broken neck

Cervical break: Description

An ankle fracture refers to a vertebral fracture of the cervical spine. The cervical spine consists of seven vertebral bodies, between which there are cartilaginous discs, as well as ligaments, muscles and nerves. With the upper cervical spine, especially with the joint between the first cervical vertebra (Atlas) and the second cervical vertebra (Axis), we can turn the head. The lower cervical spine allows us to bend and stretch the head.

Only 15 to 20 percent of all spinal injuries affect the cervical spine. However, the spinal canal of the cervical spine is very narrow, which causes additional spinal cord damage in 70 percent of cases. Depending on the location of the neck break (cervical vertebra) is divided into two groups:

• Cervical Dislocation of the Upper Cervical Spine: Lesions of the Atlas and Axis
• Cervical eruption of the lower cervical spine: injuries to the third to seventh cervical vertebrae

In addition, depending on the type of fracture, a distinction is made between the following fracture types:

Cervical opening of the occipital condyles

The occipital condyles are the articular surfaces for the first cervical vertebra located on the skull base. A cervical fracture of the occipital condyles is rare and usually occurs as an accompanying injury.

Atlanto-occipital dislocation

Atlanto-occipital dislocation separates the skull base from the cervical spine. The two parts are shifted against each other (dislocated). This type of cervical dislocation is rare and usually deadly or survives only a few hours.

Injuries of the atlas

A neck fracture of the first cervical vertebra (atlas) affects the anterior and posterior arch of the atlas or the spinous process. An isolated break is rare. More common is a combined rupture of the anterior and posterior arch of the atlas, which may be single or double fractured. This neck break is called the Jefferson fracture and is very unstable. 30 to 70 percent of atlas fractures occur along with other cervical spine injuries. Often the Axis (2nd cervical vertebra) is affected.

Injuries to the Axis

A neck fracture of the second cervical vertebra (Axis) is usually one dens fracture – a breakage of the dens axis. This is an extension that sits like a tooth on the top of the axis. The dens fracture accounts for approximately seven to 15 percent of all cervical spine injuries in adults. In over 70-year-olds, it even represents the majority of isolated cervical spine injuries. In half of the cases, additional fractures occur in the further course of the cervical spine. About 12 to 42 percent of those affected show nerve damage and thus neurological deficits.

A typical injury mechanism in the dens fracture (dens-axis fracture) is a severely stretched or flexed head, which collides head-on with frontal shear forces. In this case, a Stirnprellmarke be a decisive hint. The common cause of old people is when they fall on the face.

The various Dens fractures are classified according to Anderson and D’Alonzo. They are based on the height of the fracture line:

• Type I Densfraktur: The tear fracture of the Densspitze (mostly oblique fracture) is rare. It is a stable neck break.
• Type II Densfracture: The most common fracture type. The fracture line is located above the den base. This is an unstable neck break.
• Type III Densfraktur: The fracture runs below the Densbasis by the cancellous part of the vertebral body. This cervical fracture is stable.

A cervical dislocation of the second cervical vertebra may also occur as a pelvic root fracture caused by hyperextension and compression. A double-sided arch fracture is called “Hangman Fracture“As it is often found in hanged people. The neck is extremely overstretched and pulled apart, which usually tears the elongated spinal cord, the medulla oblongata.

Neck fracture of the lower cervical spine

In lower cervical injuries, one distinguishes between different forms:

• purely bony injuries
• Injuries of the intervertebral discs and ligaments (discoligamentous injuries)
• Combination forms of bony, ligament and disc injury

For all types of lower cervical spine injuries, an intervertebral joint (facet joint) may additionally be dislocated. Dislocation (dislocation) can be unilateral or bilateral, incomplete or complete.

compression fractures differ depending on the extent of the violence. There may be small deformities to complete burst fractures in which the fracture fragments are displaced into the spinal canal and constrict it.

Injuries of the intervertebral disc and ligament structures (disco-ligamentous injuries) are easily overlooked if there is no dislocation (dislocation). When the head is extremely bent, the anterior longitudinal ligament and intervertebral disc rupture. Since the posterior ligaments are preserved, the cervical spine is still stable. If the head is extremely stretched and shifted, the rear strap connections will also tear. Only the front longitudinal band is retained.

