The incidence of cervical spine injuries associated with facial fractures varies from study to study. The presence or absence of a cervical spine injury has important implications in trauma patients, influencing airway management techniques, choice of diagnostic imaging studies, surgical approach and timing for repair of concomitant facial fractures. There is general agreement that immediate management of cervical spine injuries is mandatory to prevent further neurological injury. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to review the incidence of cervical spine injury associated with various upper, middle and lower one-third facial fractures presenting to St. Michael's Hospital Regional Trauma Centre. A retrospective chart review was performed of patients presenting to the Trauma Service at St. Michael's Hospital from 1 January 1993 to 31 December 2003 inclusive. The data from this 10 year time span revealed a total of 124 patients with cervical spine injuries drawn from a cohort of 3,356 patients with craniomaxillofacial fractures. The overall incidence of cervical spine injury was 3.7%. Isolated upper 1/3 facial and skull fractures accounted for 1,711 of the patients and were associated with cervical spine injury in .53% of cases, while isolated middle 1/3 facial fractures were seen in 1,154 patients and were associated with a 1.13% rate of cervical injuries. The largest rate of association for cervical spine injury and isolated fractures was seen with lower 1/3 facial fractures at 1.51%. In contrast, combined facial fracture patterns involving two or more facial thirds accounted for the great majority of cervical spine injuries occurring at an incidence of 7.1%. The implications for trauma assessment, diagnosis and treatment of these injuries are reviewed

Introduction: Sports injuries to the cervical spine account for about one in ten of all cervical spine injuries. They occur at all levels of participation. Fortunately, the number of patients suffering spinal cord injury is relatively small. Neurological injuries may range from transient quadriparesis through to complete quadriplegia. The decision to allow sportsmen to return to sport following a cervical spine injury is complex. It is based on such factors as history, clinical examination, the nature of the injury, as well as age and other psychosocial factors. The evidence that exists to aid this decision process is at times conflicting. The aim of this presentation is to review some of the contentious issues that exist in the decision making by reference to case presentations of high level sportsmen who were treated following a variety of cervical spine injuries. Methods: Four high-level rugby players (22–31 years old) presented with different cervical spine injuries sustained during sporting activities. Two subjects sustained a “stinger” and two a transient quadriparesis which rapidly resolved. Radiological evaluation included assessment of spinal canal diameter. 1. Results: Two had a C5-6 disc bulge with developmental spinal stenosis. A third had a congenital fusion C2-3 with a disc bulge and developmental stenosis at C3-4. Case 4 had degenerative disc disease at C5-6. All were treated non-operatively and returned to sport. All suffered a recurrence of the neurological symptoms and subsequently underwent an anterior interbody fusion (Case 4 for subluxation of C6-7). Three successfully resumed rugby six months after surgery while one elected not to continue. Discussion: The decision to allow a patient to return to contact sports following a cervical spine injury may be difficult. The four cases presented highlight some of these contentious issues such as transient neurological deficit and the effect that surgery may have on a patient’s ability to return safely to sport. A review of the literature may assist in the decision making. 1,. 2. This may be conflicting and difficult to interpret. Neurological signs, instability, displacement, fusion of more than one level and occipito-atlanto-axial pathologies are considered absolute contraindications. 3

