Reviews

The Unstable Occult Cervical Spine Fracture: A Review

SHARON E. MACE, MD

The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and man- agement on the patient’s eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. The existence of patients with an unsuspected cervical spine fracture who have few, if any, symptoms and/or signs of an injury to the cervical spine is a valid concern and a dilemma for the practicing physician. Thus the principle of the occult unstable cervical spine fracture, which has been established as the standard of care, has major significance and implica- tions. Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature. (Am J Emerg Med 1992;10:136-142. Copyright 0 1992 by W.B. Saunders Company)

In the past, indications for cervical spine radiographs have generally included the following: patients with a significant mechanism of injury, patients with an unreliable history and/ or with an altered mental status, patients with complaints of neck pain or neurologic symptoms, and patients with a pos- itive physical examination including pain on palpation of the neck and/or neurologic signs (weakness, abnormal reflexes, etc)lV6 (Table 1).

These guidelines were almost universally accepted and have become the dogma of physicians in the emergency de- partment. Recently the criteria for obtaining cervical spine radiographs have been challenged. i7-24 In today’s cost- conscious society, these indications have been criticized as expensive, with a low yield, and resulting in unnecessary radiation to patients.2s

Past reports of occult cervical spine fractures”“‘30 have been discounted as not fulfilling the criteria for being an unsuspected or occult cervical spine fracture with few, if any, symptoms and/or signs of a cervical spine fracture.

Yet recent reports continue to document patients with un- stable occult cervical spine fractures.3’-33

What is the status of the occult cervical spine fracture?

From the Department of Emergency Medicine, St Mary’s Hos- pital, Rochester, NY.

Manuscript received May 21, 1991; revision accepted August 26, 1991.

Address reprint requests to Dr Mace, Department of Emer- gency Medicine, St Elizabeth Hospital, 2209 Genesee St, Utica, NY 13501.

Key Words: Silent cervical spine fracture, occult cervical spine injury.

Copyright 0 1992 by W.B. Saunders Company 07356757/92/l 002-0010$5.00/O

According to the literature is the unstable occult cervical spine fracture a reality or a myth, and what should the cri- teria be for obtaining cervical spine radiographs? How can we balance the importance of not missing a cervical spine fracture in any given individual against the desire to be cost- effective and limit unnecessary radiographs?

We present a case of an occult cervical spine fracture and a review of the literature regarding cervical spine injuries.

CASE PRESENTATION

A 5 l-year-old male was being evaluated for a fever and sore throat with possible epiglottitis. He was alert, oriented x 3. with a class I level of consciousness (Glascow Coma Scale = 15), and he was not under the influence of alcohol or drugs at the time he was seen. Past medical history included seizures and alcohol abuse. His physical examination, including the neurologic examination (eg, mental sta- tus, cranial nerves, motor, sensory, gait, reflexes) was normal. A soft tissue film of the neck was taken to rule out epiglottitis. The report by the attending radiologist was “fullness in the subglottic tissue, odontoid fracture of the Type I1 variety at its base with anterior subluxation of the arch of C2 on C3 of approximately 1 cm” (Figure 1). Radiographs of the skull and cervical spine taken 1 year earlier were normal (Figure 2). He denied any history of recent trauma. He had no neck pain or tenderness on palpation of the neck. There were no symptoms or signs of neck, neurologic, or traumatic injury. He had cervical spine immobilization (Figure 3). His unstable fracture dislocation of C2 required neurosurgery with a bone graft and fusion of C I-C2.

