after a spinal fracture to stabilize the cervical spine.
Traction is applied by placing special tongs into the skull under local anesthetic. The tongs are
made of two parts: a C-shaped metal brace that will be placed over the skull, and two metal
pins threaded through the ends of the tongs. The metal pins are inserted through the skin and
into the bone of the skull, one on either side of the head just above the ear. The tongs grip the
skull so that traction can be applied pulling the head away from the body.

A cord is placed from the tongs to a pulley at the head of the bed and
weights applied. Traction is usually a temporary measure to assist with reduction of fractures or
dislocation of the neck, or to keep the neck stable while assessment is made or a treatment
plan. Traction is often followed by immobilization in a halo thoracic brace or by definitive
surgery to maintain position while the bones heal.
Halo-thoracic Brace

A Halo is used when an unstable fracture requires immobilization of the cervical spine. The
"halo" gets its name from the metal ring which is fixed to the skull with screw pins. It is
attached by metal bars to a vest which goes around the chest (thorax). This arrangement means
that the weight of the head is not transferred to the neck but is diverted through the brace. The
brace also reduces movement of the neck. The upper end of the neck is held more stationary
than the lower end where there is movement between the vest and the chest. This option is
used for more unstable patterns of upper cervical injury and post operation to protect the area
while the bone heals.
Surgery
Surgery is avoided where possible. Surgery is undertaken without hesitation in an unstable
fracture with risk of causing or worsening SCI.
Surgery is required for many unstable cervical spine fractures. If an unstable fracture shifts
position in a brace or traction, or if the patient's neurological condition gets worse, then
surgery is undertaken to restore stability. Some fracture patterns are so unstable that
deterioration is very likely. Surgery may be recommended as a preventive measure to prevent
spinal cord damage. The surgeon analyzes the fracture pattern to determine whether the most
serious disruption is in front or behind. If the main problem is in front the neck is exposed from
the front and stability restored by fixing the bones with screws, wires, or metal plates. When
the damage is at the back, then surgery is undertaken through the back of the neck.
Fusion means joining one vertebra to another and allowing the two (or more) vertebrae grow
together, or fuse, into one bone. When the vertebrae are fused, the motion between the two
vertebrae is eliminated permanently and stability is restored. This type of operation may be
undertaken for burst fractures and some unstable odontoid fractures. The metal implants
inserted to hold the bone usually remain in place forever. It is unusual for wires, screws, or
plates to cause any symptoms in this region.

Rehabilitation
What happens as I recover?

Healing of the bony injury takes approximately three months to achieve 80% of eventual
strength, enough to return to light normal activities. Bracing is usually continued for this length
of time. After that there are slow improvements that may continue for up to 18 months.
The healing of the soft tissue components of a neck injury are even more important than they
are in other injuries. If the muscles and ligaments are torn, the mechanics of the cervical spine
may never fully recover. If there is a nerve injury or spinal cord injury the recovery is often
incomplete. A nerve or spinal cord injury affects recovery far more than the bone injury.

The spectrum of outcomes after a neck fracture goes from complete recovery and full return to
normal function in three to six months to permanent paralysis and a wheelchair existence. It is
usually possible to determine, quite early, which of these outcomes will occur. Both of these
extremes require physical therapy but, of course, of very different types. Those destined for full
recovery need to undertake an early exercise program that will safely maintain the function of
the unaffected limbs and then exercise the neck and upper extremities to recover strength,
range, and endurance. By contrast, those with a spinal cord injury need early rehabilitation
focusing on strengthening the remaining function of the arms and learning mobility in a
wheelchair. Maintaining independence despite paralysis is the goal of rehabilitation.
Apart from the permanent nerve injuries, the main long-term concern from neck fractures is
post traumatic arthritis. If the joints of the neck are injured or if the disc is disrupted, neck
mechanics will not be normal. Over time, this may result in pain and stiffness of the neck.
Arthritis in the neck may cause formation of bone spurs around the joints. In time, these may
interfere with nerve or spinal cord function. Fusion at the time of the acute injury is intended to
prevent this type of outcome.

Complications
What are the potential complications of this fracture?

Because neck fractures often occur in the setting of multiple trauma the complications of other
injuries, head trauma, shock, chest and abdominal injuries or long bone fractures may take
precedence. Spinal shock in the context of SCI is also a concern. However, assuming that these
elements are cared for by the trauma team there are still complications specific to the injury.
Malunion

Malunion occurs when a fracture heals in a bad position. This can occur if reduction is
unsuccessful or efforts to hold an unstable fracture fail. In the cervical spine, bad position usally
means that the nerves or spinal cord is vulnerable to further injury. This situation is rare.
Usually, when the bone heals the stability of the neck is improved even if the new shape is not
normal. If malunion occurs where the angulation or displacement is so severe that nerve or
cord injury becomes likely, surgery is required to decompress the neurological elements and
fuse the spine.
Nonunion

Complete failure to heal (nonunion) is very rare in nonsurgical cases. After most types of fusion
operations in the neck healing rates are between 90 & 95% leaving 5 - 10% with nonunion of
10

the fusion (not usually the fracture). If the result is stable and not too painful you may elect to
leave this alone. However, the situation can result in breakage of the metal pins and screws by
fatigue failure. This is a rare and difficult situation which usually requires repeat surgery to
achieve painless healing of the fusion.
Infection

Infection of an operative site occurs with a frequency of between 1/200 and 1/50. Treatment of
this situation will always include antibiotics. Ideally, one would like to remove all the metal
pieces to help clear up the infection then re-operate to make the situation stable and painless.
This may not always to possible and the treatment depends on the individual case.
Progressive Neurological Deterioration

Deterioration of the neurological injury during the course of recovery of the bony injury is a
feared complication. Any extension of a cord injury at this level has very serious consequences
with further disabilities and a greater risk of mortality. Surgery to attempt to stabilize the spine
and prevent this complication may itself damage the spinal cord or its blood supply. The
balance is in favor of surgery helping the situation but not always.
Depression

Depression is common and understandable when faced with the change from an active life to
one of dependency. It is a fact that spinal cord injured patients lead a full and fulfilling life but
the process of coming to terms with the new situation can be very stressful.
Degerative Arthritis

As discussed earlier, the long-term risk of posttraumatic arthritis of the neck is significant. Any

11