Complex cervical spine fracture

Case contributed by Bálint Botz
Diagnosis certain


Sustained a fall during a vertigo attack, hit the occipital region of the head. Head and neck pain, no gross neurological deficit.

Patient Data

Age: 90 years
Gender: Male
  • the spinous processess of the C5-6 vertebra show hairline fractures without displacement, which is best seen in the sagittal plane. We should look for further injuries along these segments. 
  • the left pedicle and both tranvserse processes of C6 also show undisplaced fractures. 
  • in keeping with this, the flowing osteophytes show an abrupt break anteriorly between C5 and C6, while a discrete fracture line extends to the superior endplate of C6 too.
  • since the (calcified) anterior longitudinal ligament is also injured resultant soft tissue injury, namely prevertebral hematoma should be scrutinised. Indeed there is an about 30 mm long, 5 mm thick soft tissue density collection anteriorly, in keeping with hematoma. 
  • careful assessment of the facet joints also reveal a right C5-6 subluxation. 

Altogether the observed findings make this an unstable complex fracture involving all three columns of the spine. 

Head CT was unremarkable considering the age group and showed no acute bony or brain injury or other significant pathology (not shown).

Annotated image

It is worth going through the injuries once again: 

  1. C5 spinous process fracture
  2. C6 spinous process fracture
  3. C5-6 right facet joint subluxation
  4. C6 left pedicle fracture 
  5. C6 right transverse process fracture
  6. C6 left transverse process fracture 
  7. C5-6 anterior eintervertebral opening indicating injury of the calcified anterior longitudinal ligament, also extending to the superior endplate of C6
  8. Resultant prevertebral hematoma

Case Discussion

This is an extremely difficult case, not only due to the chronic comorbidity (DISH) but also due to the overwhelming amount of insidious but clinically important injuries, altogether culminating in a severely unstable complex fracture.

At first striking degenerative changes of the cervical spine are noted, the flowing anterior osteophyte complexes are in line with diffuse idiopathic skeletal hyperostosis (DISH). It unfortunately makes 1) the spine more rigid and thus more prone to injury, 2) it also makes aforementioned injuries much harder to spot in imaging. With this in mind we should tailor our search pattern to the situation and operate with a high level of suspicion.

One probable "take home message" of the case is to always try to work our way from the more obvious injuries towards the more subtle ones. Do not fall into the satisfaction of search trap (e.g. labeling this a stable clay-shoveler fracture and calling it a day), and that soft tissue window reconstructions often show important additional pathology in the trauma C-spine too. 

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