OISCUSSION

The importance of the detection and initial management of cervical spine injuries in the emergency department is uni- versally accepted and well recognized.34-43 However, it may be difficult to detect cervical spine injuries in certain pa- tients.44-47 This includes, but is not limited to: patients with an altered mental status, patients with loss of consciousness, and patients with other significant injuries, such as an ex- tremity fracture. ‘-1634-47 The possibility of an occult cervical spine injury complicates the issue, making it difficult to rec- ognize cervical spine injuries in emergency department pa- tients since patients with an occult cervical spine fracture have few, if any, symptoms or signs of cervical spine injury. yet have significant fractures of the cervical spine (Table I). 26-33.44.47

The first report of an occult cervical spine fracture was in 1972 by Thambyrajah.26 In this study of four cases of occult cervical spine fracture, all four patients were awake, alert, nonintoxicated, ambulatory, and had no neurologic deficits. Three of the four patients presented 1 to 2 days after the

136

SHARON E. MACE n SILENT CERVICAL SPINE FRACTURES

TABLE 1. indications for Cervical Spine Radiographs

History or Mechanism of Injury

Multiple trauma patients

Patients with significant head injuries

Patients with significant facial injuries

Patients with other significant injuries (such as an

extremity fracture-wrist, femur, etc) and a significant

mechanism of injury

Unreliable History or Altered Mental Status

intoxicated patients (due to history of alcohol and/or drug

abuse) Patients with an altered mental state

Patients with loss of consciousness

Significant History of Present Illness

Patients with complaints of neck pain

Patients with neurologic symptoms (weakness, paresthesias, etc)

Abnormal Physical Examination

Patients with pain on palpation of the neck Patients with abnormal neurologic signs (weakness,

abnormal reflexes, etc)

trauma occurred. Two of the four patients had been drinking at the time of the trauma, but by the time they were seen the next day they were not intoxicated. The amount of force involved was variable in these four cases, including: a driver in a motor vehicle accident, a person hit in the jaw who then fell backward, a person who was hit in the back of the head, and a person who merely twisted her neck. One patient de- nied neck pain, stiffness, or tenderness, had full range of motion, no neurologic symptoms, and his cervical spine frac- ture was discovered incidentally on his skull roentgeno-

137

grams. Three of the four patients had a history of trauma. The cervical spine injuries were significant and ranged from a fracture of the pedicle of C3 with subluxation of the C2-C3 apophyseal joint, to a fracture of the pedicle of C3 extending into the body, and a fracture of the lamina of C2. Treatment in the four patients ranged from cervical collars to crutch- field tongs and traction for weeks.26

The fourth patient might be considered to not have any trauma at all, ie, she was not in a motor vehicle accident, nor did she hit her head, face, or neck.26 She started to slip but caught herself and did not actually fall, but only twisted her neck. She had a subluxation of the atlanto axial joint with a fracture of the atlas. It should also be noted that this patient was not elderly with severe degenerative disease of the spine, nor did she have any congenital anomalies which might predispose to injuries of the spine.48*49 Indeed, she was only 23 years old.

It should also be noted that routine roentgenograms did not show the fractures in three of the four cases.26 Only after repeated x-rays and coned views were the cervical spine fractureslsubluxations detected.26 The inadequacy of plain roentgenograms in many cases, as noted in this study,*” has been confirmed by others.50-W

Following this initial report, additional cases have been noted over the years.27-33 Bresler and Rich presented the case of a fully conscious ambulatory patient who fell out of a car and offered no complaint of neck pain.*’ Physical ex- amination including the neurologic examination was normal except for a wrist deformity secondary to a fracture, and only mild tenderness on palpation of the neck. She had sub- luxation of C4 on CS, fractures of the pedicle and neural arch of C4, and a wrist fracture. She was immobilized, admitted

FIGURE 1. Cervical spine radiographs in our patient showing “fullness in subglottic tissue, marked degenerative changes in the cervical spine with large osteophytes, odontoid fracture of the Type II variety at its base with anterior subluxation of the arch of C2 on C3 of approx- imately 1 cm” (Report of attending radiologist).

