Occult Cervical Spine Fractures Research Articles

Role of cervical spine radiography in the initial evaluation of stable high-energy blunt trauma patients

BackgroundDetecting cervical spine injuries in trauma patients is essential because undetected injuries in the this area may result in severe neurological disability and probably quadriplegia. Thus, radiography of the cervical spine is considered mandatory in the initial evaluation of trauma patients according to Advanced Trauma Life Support. This approach results in many unnecessary normal radiographs. Therefore, we performed this study to determine the role of routine cervical radiography in the initial evaluation of stable high-energy blunt trauma patients. MethodsThis was a prospective cross-sectional study including all hemodynamically stable high-energy blunt trauma patients with negative cervical physical examinations referred to our trauma center during a 5-month period (May to September 2010). Cervical radiographs, computed tomography (CT) scanning and magnetic resonance imaging were performed and reviewed for abnormalities. ResultsDuring the study period, 1,679 high-energy blunt trauma patients were referred to our center, of which 400 were hemodynamically stable and had negative cervical physical examinations. Cervical radiographs were found to be normal in all patients. ConclusionCross-table cervical spine radiographs can be limited to those high-energy blunt trauma patients who have a positive cervical physical examination or those in whom the physical examination is not revealing. These radiographs also have low value for detecting occult cervical spine fractures, and CT imaging is considered the modality of choice in these cases.

Evaluation of occult cervical spine fractures on radiographs and CT.

The aim of this study was to evaluate occult cervical spine fractures on radiographs and CT. We reviewed radiographs of 68 patients with cervical spine fractures at a level 1 trauma center. Twenty-six patients showed occult fractures on initial radiographs. Of seven odontoid fractures, two were diagnosed only after thinner repeat CT reconstructions. Five facet fractures were best seen on CT reconstructions. Three occult hangman's fractures were seen by CT. A C1 fracture was diagnosed on CT only. Two fractures through the C2 body were seen only by CT. Eight fractures were obscured by patient's shoulders, including five clay shoveler's fractures, a C6 facet fracture, a bilateral C6 pedicle fracture, and a C7-T1 fracture-dislocation. Odontoid, facet, and lower cervical spine fractures are most commonly occult on radiographs. CT, especially high-quality CT reconstructions for odontoid and facet fractures, can improve the diagnosis of cervical spine fracture.

Odontoid Fractures: Evaluation and Management

Fractures of the odontoid process are uncommon injuries. Fracture displacement, compromised blood supply, comminution, and iatrogenic distraction have all been implicated in the reported high rates of nonunion. Plain radiography, polytomography, and computed tomography are all useful in delineating the fracture pattern. Magnetic resonance imaging has been recommended for evaluating associated ligamentous injuries and may be helpful in detecting occult cervical spine fractures. Type I fractures are avulsion fractures of the tip of the odontoid process. These rare injuries require only external immobilization with an orthosis if there is no associated ligamentous injury. Type II fractures occur at the junction of the odontoid process and the body of the axis. These are the most common odontoid fractures and are associated with a high incidence of nonunion. Nondisplaced fractures should be treated with halo immobilization for 8 to 12 weeks, with careful clinical and radiographic monitoring. Displaced fractures should be considered for operative treatment, either with atlantoaxial arthrodesis or anterior screw fixation. Type III fractures, which extend into the body of the axis through cancellous bone, are treated with closed reduction and halo immobilization.

Determining the probability of detecting cervical spine fractures with computed tomographic scans using the visible human database

