An Occult Cervical Spine Fracture
Rocky Khosla, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 12 - DECEMBER 97
In Brief: A 16-year-old athlete developed neck pain after being dropped on his head with his neck flexed while recreationally wrestling. Initial cervical spine radiographs were negative, but he continued to have neck and arm pain, especially after heading a wet soccer ball. Two months after the initial injury, he had a positive Spurling test; cervical spine CT then revealed a parasagittal linear fracture through the body of C-7. The patient avoided contact and collision activities and had no further physical problems. For patients who suffer cervical spine trauma, adequate visualization of the cervical spine can help prevent catastrophic outcomes.
Between 6,000 and 10,000 Americans sustain spinal cord injuries every year (1). Motor vehicle accidents and falls cause about 55% to 75% of these, while sports and recreational activities account for a significant percentage of the remainder (2).
Since an estimated 50% of neurologic deficits in these patients result from injury occurring after the initial trauma (3), physicians need a thorough, systematic approach to managing the patient who has suffered cervical spine trauma. As the following case report shows, initial radiographic studies may not demonstrate a potentially catastrophic occult fracture.
A 16-year-old boy was brought to the emergency room on a backboard with his neck immobilized by a cervical spine collar and sandbags. One hour earlier, while wrestling with his 14-year-old brother, he had been dropped on his head with his neck flexed. The patient had noted mild posterior neck and right shoulder pain immediately, but had no numbness, tingling, or weakness in any extremity.
The physical examination showed a muscular young man with normal vital signs and no other notable signs or symptoms, except for mild tenderness along the right trapezius without involvement of the sternocleidomastoid.
Plain radiographic studies included a cross-table lateral cervical spine view (figure 1), odontoid and anteroposterior (AP) cervical spine views, and chest and shoulder views; all were read as negative by the emergency room physician.
The patient was diagnosed as having neck and shoulder strain and was discharged with a soft neck collar. He was instructed to use ibuprofen as needed for neck pain and to follow up with his regular physician for routine care.
Persisting symptoms. The patient presented to his regular physician 2 months after the emergency room visit with a complaint of occasional neck pain that worsened when he headed a soccer ball. Specifically, he noticed that when he had headed the soccer ball on a rainy day 1 week prior to this visit, he had had increased pain, like an electrical shock going down the neck and into his right arm and hand. He had participated in wrestling, soccer, track, and football with no problems prior to the initial injury and reported no further injuries in the past 2 months.
On physical examination at this time, the patient's neck showed no obvious deformities, and he had good active and passive range of motion in flexion, extension, and lateral bending. His neck, back, and shoulders were nontender on palpation, and there was no localized muscle atrophy. His extremities showed good bilateral strength and normal reactions to sharp-dull and vibration sensory exams. Deep tendon reflexes were 2+ and symmetric over the biceps, brachioradialis, triceps, knees, and ankles.
The Spurling test (4) was of particular note, because it reproduced the symptoms that the patient had had when heading the wet soccer ball a week earlier. (In this test, figure 2 (not shown), the patient extends the neck and then rotates and laterally bends the neck while the examiner applies downward pressure to the top of the head.) The ipsilateral symptoms, a burning pain down the right side of the neck into the lateral aspect of the right arm, suggested a cervical radicular cause.
Radiographic studies. In view of the persistent symptoms, a computed tomography (CT) scan of the cervical spine (figure 3a) was obtained and showed a nondisplaced linear fracture of the vertebral body of C-7. Magnetic resonance imaging (MRI) of the cervical spine (figure 3b) was done to rule out spinal cord compression or impingement; the MRI was read by the radiologist as "essentially normal, with irregularity of the posterior body of C-7 that might represent a fracture site."
Treatment. After neurosurgical consultation, the patient was diagnosed as having a stable fracture that did not require surgery. To maintain his cardiovascular fitness, he was instructed to run, bike, or use a stair-climbing machine for at least 30 minutes per day, and he was also instructed to avoid contact or collision sports for 6 months. After that interval, a repeat CT scan of the lower cervical spine (figure 4) showed that the parasagittal fracture was nearly healed. His neurologic examination was normal and the Spurling test negative. The patient was advised to avoid contact or collision sports indefinitely.