138 AMERICAN JOURNAL OF EMERGENCY MEDICINE W Volume 10, Number 2 n March 1992

FIGURE 2. Normal cervical spine radio- graphs obtained I year earlier.

to the hospital, and underwent an anterior cervical diskec- tomy, decompression, and fusion. The symptoms from her fractured wrist far overshadowed any symptoms from her cervical spine fracture and led to the recommendation that cervical spine films be obtained in trauma patients with other significant injuries, or an altered mental status due to alcohol and/or drugs, and those with loss of consciousness2’

Haines reported two cases of occult cervical spine frac- tures.28 Both patients were alert, not intoxicated, and seen a day after the incident. One came to the emergency depart- ment and one to a family physician’s office; both were am- bulatory. One patient had “mild neck pain” after striking his head. The other patient was in a motorcycle accident and complained only of wrist pain and soreness all over. He denied any specific injury to his head or neck. Roentgeno- grams revealed a burst fracture of the body of CS with sub- luxation of CS on C6 in the first patient and subluxation of C4 on C5 in the second. Both were referred for neurosurgical

evaluation. The second case illustrates the fact that denial of neck pain does not rule out significant cervical spine injury, and again, that other injuries (in this case a fractured wrist) may lead to ignoring or minimizing signs and symptoms of cervical spine injury.28

In the case report by Lieberman and Mau11,29 an unre- strained, intoxicated victim of a motor vehicle accident, who did not lose consciousness, complained of shoulder and arm pain, but denied neck pain and had a normal neck examina- tion without pain on palpation of the neck. The lateral cer- vical spine was read as negative by the “Senior Staff Radi- ologist”. He was admitted with the diagnosis of multiple trauma, subdural hematoma, renal hematoma, and fracture radius and ulna. The next day he complained of neck pain so a repeat lateral cervical spine roentgenogram was done, re- vealing a C2 fracture dislocation with narrowing of the canal from 23 mm to 12 mm. Computed tomographic scan con- firmed an unstable odontoid fracture. He was treated with

SHARON E. MACE W SILENT CERVICAL SPINE FRACTURES 139

FIGURE 3. Repeat cervical spine radiographs after cervical spine immobilization showing im- provement in alignment of Cl on CZ.

Gardner Wells tongs, reduction of the displacement under traction, and a halo vest, 29 Once again, the presence of other injuries masked a cervical spine injury.29

Again, both the history and physical examination (eg, de- nial of neck pain and no pain on palpation over the neck), when initially seen in the emergency department,29 were misleading.

Thus, the concern is that an alert nonintoxicated patient with a normal mental status may have a significant injury of the cervical spine while denying neck pain and with a normal neurologic and neck examination.26M33

In another alarming case report by Ogden and Dunn,30 an alert nonintoxicated female driver in a motor vehicle acci- dent had a right flail chest and bilateral femur fractures. She denied neck pain, had no tenderness on palpation of the neck, and a normal neurologic examination in the emergency department. Eighteen hours later in the intensive care unit she complained of neck pain, so a roentgenogram was done which revealed a burst fracture of C2. The investigators noted that denial of neck pain and absence of neck pain on palpation on physical examination does not rule out signifi- cant cervical spine injury, and that patients will focus on the areas of greatest pain and often ignore the less painful but certainly not less significantly injured parts.30

Several clinical reviews3’,32 of patients have confirmed the findings of these various case reports.2G30.33 In the study by Williams et al of 50 consecutive patients with cervical spine injuries seen in the emergency department,3’ it was

concluded that “the initial history and physical examination may be misleading in a large number of patients”. They found that “in a significant number of instances (> 25%), objective careful radiographic interpretation is more impor- tant to the patient’s welfare than is any other diagnostic modality-including history and physical examination.“3’