At a Luxationsfraktur There is simultaneously a dislocation of a facet joint and a fracture injury.

A dislocation without bow fracture is very dangerous. By the dislocation of the spinal canal is greatly restricted. Depending on the extent of the dislocation are neurological symptoms to paraplegia before. However, if a rupture of the vertebral arch occurs at the same time, the vertebral canal is dilated and the risk of it being narrowed is much lower. This neck break is also called “saving sheet break”.

Transverse and spinous processes are often found as a combination injury with the above-mentioned fractures. Only in rare cases are they isolated.

whiplash

Whiplash is a pure soft tissue injury of the cervical spine and a common injury in traffic accidents, especially in rear-end collisions. Sufferers often suffer from prolonged painful conditions. Visible changes such as disc or joint capsule injuries and stretched ligaments are rare.

Cervical Dislocation: Symptoms

Typical symptoms of cervical dislocation include neck pain, headache, painful restraint of the cervical spine (especially when turning the head) and dizziness. Some sufferers support their heads with their hands and have neurological disorders in one arm or in both arms.

In a whiplash trauma often leads to head and neck pain, sensory abnormalities of the extremities and a reflex weakening. Temporarily, dizziness and hearing impairment also occur.

Cervical Dislocation: Causes and Risk Factors

A broken neck typically occurs in car crashes when the neck is severely bent or severely stretched or the head bumps. Other common causes are dives in shallow water, bicycle and riding accidents.

For example, a neck fracture of the occipital condyles is the result of a traumatic trauma (accident in which a lot of kinetic energy = kinetic energy acts on the body as in a car accident) or a fall on the head with direct axial force. An atlas of the atlas is often caused by an indirect force when an axial force hits the hyperextended head, thereby pinching the posterior atlas between the skull and spinous process. The Hangman Fracture is common in people who have hanged themselves. Discoligamentous cervical spine injuries often occur in severe deceleration traumas. The head is suddenly slowed down during a quick head movement.

Cervical Dislocation: Examinations and Diagnosis

If you suspect a cervical spine injury, your neck should be immediately immobilized in a stiff neck support (stiff neck). The medical specialist for the diagnosis and treatment of cervical dislocation is a specialist in orthopedics and trauma surgery. To be able to make the diagnosis, this will first raise the exact medical history, then physically examine the patient and also use imaging techniques.

To collect the medical history (medical history) the doctor will ask you various questions, for example:

• When exactly did the accident happen?
• Can you remember the accident?
• How strong was the impact?
• Describe exactly the direction of the violence.
• Do you have severe pain such as neck pain or headache?

Important for the diagnosis is the precise analysis of the accident mechanism: Potential injury mechanisms of the cervical spine are hyperextension, over-bending, axial compression and displacement.

Cervical Dislocation: Physical Examination

Next is the physical examination, in which the patient’s state of consciousness must be assessed. The doctor then examines the cervical spine, whether a hump has formed or diverge the spinous processes. He pays attention to pressure or pain points as well as compression and radiation pain.

The physical examination always includes a neurological examination to exclude paraplegia. The examiner examines some characteristic muscles and the sensitivity of the segmental skin areas (dermatomes) – skin areas, which are autonomously supplied by individual nerve fibers of a certain spinal cord root. If a muscle or the sensitivity of a dermatome fails, the doctor can estimate the level of injury to the spine.

Subsequently, the doctor tests the important regions of the spinal cord. For example, if the person feels that he is being touched on the shoulder, or if he can lift his shoulders, the spinal cord is intact up to the fourth cervical vertebra. The fourth cervical vertebra is a special height, because from there the diaphragm is supplied with nerves. Trauma above the fourth cervical vertebra impairs breathing to such an extent that ventilation via intubation becomes necessary.

Cervical Dislocation: Apparative Diagnostics

Spinal injuries are often not recognized or recognized too late. Therefore, a correct X-ray examination and – if the areas are poorly visible – a computed tomography (CT) is of great importance. An X-ray survey of Atlas and Axis from different directions is therefore a standard diagnostic for cervical dislocation – it is often referred to by doctors as “Dens-Zielaufnahme”.

