Three-column hyper-flexion cervical spine injury

Case contributed by Dr Rajalakshmi Ramesh


Restrained rear-seat passenger involved in a high speed motor vehicle accident (car vs car). Complaining of severe neck pain following the accident.

Patient Data

Age: 66
Gender: Female

Anterolisthesis of C2 on C3 by 3 mm. Bilateral C2 lateral mass fractures. On the left the fracture extends from the anterosuperior aspect of the lateral mass to the intervertebral foramen, involving the superior articular process. There is up to 3mm separation of the fracture fragment, with retropulsion and narrowing of the left lateral recess and central canal on the left. The fracture line runs just anterosuperior to the foramen transversarium. On the right minimally displaced comminuted pedicle fracture. The fracture does not extend into the foramen transversarium.

Small C2/3 broad based disc protrusion, consistent with acute traumatic disc protrusion. This just contacts the thecal sac. Small amount of hematoma adjacent to the fracture lines.

There is widening of the interspace between the posterior elements of C1 and C2 with hemorrhage evident in this region. These findings are compatible with rupture of the interspinous ligaments at this level. There is mild kyphosis at C2/3 with fluid signal evident within the disc compatible with disc injury. The C2/3 disc is widened posteriorly. There is edema within the prevertebral soft tissues. In addition the distance between the tip of the dens and the clivus is mildly increased, with edema in this region, suggesting disruption of the apical ligament.

Case Discussion

This case illustrates a three-column and therefore unstable injury to the cervical spine, with hyperflexion as the most likely offending mechanism of injury. Common radiographic signs of cervical hyperflexion injuries include:

  • a localized kyphotic angulation of the cervical spine limited to the level(s) of the ligamentous disruption
  • anterior translation of a subluxed vertebra
  • anterior narrowing and posterior widening of the intervertebral disc space
  • increased distance between the posterior cortex of the subluxed vertebral body and the anterior cortex of the articular masses of the subadjacent vertebra
  • abnormal widening of the interspinous and interlaminar spaces
  • partial uncovering and loss of congruity of facets
  • disruption of ligamentous structures

There is a high risk of spinal cord damage, and as such early diagnosis  and cervical spine stabilization are imperative for patient survival and/or recovery.



Case courtesy of Associate Professor Pramit Phal

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Case information

rID: 33681
Published: 24th Feb 2015
Last edited: 14th Aug 2019
System: Spine
Inclusion in quiz mode: Included

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