In a review of 67 patients with acute cervical spine frac- tures seen in the emergency department.32 the results of these earlier reports and studies26*27*3’ were once more con- firmed. The investigators concluded that “the absence of mental status changes, craniofacial injuries, range of motion abnormalities, and focal neurological findings is not uncom- mon in patients who have sustained cervical spine inju- ries.“32 They noted that 18% (12167 patients) had no com- plaint of neck pain. Their results suggested that “the pain- less cervical fractures alluded to in the literature may exist especially in inebriated or confused patients, those with mul- tiple organ system injury or those with multiple lacerations/ contusions.“32

In a large retrospective study of 795 patients with blunt cervical spine trauma,6’ a subset of 20 patients with docu- mented neurologic deficits of the cervical spinal cord with- out fracture or dislocation were identified. In these 20 pa- tients with documented neurologic deficits, eg, motor weak- ness in all patients (100% or 20120) and absent reflexes (50% or 10/20), and documented blunt cervical spine trauma; only 70% had cervical spine tenderness.“’ Thus, nearly one third of the patients (30%) with documented cervical spine injury,

Tab

le 2

. Li

tera

ture

R

evie

w

of

Cas

es

of

Occ

ult

Cer

vica

l S

pine

F

ract

ure

Aut

hor

Tha

mby

raja

h

Com

plai

nt

Pam

on

C

hief

of

N

eck

Pat

ient

H

isto

ry

Com

plai

nt

Neu

rolo

gic

Pal

patio

n of

A

mbu

lato

ry

Neu

rolo

gic

Men

tal

Sta

tus

Cer

vica

l S

pine

LO

C

Pai

n S

ympt

oms

Nec

k E

xam

mat

ion

Oth

er

Inju

ries

Com

men

ts

Abn

orm

ality

elde

rly

mal

e.

cont

usio

ns

of

ves

aler

t.

orie

nted

. no

no

“0

hit

on

back

of

he

ad

then

fe

ll on

fa

ce

fem

ale

(23)

tw

iste

d he

r ne

ck

head

in

tact

fa

cial

ab

ra-

sion

s,

con-

tu

sion

s,

shou

lder

, fa

ce,

LS

spin

e

frac

ture

no

t se

en

on

C s

pme

film

, fo

und

on

skul

l fil

ms

frac

ture

pe

dicl

e of

C

2.

subl

uxat

ion

c2lc

3

stiff

ness

of

ne

ck

yes

aler

t,

orie

nted

, in

tact

ye

s-m

ild

no

no-in

itial

, ye

s-on

de

ep

palp

atio

n on

ly

on

repe

at

exam

inat

ion

Yes

no

or

m

inim

al

trau

ma,

no

t se

en

on

initi

al

film

s ne

ed

cone

d vi

ew

mis

sed

on

initi

al

film

s,

seen

2

days

af

ter

inci

dent

frac

ture

O

f c2

. su

blux

atio

n of

at

lant

oaxl

al

fom

t

no

no

no

tingl

ing

left

fore

arm

no

“0

none

no

w7 8

2%

(41/

50)

20ye

ar-o

ld

MV

A

car

skid

ded

8 ro

lled

mal

e (4

7)

punc

hed

in

jaw

8

fell

back

war

d fe

mal

e (3

2)

tell

out

of

car

mal

e (1

9)

divi

ng

acci

dent

m

ale

(15)

m

otor

cycl

e ac

cide

nt

mal

e un

re-

stra

ined

dr

iver

in

M

VA

33

year

s ol

d M

VA

50

patie

nts

with

ac

ute

C

spin

e in

jurie

s

67 p

aben

ts

with

ac

ute

C

spin

e in

jurie

s

mal

e (5

1)

neck

/sho

ulde

r pa

in

neck

pa

m

wris

t pa

in

neck

pa

in

wns

t pa

in

head

ache

le

ft fo

rear

m

pain

, rig

ht

shou

lder

pa

in

ches

! 8

leg

pain

C s

pme

(fra

ctur

e or

di

sloc

atio

n)

C s

pine

(f

ract

ure

or

disl

ocat

ion)

