Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma

BACKGROUND AND PURPOSE: This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. CASE DESCRIPTION: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. OUTCOMES: The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangman's fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management. DISCUSSION: In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.     

Delayed Subluxation of an Occult Traumatic Odontoid Fracture in an Elderly Patient

The issue of whether a traumatic but occult cervical spine fracture can exist has generated significant debate in emergency medicine. The profound clinical and legal implications of missing an unstable cervical spine injury are well known to the emergency care provider. An elderly patient who satisfies all of the rigorous criteria for this type of injury is discussed. The patient experienced delayed subluxation of her acute odontoid fracture during a flexion/extension examination completed in the ED, with resultant development of cervical discomfort. Elderly victims of trauma with an appropriate mechanism of injury should be suspected of subtle or occult neck injuries.     

训练致急性颈椎损伤X线和CT诊断分析

目的：在武警军事训练科目中,单双杠及倒功引起急性颈椎损伤,分析X线及CT诊断价值。材料与方法：10例中,5例被动体位下摄颈椎侧位片,4例摄正侧位片,1例直接CT扫描。结果：10例经X线和CT扫描,颈6椎骨折5例,伴轻度滑脱,1例爆裂性骨折伴椎管狭窄,寰椎骨折1例,寰枢关节脱位3例。结果：X线检查能详细了解颈椎曲度、序列、利于观察椎体半脱位。单纯楔状骨折,两侧小关节脱位,CT扫描诊断不困难,扫描可清晰显示颈椎三柱解剖结构和骨折线走向,尤其对于X线片难以发现颈椎后柱结构的骨折,碎骨片的移位及小关节骨折、椎管狭窄、脊髓是否受损,评估颈椎损伤的严重程度。     

股骨颈骨折的多层螺旋CT与临床分析

目的 探讨多层螺旋CT扫描诊断股骨颈骨折的应用价值。 方法 对102例股骨颈骨折患者的临床特点及多层螺旋CT表现进行回顾性总结分析。 结果 股骨颈骨折头下型16例,经颈型24例,基底型62例;Garden Ⅰ型骨折18例,Garden Ⅱ型骨折59例,Garden Ⅲ型骨折19例,Garden IV型6例。3例股骨颈骨折继发缺血性坏死。 结论 多层螺旋CT能全面、准确地诊断股骨颈骨折,对患者治疗方法选择、预后判断具有重要意义。       

A missed Jefferson fracture in chiropractic practice

OBJECTIVE: To review the case of a missed cervical spine fracture in a patient with neck pain. CLINICAL FEATURES: A 21-year-old thatcher with neck pain presented to a chiropractic clinic after a fall from a roof 4 m high. The hospital radiographs were read as normal. The chiropractor suspected a Jefferson fracture of the atlas after evaluation of the same radiographs. INTERVENTION AND OUTCOME: The chiropractor retook the anteroposterior open-mouth radiograph to confirm the suspected fracture. The patient was referred for further imaging and underwent neurosurgical treatment, after which he recovered well. CONCLUSION: Normal radiologic reports from a hospital cannot be relied on for contraindications to manipulative treatment in all instances, as shown in this case of a missed fracture. Chiropractors should therefore always evaluate radiographs that are brought to them.     

血小板激活因子在颈椎间盘突出中的表达

目的:研究血小板激活因子(PAF)在颈椎间盘突出中的表达及其与颈肩痛的关系,为颈椎间盘突出症的临床康复治疗起指导作用.方法:以30例颈椎间盘突出症患者(突出组)手术取出的突出髓核组织用酶联免疫吸附法测定其PAF;另7例颈椎骨折患者(对照组)手术中所取的髓核组织作为正常对照.对颈椎间盘突出症所导致颈肩痛以达拉斯(Dallas)疼痛调查表作评分.结果:髓核组织中PAF 2组均存在,突出组含量明显高于对照组(P＜0.01),且PAF的含量与颈肩痛程度有相关性.结论:PAF与颈椎间盘突出引起的颈肩痛有明显相关性,使用康复措施阻止PAF等炎性因子的合成、释放、乃至清除,可能对改善颈肩痛有重要作用.     

Biomechanics of the cervical spine Part 3: minor injuries

Minor injuries of the cervical spine are essentially defined as injuries that do not involve a fracture. Archetypical of minor cervical injury is the whiplash injury. Among other reasons, neck pain after whiplash has been controversial because critics do not credit that an injury to the neck can occur in a whiplash accident. In pursuit of the injury mechanism, bioengineers have used mathematical modelling, cadaver studies, and human volunteers to study the kinematics of the neck under the conditions of whiplash. Particularly illuminating have been cinephotographic and cineradiographic studies of cadavers and of normal volunteers. They demonstrate that externally, the head and neck do not exceed normal physiological limits. However, the cervical spine undergoes a sigmoid deformation very early after impact. During this deformation, lower cervical segments undergo posterior rotation around an abnormally high axis of rotation, resulting in abnormal separation of the anterior elements of the cervical spine, and impaction of the zygapophysial joints. The demonstration of a mechanism for injury of the zygapophysial joints complements postmortem studies that reveal lesions in these joints, and clinical studies that have demonstrated that zygapophysial joint pain is the single most common basis for chronic neck pain after injury.     

