Open Fracture of the Cervical Spine Due to a Peculiar Injury Mechanism

Abstract

Introduction Scarce literature is available regarding traumatic open injuries of the cervical spine. In the majority of the reported cases, the injury was caused by a penetrating trauma due to a gunshot. We present the case of a patient with an open fracture of the cervical spine due to a peculiar injury mechanism. Material and Methods Case report of a healthy 29-year-old male who suffered an accident while riding a bicycle on his way to work. Characteristics of the injury mechanism, reported lesions, their treatment and follow-up are described. Results This 29-year-old male crushed his bicycle against the inside of the door of a parked car, which was suddenly opened while he was riding by it. As a result, he was expelled from the bicycle and hit the right side of the anterior aspect of his neck against the posterior superior corner of the car's door, causing a small stab wound-like injury. The patient had no head injury, dysphagia or dysphonia and was neurologically intact, but presented subcutaneous emphysema of the neck. He was initially assessed with cervical spine X-rays and a neck computed tomography (CT) scan, which revealed a marginal fracture of the anterior inferior border of the C4 vertebral body with extension to the inferior platform of the same level, but with normal sagittal alignment of the cervical spine. A cervical spine magnetic resonance imaging study was also obtained, which demonstrated hyper intensity at the anterior longitudinal ligament, the C4-C5 disc and the C4 vertebral body on T2-weighted images. He also presented a traumatic dissection of the right common carotid artery, detected on a CT-angiogram, but no injury of both the airway and the esophagus was identified. Due to the lack of clinical guides for the treatment of open spine fractures, this patient received empiric IV antibiotic treatment with ceftriaxone and clindamycin for one week follow by another week of PO amoxicillin with clavulanic acid. The wound was cleaned and closed with 2 interrupted stitches. The C4 fracture was initially treated with a hard collar, but retro listhesis at the C4-C5 level was detected on follow-up X-Rays 6 days after the accident, probably due to anterior longitudinal ligament and/or disc disruption, so an anterior discectomy and instrumented fusion of the C4-C5 level was performed. The carotid artery dissection was treated non-surgically with anti-coagulants (initially subcutaneous followed by PO treatment). C4-C5 anterior fusion was confirmed with a CT scan performed 2 months after the surgery. The patient presented no complications due to his injuries or their treatment, returned to work 3 months after the accident and evolved with no neck pain during follow-up. Conclusion Open fractures of the cervical spine present particular characteristics that must be considered during their initial work-up and treatment, usually involving a multidisciplinary approach to assess and treat associated injuries. Injury of the anterior longitudinal ligament and/or intervertebral disc disruption due to penetrating trauma may cause segmental instability requiring surgical treatment.