(a

t a

com

mun

ity

hosp

ital)

feve

r ep

iglo

ttis

yes-

mild

seen

1

day

afte

r in

cide

nt

aler

t, or

ient

ed,

inta

ct

WS

frac

ture

pe

dicl

elbo

dy

of

C3

frac

ture

la

mm

a of

c2

ye

s al

ert,

orle

nted

, in

tact

ye

s-m

ild

Yes

Bre

Sle

r &

Ric

h

Hai

nes

Lieb

erm

an

8 M

auli

Ogd

en

h D

unn

Will

iam

s et

al

Wal

ter

et a

l

Mac

e

Yes

aler

t,

orie

nted

, In

tact

ye

s-m

tld

wris

t fr

actu

re.

fore

head

la

cera

tion,

m

ultip

le

abra

sion

s no

ne

seen

6

hrs

late

r fr

actu

re

of

C4

pedi

clel

neur

al

arch

, su

blux

atio

n of

C

4 on

C

5

burs

t fr

actu

re

of

C5.

su

blux

atio

n of

C

5 on

ffi

subl

uxat

ion

of

C4

aler

t,

orie

nted

, in

tact

aler

t. or

ient

ed,

inta

ct

awak

e,

into

w

cate

d.

follo

win

g co

mm

ands

aler

t, or

ient

ed,

Inta

ct

no

no

no

Y@S

no

no

yes-

mild

de

crea

sed

left

hand

gr

ip

NM

L

NM

L

seen

16

hou

rs

late

r

wris

t fr

actu

re

seen

1

day

late

r o

n C

5

frac

ture

di

sloc

atio

n im

mob

ilize

d by

E

MS

(m

otor

se

nsor

y in

tact

) !m

mob

illre

d by

E

MS

(m

otor

se

nsor

y in

tact

)

no

re

nal

hem

a-

tom

a.

smal

l su

bdur

al

hem

atom

a.

wris

t fr

actu

re

flat1

rig

ht

ches

t, bi

late

ral

fem

ur

frac

ture

seni

or

radi

olog

ist

mis

sed

the

frac

ture

; no

do

ne

ck

pain

on

pa

lpat

ion

of

neck

ne

urol

ogic

N

ML

no

do

neck

pa

in

no

pain

on

pa

lpat

ion

of

neck

in

grea

ter

than

25

%

Hx.

P

E

wer

e m

isle

adin

g (n

o ne

ck

pam

, ne

urol

ogic

ex

am-N

ML)

2

patie

nts

had

no

l-lx

or

sign

s of

tr

aum

a (3

%)

at

C2

with

na

rrow

ing

of

the

cana

l

burs

t fr

actu

re

of

C2

no

no

“0

NM

L

no

in

26%

(1

3150

) no

in

26

%

(13/

50)

NM

L in

62

56

(411

50)

C s

pine

fr

actu

re

and/

or

disl

ocat

ion

6%

unkn

own

16%

ha

d no

31

%

yes

neck

pa

in

63%

no

(1

2’67

)

12%

ha

d no

ne

ck

pam

on

pa

lpat

ion

of

nec

k (6

/67)

NM

L m

l m

66

%

(591

67)

46%

h

ad

no

cr

anio

taci

al

inju

ries

(N

/67)

C s

pine

fr

actu

re

and/

or

disl

ocat

ion

yes

aler

t, or

ient

ed,

no

inta

ct

no

no

no

n

o

disc

over

ed

unst

able

fr

actu

re,

inci

dent

ally

su

blux

abon

of

du

ring

wor

kup

of

odon

toid

, ha

d ep

iglo

ttis,

no

H

x su

rgic

al

fusi

on

of

of

trau

ma

Cl/C

2

Abb

revi

atio

ns:

LOC

, IO

SS of c

onsc

ious

ness

; WA

. m

otor

veh

icle

ac

cide

nt;