Salon sink radiculopathy: a case series.

Cervical radiculopathy can be diagnosed on physical examination with the Spurling test, which narrows neural foramina via neck extension along with coupled rotation and side-bending. In the presence of cervical radiculopathy, this test can reproduce radicular symptoms by transmitting compressive forces to affected nerve roots as they traverse the neural foramina. Treatment of cervical radiculopathy includes patient education to avoid obvious postures that exacerbate radicular symptoms and to assume positions that centralize discomfort. A potentially harmful position to which many patients are unwittingly subjected at least several times per year occurs when their hair is being shampooed in a salon sink before a haircut. This posture causes neck extension and is combined with rotation and side-bending as the patient's head is being manipulated during the shampooing. When the stylist then also applies a mild compressive force while shampooing the patient's hair, hyperextension of the neck is produced. We present two patients with cervical radiculopathy that was significantly exacerbated after the patient's hair had been shampooed in a salon sink; subsequently, these patients required oral administration of steroids. These cases illustrate that patients with suspected or known cervical radiculopathy should be forewarned to avoid this otherwise seemingly innocuous activity.     

Unstable cervical spine without spinal cord injury in penetrating neck trauma

Cervical spine instability in the neurologically intact patient following penetrating neck trauma has been considered rare or non-existent. We present a case of a woman with an unstable C5 fracture without spinal cord injury after a gunshot wound to the neck. Considerations regarding the risk of cervical spine instability are discussed, as well as suggestions for a prudent approach to such patients.     

A pitfall in neck pain: occult odontoid fracture

Type III odontoid fractures of the axis are the second most common injuries of the cervical spine. Most of these result from motor vehicle accidents and falls. Occult odontoid fractures without preceding trauma are rarely reported in the literature and may be difficult to diagnose. We report the case of a healthy patient who had no history of trauma, but sustained sudden pain in the neck and guarding during head movement after sleep. Initial radiographs of the cervical spine including open-mouth, anterior-posterior, and lateral views did not reveal any obvious fractures. Type III odontoid fracture was uneventfully diagnosed via high-quality three-dimensional reconstruction of computed tomography. The possible mechanism was hyperextension of the neck during the change from the supine to the sitting position. Type III odontoid fractures can occur in the absence of major trauma. The usefulness of computed tomography is emphasized and the literature is also reviewed.     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

Cervical Spine pain as a presenting complaint in metastatic pancreatic cancer: a case report

A 48 year-old female presented to her primary care physician with a two-month history of neck pain with negative cervical spine x-rays. During that office visit, the patient was noted to be tachycardic with EKG revealing ST depressions, which led to hospital admission. Acute coronary syndrome was ruled out, however, persistent neck pain warranted inpatient MRI of the cervical spine, which revealed a cervical spine lesion. Extensive investigation and biopsy ultimately confirmed stage IV pancreatic adenocarcinoma with metastases to the bone, liver, and likely lung. In the literature, the findings of a primary metastatic site being bone is rare with only a few case reports showing vertebral or sternal metastasis as the first clinical manifestation of pancreatic cancer. The uniqueness of this case lies in the only presenting complaint being cervical spine pain in the setting of extensive metastases to the liver, bone, and likely lung.     

Min-invasive surgical treatment for multiple axis fractures: A case report

BACKGROUND Fractures of the axis are commonly seen in spinal injuries. Upper cervical fractures are usually managed conservatively. However, the complications due to long-term external immobilization cannot be ignored. The traditional open surgery has the disadvantages of too much blood loss and soft tissue injury. The aim of our paper is to introduce a minimally invasive surgical treatment for multiple axis fractures.CASE SUMMARY We report a 40-year-old Chinese male who had severe neck pain and difficult neck movement after falling from 3 meters. X-ray and computed tomography(CT) scan revealed an axis injury consisting of an odontoid Type Ⅲ fracture associated with a Hangman fracture categorized as a Levine-Edwards Type Ⅰ fracture. The patient underwent anterior odontoid screw fixation and posterior percutaneous screw fixation using intraoperative O-arm navigation. Neck pain was markedly improved after surgery. X-rays and CT scan reconstructions of 3-mo follow-up showed good stability and fusion. The range of cervical motion was well preserved.CONCLUSION Anterior odontoid screw fixation and posterior direct C2 percutaneous pedicle screw fixation with the aid of O-arm navigation and neurophysiological monitoring can be an interesting alternative option for complicated multiple axis fractures.     