Cross-table lateral radiography alone is frequently unreliable for clearing of the cervical spine in cases of acute trauma. Computerized tomography (CT) is a standard procedure for detecting occult cervical spine fractures when cervical spine radiographs are equivocal or inadequate. There is evidence, however, that a significant number of fractures may still be missed by CT scans if too large a distance is used between scanning cuts in the axial plane. The purpose of this study was to determine the probability of detecting hidden fractures of the cervical spine over a wide range of fracture sizes and CT axial cut intervals. Digitized anatomic data of the cervical spine from the Visible Human ProjectTM of the National Library of Medicine were used as a model template for the study. From a series analysis, it was determined that use of the standard 5-mm cut intervals missed 25–75% of fractures, depending on the size of the lesion. The 4-mm cuts were able to detect all of the 3-mm lesions but still missed a significant number of the smaller fractures. The probability of finding occult fractures at the 3-mm axial interval was 100% for all except the smallest fracture sizes. This mathematical analysis suggests that computerized tomography is a less than optimal method for detecting occult fractures of the cervical spine unless the cut interval is 3 mm or less. The addition of sagittal plane reconstruction of these images would further enhance the ability to detect subtle subluxations or fractures.

Delayed sequelae of vertebral artery dissection and occult cervical fractures

We report three patients who developed delayed (ie, more than a week after the injury) symptoms of vertebrobasilar ischemia following motor vehicle accidents. The patients all had angiographic evidence of vertebral artery dissection and, upon further evaluation, occult fractures of the second cervical vertebra that were not detected by simple cervical spine radiography and required polytomography or CT for diagnosis. Vertebral artery dissection can result from occult cervical spine fractures and may present with delayed symptoms of brain ischemia.

Occult cervical spine fracture in a wilderness setting

Cervical spine fractures can be difficult to diagnose solely upon the patient's symptoms and physical exam. There have been several case reports of trauma patients without any of the signs or symptoms of cervical spine injury who were subsequently found on radiography to have fractures. This article presents a case report of an occult cervical spine fracture occurring in a wilderness setting and discusses the special considerations of managing wilderness trauma patients who may have an occult cervical spine injury.

Intracranial Hemorrhage as a Predictor of Occult Cervical-Spine Fracture

Study objective: To determine whether intracranial hemorrhage is a predictor of occult cervical-spine fracture. Design: A prospective, cross-sectional study. Setting: University-affiliated Level I trauma center. Participants: Ninety-three blunt trauma victims with a Glasgow Coma Scale score of 12 or less. Exclusion criteria were incomplete radiographic evaluation caused by hemodynamic instability, death, or other reasons. Interventions: The study protocol required that all patients undergo a five-view cervical-spine trauma series, head computed tomography (CT), and upper cervical-spine CT. Cervical-spine radiographs and CT scans were read by two radiologists blinded to each other's interpretations. The results were compared with each patient's head CT diagnosis. Medical records were reviewed for demographic information and mechanism of injury. Results: Of the 93 patients, 54 had intracranial hemorrhage noted on CT scan; two of these patients had an upper cervical-spine fracture, but only one was an occult cervical-spine fracture. Thirty-nine patients had no intracranial hemorrhage; two patients had an upper cervical-spine fracture, but only one had an occult cervical-spine fracture. Fisher's exact test showed no significant difference between the rate of occult cervical-spine fracture between patients with and without hemorrhage. Conclusion: Despite a high percentage of patients with traumatic intracranial hemorrhage, our study failed to demonstrate that intracranial hemorrhage is predictor of occult cervical-spine fracture. [Frye G, Wolfe T, Knopp R, Lesperance R, Williams J: Intracranial hemorrhage as a predictor of occult cervical-spine fracture. Ann Emerg Med April 1994;23:797-801.]

Asymptomatic Occult Cervical Spine Fracture

Lack of case documentation has led to controversy over the existence of asymptomatic occult cervical spine injury. We report a case of an elderly patient involved in a motor vehicle accident who sustained an asymptomatic occult cervical spine injury, and review the literature with regard to this controversial injury.

Occult cervical spine fracture in an ambulatory patient

Significant injury to the cervical spine many not be obvious in patients whose mental status is decreased. We present the case of a fully conscious, ambulatory patient with no complaint of neck pain and only mild tenderness on examination who nevertheless had sustained an unstable fracture-dislocation of the cervical spine. Following surgery, the patient recovered without permanent neurologic sequelae. Criteria are suggested for ordering radiographic studies of the cervical spine for victims of trauma.