C,

cerv

ical

; E

MS

, em

erg

ency

m

edic

al

serv

ices

; N

ML

, n

orm

al;

PE

, p

hys

ical

ex

amin

atio

n;

Hx,

his

tory

;

SHARON E. MACE n SILENT CERVICAL SPINE FRACTURES 141

eg, motor deficits, often with additional sensory deficits and oriented x 3, and not intoxicated, and have a normal mental absent reflexes, had no tenderness on palpation of the cer- status. ‘5.26-33.6’

vical spine.6’ Of even greater concern for the clinician is the fact that some alert patients with cervical spine injury, with a normal mental status, when carefully examined may have no ten- derness or pain on palpation on physical examination.26’28‘33

Finally, in a small number of cases,32,33 there may be no history of trauma.

A prospective study of 233 patients demonstrated the in- ability of physicians to accurately predict the presence of cervical spine injury. 62 Physicians were able to predict cer- vical spine injury with only a 50% accuracy. Furthermore, “twenty percent (5 of 24) of cervical spine injuries would have been missed if physicians had used physical examina- tion and mechanism of injury as criteria.“62 SUMMARY

Our report is of particular concern because the patient denied any history of recent trauma, had no complaints of neck pain, did not have any tenderness or pain on palpation of the neck on physical examination, and had no symptoms or signs of neck trauma, neurologic injury, or traumatic in- jury. Furthermore, he had normal cervical spine films taken 1 year ealier, which indicates that the cause of the trauma and the resultant symptoms were so trivial as to be forgot- ten.33

In reviewing the literature (Table 2), the following has been noted in patients with known significant cervical spine injuries:

Although in today’s cost-conscious society, some have advocated various different indications for obtaining cervical spine roentgenograms,‘7-25 our review indicates that the un- stable occult cervical spine fracture can and does exist, and that, as suggested by many physicians,‘-‘6S26-33 it is impor- tant to maintain a high index of suspicion, especially in high- risk patients. We should heed the recommendations of those who advocate obtaining cervical spine roentgenograms in certain high-risk trauma patients, knowing that the entity of occult cervical spine fracture does exist.

REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Patients may have no neurologic symptoms (such as numbness, weakness, parethesias’4,‘5.26-33). This is usually the case.3’,32

Patients may have a normal neurologic examina- tion, including normal motor, sensory, and re- flexes. ‘5,‘6,26-33 This is true in the vast majority of patients (80% to 90%)‘5S’6S31V32 with known cervical spine fractures and/or dislocations.3’,32 In one se- ries 82% (or 41/50) patients, and in another series 88% (59/67). had a normal neurologic examina- tion 31.32

Patients may be ambulatory.‘5,‘6,26-28~3’-33

Patients often delay in seeking medical care and of- ten are seen hours to days after the actual trauma occurred.‘h-28

The chief complaint or presenting symptom is often not neck pain.‘4-‘6,26-33

The mental status is often normal with no history of loss of consciousness.‘s*‘6.26-33

The injury may occur following minor or seeming- ly “trivial” trauma, such as twisting of the neck. ‘5.16.26-33

Patients may have no complaint of neck pain.‘5,26-33

Patients may have no tenderness or pain on palpa- tion over the cervical spine or neck.26,29-33

The injury may occur with or without significant head or facial injuries.“.‘4,32

The injury may occur with no history of trauma.32,33

It is a significant and disturbing fact that one fourth to one third of patients with cervical spine injuries (18% in the Wal- ters et al study,32 24% in the Nichols et al study,15 35% in the Williams et al study,3’ 30% in the Blanda et al study”) may have no complaints of neck pain.‘5,3’-33.6’ Furthermore, the absence of neck pain can occur in patients who are alert,

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10. Reid DC, Henderson R, Sabol L, et al: Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980-986

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(ads): Emergency Medicine: A Comprehensive Review. Rock- ville, MD, Asoen Svstems Core. 1983. DD 615-626

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