Cervical Spine Fracture / Trauma

Symptoms range from a stiff sore neck to complete neurological devastation. Pain is the most consistent feature: midline cervical tenderness, restricted range, and posterior neck spasm. Neurological symptoms or signs (paraesthesia, weakness, sensory loss, sphincter disturbance, priapism) imply cord or root involvement and dramatically raise the urgency.

Examination should never include "stress testing" of an unevaluated neck. With spinal precautions in place, document GCS, examination limitations (intoxication, distracting injury, sedation), midline cervical tenderness, focal neurological deficit, and any cord syndrome features. Concomitant head injury is common and must be screened for. Where spinal cord injury is suspected, perform a structured neurological assessment (ASIA / ISNCSCI in hospital), including sacral sparing where appropriate.

The classic red-flag triad of any spinal injury is midline pain, neurological deficit, and significant mechanism. NICE NG41 highlights altered consciousness, intoxication, distracting injury, and inability to complete a reliable assessment as triggers for immobilisation and imaging.

Maintain a lower threshold for imaging in older adults, osteoporosis, ankylosing spondylitis, DISH, rheumatoid arthritis, chronic steroid use, and previous spinal surgery - low-energy falls can produce unstable fractures in these groups.

Incomplete cord syndromes to know:

• •Central cord syndrome: upper limbs worse than lower; classically hyperextension in an older stenotic spine
• •Anterior cord syndrome: motor and pain/temperature loss with dorsal column sparing
• •Brown-Sequard syndrome: ipsilateral motor and proprioception loss with contralateral pain and temperature loss
• •Neurogenic shock: hypotension and bradycardia after high cord injury

The classic upper cervical fracture patterns are central to the named-injury question. A Type II odontoid peg fracture (transverse fracture at the peg base, low-energy hyperextension mechanism, high non-union risk) is the commonest cervical fracture in the elderly. A Hangman's fracture is a bilateral C2 pars interarticularis fracture from hyperextension-distraction. A Jefferson burst fracture is a C1 ring burst from axial load, with stability determined by transverse atlantal ligament integrity.

UK adult trauma follows the NICE NG41 pathway using the Canadian C-spine rule.

High-risk factors that mandate imaging:

• •Age 65 or older (automatic trigger regardless of mechanism)
• •Dangerous mechanism
• •Paraesthesia in upper or lower limbs

Low-risk factors permit active rotation assessment: if the patient can rotate the neck 45 degrees in each direction, imaging may not be required. All others get imaging.

For adults aged 16 or over with suspected traumatic cervical spine injury who require imaging, NG41 recommends CT cervical spine (not plain radiographs). MRI is added after CT when there is a neurological abnormality attributable to spinal cord injury, when CT is normal but ligamentous injury is suspected, or when imaging is needed prior to reduction.

In children under 16, MRI is recommended when there is strong suspicion of cervical cord or column injury based on clinical assessment or abnormal neurology; plain radiographs are considered only when MRI criteria are not met and clinical suspicion remains.

Cervical fracture, subluxation, or ligamentous injury should trigger consideration of CT angiography for blunt cerebrovascular injury per Denver criteria, particularly with upper cervical injury, transverse foramen fracture, subluxation or dislocation, or high-energy mechanism.

Acute flexion-extension radiographs are NOT performed in suspected cervical injury or ongoing pain or neurology - they are unsafe and superseded by CT and MRI.

Pre-hospital and emergency-department management follows BOAST 2025 spine trauma principles. Assume spinal injury after blunt trauma until clinically and radiologically excluded. Spinal precautions follow the local trauma network protocol and may include MILS, head blocks and tape, vacuum mattress, scoop stretcher, and a soft, semi-rigid, or rigid collar where appropriate. The reflexive rigid collar is no longer the universal default but collars remain part of trained spinal precautions in many scenarios. The principle is minimal handling and continued precautions until injury is excluded.

BOAST 2025 standing-takedown update: if a patient is found standing or walking after suspected cervical injury, do NOT perform a standing takedown. Guide the patient to self-extricate to a trolley or ground under careful verbal instruction, using muscle spasm to splint the neck.

ATLS principles apply for the rest of resuscitation: airway with cervical spine protection, breathing, circulation, disability, exposure.

The clinical question is then stable versus unstable and operative versus non-operative.

