A Case of Neck Pain

Author: Dacia Ticas, MD

Peer editor: Kim Barron, DO

Final Editor: Alex Tomesch, MD, Will Denq, MD

A 32-year-old female presents to the ER with neck pain after a head on motor vehicle collision. An X-ray of her cervical spine is shown below.

 

 

Figure 1: Image prompt. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 36014

 

1.     What is the diagnosis and is it stable or unstable?

2.     What are the common mechanisms of injury?

3.     What type of imaging modality is needed?

4.     What is your management in the ER?

5.     What is your final disposition?

 

See below for answers!

1.     What is the diagnosis and is it stable or unstable?

Hangman’s fracture, also known as traumatic spondylolisthesis of the axis (C2). This is considered an unstable cervical spine fracture1.

 PEARL: Unstable C spine fractures can be remembered by the mnemonic: Jefferson Bit Off A Hangman’s Thumb

                                               i.     Jefferson fracture

                                              ii.     Bilateral Cervical Facet dislocation

                                             iii.     Odontoid fracture type II or III

                                             iv.     Atlanto- occipital dissociation

                                              v.     Hangman’s fracture

                                             vi.     Flexion teardrop fracture

 

2.     What are the common mechanisms of injury?

Forced hyperextension mechanisms such as a passenger in a high-speed MVC, sporting injuries such as in diving, or falling forward onto a chin2.

 

3.     What type of imaging modality is needed?

a.     Diagnosis can usually be made with a C-spine x-ray. CT scan has become the gold standard for initial evaluation. However, it does not adequately evaluate ligamentous injury and non-contrasted studies do not adequately assess vascular injury. 

PEARL: Consider CT angiography in patients with blunt cervical injury to assess for vertebral artery injury. Among others, fractures of C1-3 are a risk factor for arterial injury.

 

4.     What is your management in the ER?

Spine stabilization and immobilization, pain control, trauma evaluation, and spine service consultation.

 

5.     What is your final disposition?

Admission and further management with your spine service

 PEARL: Definitive management will be guided by the Hangman’s fracture classification3. 

Table 1: From Management of Typical and Atypical Hangman’s Fractures3

 

PEARL: Type I can usually be managed non-operatively with a cervical collar or halo, type II will vary depending on the ligamentous stability whether it is surgical or non-operative, and type III will likely need surgical stabilization3.

 

 

 

 

References

1.     Duggal, Neil MD; Chamberlain, Robert H. MS; Perez-Garza, Luis E. MD; Espinoza-Larios, Adolfo MD; Sonntag, Volker K. H. MD; Crawford, Neil R. PhD. Hangman’s Fracture, Spine: January 15, 2007 - Volume 32 - Issue 2 - p 182-187. doi: 10.1097/01.brs.0000251917.83529.0b

2.     Turtle, Joel MD, PhD; Kantor, Adam MD; Spina, Nicholas T. MD; France, John C. MD; Lawrence, Brandon D. MD. Hangman’s Fracture, Clinical Spine Surgery: November 2020 - Volume 33 - Issue 9 - p 345-354. doi: 10.1097/BSD.0000000000001093

3.     Al-Mahfoudh R, Beagrie C, Woolley E, Zakaria R, Radon M, Clark S, Pillay R, Wilby M. Management of typical and atypical Hangman's fractures. Global spine journal. 2016 May;6(03):248-56