Image Quiz

Pain and Weakness Following Cervical Spine Trauma1 (continued)

Answer: Fractures of the C2 through C5 vertebrae with multilevel bilateral pedicle involvement.


Fig. 1		 Fig. 1 Preoperative lateral radiograph demonstrating anterior spondylolisthesis of C3 and C4 with respect to C2 and C5.

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Fig. 2-A
Fig. 2-B		 Figs. 2-A and 2-B Computed tomographic scans demonstrating fractures of C2 (Fig. 2-A) and C5 (Fig. 2-B).

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Magnetic resonance imaging revealed a widely patent spinal canal. Other injuries included a proximal fracture of the right humerus, a fracture of the left scapula, and a pulmonary contusion. These injuries were managed nonoperatively.

Discussion

The potential for injury to the spinal cord is substantial when multiple levels of the cervical spine are fractured. This patient sustained a unique injury involving fractures of the vertebral bodies of C2 and C5, laminar fractures at C3 and C5, and bilateral pedicle fractures at C3 and C4. This pattern of injury was grossly unstable and required careful management.

The minimal neurological sequelae in our patient were likely related to the unique fracture pattern. With the facets and the posterior elements intact, the anterior spondylolisthesis of the vertebral bodies increased the diameter of the spinal canal.

This pattern of injury is consistent with a high-grade compression-extension mechanism, as described by Allen et al. In this scheme, a compression-extension injury indicates that compression is the stress accounting for the major damage, and extension is the attitude of the cervical spine at the time of failure. The injury starts with a fracture of the vertebral arch, and with additional compression, the pedicles fail. In our patient, both pedicles were fractured at C3 and C4, allowing anterior displacement of the vertebral bodies.

With this extremely unstable injury, we believe that rigid fixation is desirable.

Reference

1. Phipatanakul WP, Minster GJ. Fractures of the second through the fifth cervical vertebra with multilevel bilateral pedicle involvement: a case report. J Bone Joint Surg Am. 2003;85:1347-50.