Stable injuries (typically hard collar 6-12 weeks with serial imaging):

• •Minimally displaced odontoid type III
• •Isolated spinous process avulsion (Clay-shoveller's)
• •Unilateral facet fracture without listhesis or neurological deficit
• •Stable subaxial compression

Unstable injuries (specialist spinal centre referral):

• •Jefferson burst with transverse ligament disruption
• •Hangman's types II and III
• •Displaced odontoid type II
• •Flexion teardrop
• •Bilateral facet dislocation
• •Fractures with cord compromise

Displaced odontoid type II fractures carry a high non-union risk, especially in older adults. Management is individualised: collar immobilisation, posterior C1-C2 fusion, anterior odontoid screw fixation in selected cases, or comfort-focused non-operative care - depending on stability, displacement, frailty, bone quality, neurological status, and goals of care. Halo immobilisation should be used cautiously because of morbidity in older adults.

Spinal cord injury management follows NICE NG41 and specialist spinal injury centre protocols. NG41 explicitly advises AGAINST methylprednisolone, nimodipine, and naloxone for acute neuroprotection. Maintain adequate spinal cord perfusion and avoid hypotension per local trauma and SCI centre protocols; some specialist protocols target MAP augmentation around 85-90 mmHg, but this is specialist protocol-based rather than an NG41 target. Urgent transfer to a specialist spinal injuries centre is essential.

Rehabilitation differs sharply by injury severity.

After collar immobilisation for a stable fracture, return-to-activity is staged:

• •Phase 1 (in collar, 6-12 weeks): general fitness, scapular setting, strict cervical neutral
• •Phase 2 (collar off, after clinical and radiological union): deep cervical flexor strengthening, scapular stabiliser work, thoracic mobility, proprioceptive retraining
• •Phase 3: sport-specific and contact-loading tasks under specialist physiotherapy guidance, gated by full pain-free range, normal neurology, and full strength

Post-operative rehabilitation follows surgeon-specific protocols, typically with early mobilisation in a collar, progressive range, and a graduated return to function.

After spinal cord injury, rehabilitation is led by a specialist spinal injuries centre (eight regional NHS centres in the UK), with multidisciplinary input from physiotherapy, occupational therapy, urology, sexual health, psychology, social work, and peer support. Return to driving, work, and sport is determined individually by neurological recovery, equipment needs, and specialist centre criteria.

• •NICE NG41 Spinal injury assessment and initial management (2016): UK pathway for cervical imaging in trauma. CT first in adults aged 16+, MRI after CT for neurology, suspected ligamentous injury, or pre-reduction; MRI-first in children under 16. Advises AGAINST methylprednisolone, nimodipine, and naloxone.
• •BOAST Assessment of the Spine in the Trauma Patient (2025): UK trauma standard for spine assessment, including the standing-takedown update (do not take down a standing patient - guide self-extrication).
• •Canadian C-spine Rule (Stiell et al., JAMA 2001): cervical imaging decision rule with sensitivity approaching 100% for clinically important injury.
• •Denver Screening Criteria: identifies cervical injury patterns that warrant CT angiography for blunt cerebrovascular injury (upper cervical fracture, transverse foramen fracture, subluxation, high-energy mechanism).
• •Anderson and D'Alonzo (1974): odontoid peg fracture classification (Types I-III); Type II at the base is commonest in the elderly and most prone to non-union.
• •AO Spine subaxial cervical classification and SLIC scoring: international and UK frameworks for subaxial cervical injury characterisation and treatment decisions.

• •Named-injury bank: Jefferson burst (C1 axial load, transverse atlantal ligament stability); Hangman's (bilateral C2 pars, hyperextension-distraction); odontoid Type II (elderly low-energy hyperextension, high non-union); flexion teardrop (anteroinferior fragment with retropulsion, unstable with cord injury); bilateral facet dislocation (flexion, high cord risk); Clay-shoveller's (stable C7/T1 spinous avulsion).
• •NICE NG41 plus Canadian C-spine rule: age 65 or older is an automatic high-risk factor mandating imaging regardless of mechanism. CT is first-line in adults aged 16+. Plain films are NOT first-line in adult trauma. MRI is the key investigation in children under 16.
• •NICE NG41 advises AGAINST high-dose methylprednisolone, nimodipine, and naloxone for acute SCI.
• •BOAST 2025 standing-takedown update: do NOT perform standing takedowns - guide self-extrication with verbal instruction.
• •Distinguish cervical fracture from cervical cord neuropraxia (transient bilateral / four-limb symptoms, often normal CT) and cervical stinger (transient unilateral upper-limb symptoms, no neck pain, normal examination).
• •Stability assessment is cervical-specific (transverse atlantal ligament, AO Spine, SLIC); the Denis three-column framework is for thoracolumbar injuries.