If a cervical dislocation can not be safely ruled out, this is followed by computed tomography (CT). In such cases, a so-called spiral CT with multiplanar reconstruction is made, with which vertebral arches, joint fractures and the spinal canal can be accurately represented. The CT scan makes it possible to accurately classify the cervical dislocation.

In the case of neurological deficits, magnetic resonance imaging (MRI) must be performed as part of emergency diagnostics. Thus, the soft tissue structures can be displayed well and without radiation exposure, as it exists in CT.

Good documentation is important, especially with whiplash trauma, since questions of insurance law often have to be answered later in this context. If the symptoms persist for longer than five days, a magnetic resonance tomography should be performed.

Cervical Dislocation: Treatment

Whether a cervical dislocation is treated conservatively or surgically depends on the nature of the injury and the neurological symptoms. The shape of the injury determines how stable the neck break is. Rapid first aid and adequate treatment at the emergency ward are particularly important.

Cervical Dislocation: First aid at the accident site

In general, an unconscious accident victim has a broken neck until proven otherwise. In 20 to 45 percent of cases, cervical dislocation occurs in combination with craniocerebral trauma.

Before the patient is moved, a stiff neck tie (Philadelphia tie) should be applied. He is then rescued and stored with a sufficient number of helpers. For transport, it is then stored on a vacuum mattress and stabilized in such a way that it only has to be relocated to the clinic.

When broken neck is the means of transport of choice of helicopter. If a helicopter transport is not possible, the patient should be taken to a spinal center with an ambulance and an accompanying doctor as quickly as possible, where all the necessary diagnostic and therapeutic options are available around the clock.

Cervical Dislocation: Treatment at the emergency department

Frequently, a broken neck is associated with brain injury or life-threatening internal injury. In particular, if the spinal cord is injured, the fracture must be re-aligned without loss of time, so that no pressure is exerted on the spinal cord.

The cervical dislocation can either be closed under X-ray control in the emergency room, in order to put it on the outside. Better, however, is the open alignment in the operating room to stabilize the neck break from the inside.

Neck break: fixation

Depending on the type of fracture, different systems can be used to fix the cervical spine:

One soft collar (Schanz tie) only prevents the head from being bent extremely.

In one stiff collar (Philadelphia tie or Stiffneck) is also stored the chin. This severely restricts the mobility of the head (bending, stretching, turning). The so-called halo vest has the additional ability to stretch the head in length.

One Head and breast plaster (Minerva plaster) Involves the head, shoulders and thorax and is mainly used in children.

With all these fixation systems, however, only a cervical dislocation of the upper cervical spine can be fixed, while the lower cervical spine can not be safely immobilized.

Cervical Dislocation: Operative Treatment

An operation significantly shortens the treatment time for a broken neck. The patient also saves the collar or gypsum over several months (and the associated hygienic problem). Surgery on the cervical spine, however, is one of the most difficult and most complicated procedures ever. It should therefore only be performed by a surgeon experienced in vertebral surgery.

Treatment of atlanto-occipital dislocation

If an Atlanto-occipital dislocation is survived, it must be quickly reoriented and stabilized under X-ray control (such as with a halo fixator). However, surgery is required to permanently stabilize the skull with the cervical spine.

Treatment for fracture of the occipital condyles

An isolated occipital fracture of the occipital condyles is treated conservatively and immobilized with a soft neck tie. If the injury occurs along with another fracture, the treatment is targeted after the main injury.

Atlas fracture treatment (Jefferson fracture)

The neck fracture of the atlas is almost always treated conservatively. With the help of a reduction (extension) with the so-called Crutchfield brace one tries to prevent the atlas ring from widening. After six weeks, a chest and neck gypsum with support on the head (Minerva gypsum) is set for another six weeks.

So that the patient does not have to lie constantly during this time, treatment with the Halo Fixator can be continued. A halo fixator consists of a ring that is fixed to the calvarium and a vest that sits on the shoulders and is connected by a side rail. The cervical spine can thus be immobilized under tension.

In rare cases, the neck break after the attempt to realign the atlas (extension), is still postponed. Then an operation is possible. The atlas is stiffened with the Axis. Physicians call this operation atlantoaxial spondylodesis.

