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Cervical Spine Fractures
The purpose of this chapter is to outline a stepwise approach to C-spine fractures to aid in the safe and expedient work-up for these potentially complex injuries. The inclusion of some of the specific classifications employed by spine surgeons and the stepwise progression through localization, anatomy, neurologic status, stability, and disposition allow the reader to critically evaluate the nuances of the injury in anticipation of definitive management by a specialist or to make safe and reasonable management decisions in the absence of tertiary care resources. Unfortunately, the complexity and variety of C-spine fractures defy a straightforward algorithmic approach. However, every surgeon should feel equipped to define the injury, maintain appropriate precautions during work-up, complete appropriate initial imaging, consider factors involved in stability, and have an understanding of the most likely definitive management (e.g., surgery, immobilization, observation, etc.). This text will follow the flow of the diagram from the starting point of having already identified the presence of a fracture, presumably on either x-ray (XR) or noncontrast computed tomography (CT). Keep in mind the end goal of C-spine fracture management: to protect neurologic function and preserve alignment. The work-up is tailored to vulnerable neurologic structures and potential deformity.
Specifically outside the scope of this chapter are details of cervical collar clearance, isolated subluxation/dislocation, and the management of cervical spinal cord injury.
Cervical Spine Precautions
At the identification or suspicion of a C-spine injury, the patient should be placed in a cervical collar and maintained on bedrest until stability and the disposition plan are clarified. In the absence of concurrent thoracolumbar spine injuries, log-roll precautions are generally not necessary. Often patients arrive from the field in a one-piece, wraparound collar placed by the emergency medical services (EMS) team. Our practice is to replace this as soon as possible with a sturdier and more comfortable Aspen or Philadelphia-type collar. During the rest of the work-up, the patient should be in the collar at all times with the head supported.
Localization
The cervical spine comprises several anatomically distinct sections, each with unique stability variables and common fracture morphologies, ranging from the skull base (occipital condyle) to the axial C-spine (C1 and C2) to the subaxial C-spine (C3 to C7). After employing appropriate precautions, the next step is to define the exact level of the injury.
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