Musculoskeletal clinical topic of the month – A Cheerleader with a broken neck

VarieCervical spine injuries

Aetiology

The most common causes of cervical fractures and dislocations are motor vehicle accidents, falls, violence, and sports activities. High velocity anterior-posterior, lateral or rotatory force vectors of the neck, can cause ligamentous of bony disruption to the cervical spine. 

The resultant spinal cord injury and neurologic deficit, if it occurs, is the most devastating aspect of a cervical injury, primarily because it is often irreversible and permanent. The majority of spinal column and spinal cord injuries occur in males between the ages of 15 and 24 years old.

Pathophysiology

Cervical fractures and dislocations are typically classified according to their region/location and injury/fracture pattern. Collectively there is a large variety of pathology and classifications, some of which are listed below.

  • Occipital-cervical (occiput-C2)
    • Atlanto-Occipital Dislocation (AOD)
    • Occipital Condyle Fracture
    • Atlanto-Axial Instability
    • Atantoaxial Rotatory Subluxation
    • Atlas Fractures (C1)
    • Odontoid Fractures (C2 dens)
    • Traumatic Spondylolisthesis of the Axis (C2)
    • Axis Fractures (C2 vertebral body)
  • subaxial cervical spine (C3-C7) injuries
    • Distraction-Flexion (Facet fracture/dislocation)
    • Vertical Compression (Burst fracture)
    • Compression-Flexion (Teardrop fracture)
    • Compression-Extension
    • Distraction-Extension
    • Lateral Flexion

Within each of these categories, injuries are further stratified according to the specific location of injury and injury/fracture pattern.

Clinical history

Clinical history;

  • 21-year-old women cheerleader
  • Thrown into air during cheerleading lift (flyer position) and landed onto trampoline with neck in hyperextension
  • Did not hear any cracks or breaks at the time of landing but felt dizzy soon after
  • No focal neurological symptoms
  • Did not go to A+E for assessment or seek medical help
  • Complaining of stiffness and tension in neck over next few weeks
  • Symptoms improved but now stiffness in neck exacerbated by posture or sleeping in uncomfortable position
  • Came to LBSM 8 weeks after injury

Past Medical history;

  • BMI 22
  • Non-smoker
  • No history of previous spinal injury
  • Previously good bone health

Exercise history;

  • Cheerleading practice three times a week
  • Runs 5-10km twice a week
  • High level gymnast prior to cheerleading
  • Gym for strength and conditioning twice a week

Social history;

  • Studying at university
  • Imminently going on travelling GAP year 

Clinical examination;

  • Very good range of lumbar and thoracic rotation inhibited
  • Stiff in active range of cervical spine movement, particularly extension and left lateral flexion. 
  • Mild pain and stiffness on cervical rotation (but no onset of neurology)
  • Full power in all myotomes of the upper and lower limbs and full sensation in all dermatomes. 
  • Cranial nerve examination NAD

Next steps;

  • Suspected ligamentous injury to cervical spine with secondary paraspinal muscle spasm 

Imaging

MRI T2 weighted (taken 2 months after injury) sagittal sequence showing fracture and abnormal morphology of the superior odontoid peg.

A Cheerleader with a broken neck Musculoskeletal clinical topic of the month - A Cheerleader with a broken neck

Diagnosis

Suggestive of an old healed or healing fracture of the dens, consistent with Type 2 Roy-Camille Classification (see below)

Management

Rehabilitation

  • First 8 weeks (patient travelling around South America)
    • Gentle active range of movement restoration
    • Isometric holds (against hand and light banded resistance) 
    • Patient told be very aware of the development of new onset focal neurological symptoms e.g. pins and needles, weakness, headache 
    • Complete avoidance of activities with high velocity cervical spine movements particularly whilst travelling e.g, diving, contact sports, bungee jumping, skydiving
  • 8-12 weeks
    • CT scan to confirm full bony union of fracture and stability across fracture site performed at earliest convenience when back in UK
    • Passive exercises given once confirmed
    • Soft tissue release and mobilisations
    • Reintroduction of strength and condition and lifting weights
  • 12 weeks+
    • Gradual return to cheerleading and gymnastics

Medical

  • Patient discussed at spinal surgical MDT to consider surgical management.
  • Due to healing nature of the fracture site and time post injury, no surgery indicated. 
  • Calorie and nutritional intake optimised to help fracture healing
  • Interval CT scan at earliest convenience on return from travel to ensure complete fracture healing (see images below)

Patient Self monitoring tools

  • LBSM pain and symptom diary
  • LBSM load monitoring diary

CT scan

CT scan sagittal (left) and coronal (right) at 5 months post injury shows complete osseous union at the site of abnormality of the odontoid peg which is angulated posteriorly and consistent with either an old healed fracture 

Key Summary – Peg fractures

  • Odontoid Fractures are relatively common fractures of the C2 (axis) dens that can be seen in low energy falls in elderly patients and high energy traumatic injuries in younger patients
  • Account for 10-15% of all cervical fractures
  • Diagnosis can be made with standard lateral and open-mouth odontoid radiographs. Some fractures may be difficult to visualise on X-rays and require a CT scan to diagnose
  • Care must be taken not to perform aggressive manipulations, mobilisations or soft tissue therapy until appropriate investigation and diagnosis has taken place
  • These fractures are usually not associated with neurologic symptoms
  • Treatment may be nonoperative or operative depending on the Anderson and D’Alonzo type and risk factors for nonunion
    • type I: oblique linear fracture in which its line slopes forward, with dens displacement in an anterior direction (associated with transverse ligament failure and atlanto-axial instability)
    • type II: oblique linear fracture in which its line slopes backward, with dens displacement in a posterior direction (direct impact from the anterior arch of atlas during hyperextension)
    • type III: horizontal fracture line and the dens displacement can be either anterior or posterior

Key Summary – Peg fractures

  • Odontoid Fractures are relatively common fractures of the C2 (axis) dens that can be seen in low energy falls in elderly patients and high energy traumatic injuries in younger patients
  • Account for 10-15% of all cervical fractures
  • Diagnosis can be made with standard lateral and open-mouth odontoid radiographs. Some fractures may be difficult to visualise on X-rays and require a CT scan to diagnose
  • Care must be taken not to perform aggressive manipulations, mobilisations or soft tissue therapy until appropriate investigation and diagnosis has taken place
  • These fractures are usually not associated with neurologic symptoms
  • Treatment may be nonoperative or operative depending on the Anderson and D’Alonzo type and risk factors for nonunion
    • type I: oblique linear fracture in which its line slopes forward, with dens displacement in an anterior direction (associated with transverse ligament failure and atlanto-axial instability)
    • type II: oblique linear fracture in which its line slopes backward, with dens displacement in a posterior direction (direct impact from the anterior arch of atlas during hyperextension)
    • type III: horizontal fracture line and the dens displacement can be either anterior or posterior
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