Treatment for Axis Fracture: Hangman Fracture

If the arch-root fracture is a non-displaced fracture, the treatment may be conservative in Halo Fixator or Minerva Plaster for eight to twelve weeks. For severely displaced fractures, surgery is required. After aligning the bone fragments, the vertebral arch is screwed on both sides from behind. Alternatively, the second and third cervical vertebrae are stiffened (spondylodesis).

Treatment in Axis-Bruch: Densfraktur

Type I dense fractures are treated conservatively for two weeks with a soft cervical collar (such as the Philadelphia collar).

The Type II Densfraktur is a highly unstable injury. Most of the Densspitze is moved backwards. Untreated, there is a high risk that the fractured bone does not grow together, and a pseudo-arthrosis (“false joint”) arises. Therefore, in most cases, an operation, wherein the dens is bolted from the front. After the operation, the cervical spine is immobilized with a neck support for about six to eight weeks. For medical reasons, if surgery is not possible, this form of cervical fracture is treated conservatively with a halo fixator for three to four months. Whether this leads to success, is checked by computer tomography (CT).

The Type III Densfraktur is usually treated conservatively in the halo fixator or Minerva gypsum. It takes about three to four months for the bone to heal. If the bone is severely displaced or the patient does not tolerate the halo fixator, the fracture elements may also be surgically screwed or flattened. The aftertreatment is done with the neck support.

Treatment for cervical eruption of the lower cervical spine

Cervical erosion of the lower cervical spine will require different treatment depending on fracture type:

A compression fracture of the vertebral body is in most cases not treated conservatively. Only slight deformities can be treated in the Minerva plaster cast. For heavily deformed bones, surgery is usually performed. The operation is performed from the front, stiffening two or three vertebral bodies with angle-stable plates. In a burst fracture, if necessary, the entire vertebral body must be removed and replaced by a bone chip from the iliac crest.

contortions must be re-established immediately, and carefully under appropriate anesthesia (anesthesia). An extension brace (Crutchfield brace) is applied to stretch the spine. Since diskoligamentous injuries often heal badly, surgery is required.

As with the disco-ligamentary injury are also at a Luxationsfraktur the cervical vertebrae first aligned and then stretched. This is followed by surgical treatment to stabilize the cervical spine.

In an isolated Fracture of the transverse or spinous process is enough conservative treatment. The patient must wear a neck tie and receives painkillers. These fractures heal quickly, but usually forms a wrong joint (pseudarthrosis).

At the whiplash The cervical spine should be immobilized in the short term. In addition, analgesics and muscle relaxants can be taken. Also physiotherapeutic exercises can help.

Cervical Dislocation: Disease Course and Prognosis

Disease course and prognosis are different at the neck break depending on fracture type. For example, stable atlas fractures may be treated conservatively in six to eight weeks, while unstable fractures with a halo vest must be stabilized for about 10 to 14 weeks. Surgery is rare in the atlas fracture.

Vertebral fractures of the axis can be treated conservatively in about eight to twelve weeks. Depending on the fracture type, healing of dens fractures lasts between two weeks and four months. Injuries to the lower cervical spine are usually operated on and therefore have a faster healing time. Atlanto-occipital dislocations are mostly deadly.

The whiplash has a good prognosis, but most sufferers are only after three to nine months without complaints. Permanent damage does not arise.

Cervical Dislocation: Paraplegia

In case of a broken neck, the spinal cord can also be injured. Depending on the location of the injury, the consequence may be incomplete or complete paraplegia. Any acute traumatic paraplegia is initially flaccid. The bladder and rectum can no longer be controlled arbitrarily.

If the cervix is ​​affected, this usually manifests as tetraplegia – all four extremities are completely paralyzed. If the cervical spine is affected at the level of the fourth cervical vertebra, the diaphragmatic breathing may fail. The paralyzed diaphragm slips upward, causing the sufferers breathing difficulties. You have to be ventilated from now on.

Spinal cord injuries above the fourth cervical vertebra are not survived because of the vital centers located there.

Sometimes the spinal cord at the level of the seventh cervical vertebra is affected in case of a broken neck. Then a so-called Horner syndrome can occur: The patient has narrowed pupils (miosis), the upper lid of the eye hangs down (ptosis) and the eye has sunk into the eye socket (enophthalmos).

Immediately occurred complete paraplegia can not be restored. Causes the broken neck incomplete paraplegia, prognosis of paralysis is difficult to predict.