Three years after the previous visit, the patient was having no difficulties while participating in track and other noncontact and noncollision activities.
Danger signals. Most sports-related fractures and dislocations of the cervical spine occur in the lower cervical segment, C-4 to C-7, and most of the severe injuries involve fractures of the vertebral body with varying degrees of compression or comminution (5). These injuries usually occur with axial loading of the neck in flexion; when the vertebral column loses its normal curve, the axial force is transmitted down the straightened cervical column, sometimes resulting in fracture, subluxation, or dislocation. If an athlete has been exposed to this mechanism, as this patient was when he was initially injured, the lower cervical spine should be examined carefully.
When this patient underwent the Spurling test, he complained of radicular pain similar to the pain he had had when he headed a wet soccer ball. Several studies (6) have reported significant head trauma after heading the ball in soccer, and one (7) reported that older leather balls absorbed water and increased in weight by 20% or more, making them dangerous projectiles. Fortunately, soccer balls are now made of synthetic, waterproof materials, but this patient had been playing with one of the older, genuine leather balls.
The recurrence of symptoms is not surprising because the action of heading a soccer ball can cause stresses on the cervical spine similar to those of the Spurling test. If this maneuver causes ipsilateral radicular symptoms into the upper extremity, cervical radicular pathology is suggested, and careful scrutiny of the cervical spine is imperative.
Radiographic studies. Scrutiny includes adequate imaging. The American College of Surgeons Committee on Trauma recommends cross-table lateral views of the cervical spine in all major trauma victims (8). However, an isolated lateral cervical spine film may reveal only 70% to 90% of fractures (9). In this patient's case, the lateral cervical spine film (figure 1) was inadequate because it didn't show all seven cervical vertebrae. Even if a cross-table lateral view is normal, it is prudent to proceed with open-mouth odontoid and AP radiographs of the cervical spine. The general rule in every cervical spine trauma case is to obtain two x-rays at 90° angles to one another (10), because perpendicular views minimize the chance of missing fractures present in just one plane.
When an adequate view is not obtained with a standard cross-table lateral view, and moving the patient is a concern, a trauma-oblique view, described by Abel (11), can be obtained; the patient is supine and the x-ray tube is angled 30° to 40° from the horizontal.
Other imaging studies. If the diagnosis is still unclear, CT scanning of the cervical spine should be considered. In a study (12) of 138 alert, asymptomatic trauma patients who had CT scanning of the cervical spine because of inadequate radiographs of the lower cervical spine, only 1 nondisplaced transverse process fracture was identified. However, when acute spinal cord trauma results in one fracture, there is a 10% chance that a second, noncontiguous fracture is present (13).
In the identification of osseous defects, CT scanning is more helpful than MRI, while MRI is better at showing soft-tissue changes such as disk herniation, spinal cord contusions, and ligamentous injuries. The CT scan of this patient clearly showed the parasagittal fracture, but the MRI only suggested it. (If a stress fracture or lytic or inflammatory lesion is suspected, a bone scan may also be considered.)
Return to play. Cervical spine injuries often present difficult return-to-play decisions because of the potential for catastrophic results. Though permanent exclusion from contact activities following a healed sagittal fracture is controversial, this patient was advised to avoid participation in contact and collision sports. This advice was based on Torg's return-to-play criteria, (14) which classify any vertebral body fracture with a sagittal component as an absolute contraindication to further participation in contact activities (see "Cervical Spine and Brachial Plexus Injuries: Return-to-Play Recommendations," July, page 60).
Cervical spine trauma is a fairly common consequence of motor vehicle accidents, falls, and sports-related activities. Though most of these mishaps do not cause devastating injuries, the mechanism of injury or a suspicious symptom may suggest the presence of occult lesions. Adequate cervical spine imaging can help physicians detect these lesions and prevent the secondary injuries that could lead to catastrophic outcomes.
The author thanks Madeleine Khosla, RN, for her help with manuscript review.
Dr Khosla is director of the sports medicine tract at the Southern Colorado Family Medicine Residency Program in Pueblo, Colorado. He is a fellow of the American Academy of Family Physicians and a member of the American College of Sports Medicine. Address correspondence to Rocky Khosla, MD, University Family Medicine Center, 4007 Jerry Murphy Blvd, Pueblo, CO 81001.