Hangman's fracture resulting from improper seat belt use

Diagonal seat belt application without accompanying lap belt closure may produce severe cervical spine injuries, including hangman's fracture and decapitation. Seat belts are effective in reducing injury, but they must be worn properly to do so. Passive restraint systems involving a diagonal seat belt may be hazardous if the motorist does not use the accompanying lap belt. We have presented a case in which the driver in a motor vehicle accident sustained a hangman's fracture (bilateral fracture of the pedicles of C-2) caused by use of a diagonal seat belt without accompanying lap belt closure. The mechanism of injury, as classically described in judicial hanging, is hyperextension and distraction, which occurred when the victim "submarined" under the diagonal seat belt and was caught at the neck.     

Cervical spine fracture following a motor vehicle accident

We present the case of a 50-year-old man who visited our emergency department 12 h after an alcohol-related motor vehicle accident complaining of shoulder pain and neck stiffness. Cervical spine radiographs were obtained and interpreted as normal, and the patient was discharged. Subsequent review by a radiologist raised the question of a second cervical vertebra (C-2) abnormality, and the patient was recalled. Cervical computed tomography (CT) scan revealed an unstable oblique fracture of C-2 and a congenital nonfusion of the arch of C-1. The patient was placed in halo traction, and subsequent radiographs revealed a fracture of the transverse process of C-7. The patient made an uneventful recovery. The limitations of routine cervical radiographs are well-documented, but no feasible alternative exists as a screening procedure. Thus, a certain level of uncertainty must be accepted. Both physician and patient must recognize the limitations inherent in all medical practice and that follow-up examination and treatment are essential.     

Cervical Spondylodiscitis,Osteomyelitis, and Epidural Abscess Mimicking a Vertebral Fracture

Background: Spinal vertebral fractures are common in elderly patients, especially after a significant fall. Neck tenderness or neurologic deficits after a fall should increase the suspicion of cervical spinal fracture. Case Report: A 75-year-old woman complained of 2 weeks of gradually increasing neck and right shoulder pain after a fall. She had an X-ray study that appeared to show an unstable C6–C7 fracture. A computed tomography scan of the neck revealed no fracture and was consistent with spondylodiscitis and osteomyelitis of C6 and C7, with an adjacent epidural abscess and mild cord compression. Conclusion: It is important to consider this diagnosis in patients with a history of infective endocarditis who develop back pain, to minimize morbidity associated with this disorder.     

Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache

BACKGROUND: The clinical significance of the ponticulus posticus is far from clear. It has been associated with headaches, Barré-Lieou syndrome, photophobia, and migraine. However, little epidemiologic evidence for this exists. OBJECTIVE: This study investigated the relationship of ponticulus posticus on x-ray studies and headache symptoms in a series of chiropractic patients. METHODS: Eight hundred ninety-five patients who visited a chiropractic clinic for the first time and whose conditions required cervical spine x-ray examinations were studied. Complaints were categorized as migraine with aura, migraine without aura, cervicogenic headache, neck pain only, and other conditions. The presence or absence of the ponticulus posticus (whether partial or complete) was determined by means of a lateral cervical film and noted as a positive or negative finding. The data were analyzed by frequency analysis and Pearson's chi 2 test. RESULTS: Forty-six percent of the sample were men and the predominant complaint was neck pain (33%). Most patients were in the fourth decade of life. The frequencies of the other complaints were migraine with aura (7%), migraine without aura (4%), cervicogenic headache (22%), other conditions (33%). An 18% prevalence of ponticulus posticus was found. This finding was significantly associated with migraine without aura (chi 2 = 4.97; P = .03) and not with any other conditions. CONCLUSION: In a chiropractic patient population that required cervical x-ray examinations, a significant association was found between ponticulus posticus and migraine without aura, with an odds ratio of 2.19:1 in favor of this complaint being present with the osseous anomaly. The mechanism for this remains obscure but may be related to ischemic compression of the vertebral artery or by dural tension at the craniocervical junction.     

A delayed diagnosis of congenital midline cervical cleft

Congenital midline cervical cleft (CMCC) is an extremely rare anomaly of the neck that typically presents in the neonatal period as a thin suprasternal vertical band of erythematous skin with a nipple‐like projection. We present the management of this uncommon and rarely described entity in a 9‐year‐old girl.     

Neck pain

Six conditions cause most of the neck pain complaints seen by primary care physicians: cervical muscle strain or sprain, torticollis, acceleration injury, myofascial pain dysfunction syndrome, and cervical osteoarthritis or rheumatoid arthritis. Most of them can be diagnosed and treated by the primary care physician. Of the more unusual causes, one should not miss a clinical fracture; a herniated cervical disc, spinal cord compression from a disc, or epidural tumor; infection of the disc or the vertebral body; subluxation of the vertebral bodies; or pain referred from the chest or mediastinal structures. MRI offers new opportunity for early diagnosis of myelopathy owing to OA or RA, vertebral osteomyelitis, and metastatic involvement of cervical vertebrae.