Purpose: The purpose of the study is to access the efficacy of CT angiogram evaluation of the vertebral artery in patients with blunt cervical trauma. Our hypothesis was that there was no protocal for evaluation or treatment of vertebral artery injuries, and that patients with proven vertebral artery injury were not being treated and patients at risk were not being evaluated. An appropriate protocal was established. Method: 721consequtive patients with blunt cervical spine injuries were reviewed for cervical injury at risk for vertebral artery injury (C1–C3 fractures, fractures through transverse foreman, and significant subluxationor dislocation of the cervical spine), subsequent CT angiograms done to evaluate possible vertebral artery injury, treatment and clinical course. Results: 271 patients met criteria for possible vertebral artery injury. 156 had CT angiograms, of which 19 were positive for vertebral artery injury. 12 of the 19 patients with positive CT angiograms for vertebral artery injury were not treated with antithrombotic therapy because of associated injuries. An additional 115 patients had cervical spine injuries at risk for vertebral artry injury and did not have a CT angiogram done. There were 3 patients who had CVA’s, one patient who had a positive CT angiogram for Vertebral artery injury and 2 patients at risk and not evaluated. Conclusion:. Patients with blunt cervical trauma are at risk for vertebral artery injury, which can result in significant neurological sequalae. Antthrombotic therapy can lessen the likilihood of neurological sequalae following a vertebral artery injury. Screening for vertebral artery injury following blunt cervical trauma should be done for C1–C3 fractures, fractures through transverse foramen and significant subluxation or dislocation of the cervical spine. CT angiogram is an accurate screening method, but should be done only if antithrombotic therapy can be initiated

Abstract. Objectives. Catastrophic neck injuries in rugby tackling are rare (2 per 100,000 players per year) with 38% of these injuries occurring in the tackle. The aim of this study was to determine the primary mechanism of cervical spine injury during rugby tackling and to highlight the effect of tackling technique on intervertebral joint loads. Methods. In vivo and in vitro experimental data were integrated to generate realistic computer simulations representative of misdirected tackles. MRI images were used to inform the creation of a musculoskeletal model. In vivo kinematics and neck muscle excitations were collected during lab-based staged tackling of the player. Impact forces were collected in vitro using an instrumented anthropometric test device during experimental simulations of rugby collisions. Experimental kinematics and muscle excitations were prescribed to the model and impact forces applied to seven skull locations (three cranial and four lateral). To examine the effects of technique on intervertebral joint loads the model's neck angle was altered in steps of 5° about each rotational axis resulting in a total of 1,623 experimentally informed simulations of misdirected tackles. Results. Neck flexion angles and cranial impact locations had the largest effects on maximal compression, anterior shear and flexion moment loads. During posterior cranial impacts compression forces and flexion moments increased from 1500 to 3200 N and 30 to 60 Nm respectively between neck angles of 30° extension and 30° flexion. This was more evident at the C5-C6 and C6-C7 joints. Anterior shear loads remained stable throughout neck angle ranges however during anterior impacts they were directed posteriorly when the neck was flexed. Conclusions. The combination of estimated joint loads in the lower cervical spine support buckling as the primary injury mechanism of anterior bilateral facet dislocations observed in misdirected rugby tackles and highlights the importance of adopting a correct tackling technique. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Aims: Vertebral artery patency is not routinely documented in cervical fractures and dislocations. The incidence of vertebral artery injuries following cervical trauma is unknown, as they are rarely symptomatic. Vertebrobasilar insufficiency may be catastrophic and such vascular occlusion should be identified and treated early. Method: One hundred and eighteen patients who sustained fractures and dislocations of the cervical spine between January 1996 and February 2001 were evaluated and subjected to MRI (magnetic resonance imaging) and MRA (magnetic resonance angiography). The average age was 34 years and there were 30 females. Seventy patients had unifacet dislocations, 10 burst fractures and 38 bifacetal dislocations. Forty-five patients had neurological deficit. Seven patients died within the first six weeks of injury. Reduction and surgical fusion were performed on 115 patients. None of the patients had signs/symptoms of vertebrobasilar ischaemia. MRA was repeated in six patients three years post-injury. Results: Vertebral artery injury was diagnosed in 20 patients (23.6 %) – one patient had bilateral injury. Diagnosis was based on the loss of normal flow void on MRI and confirmed on MRA. Twelve patients with vascular compromise had unifacetal dislocations, two had burst fractures and six bifacetal dislocations. Thrombosis was present in 13 patients, three patients had intimal tears and five dissections (one patient with bilateral injury). The patient with bilateral injury also had significant neurological deficit (frankel C), confusion that resolved in 24 hours and evidence of cerebellar infarct. She had no symptoms of vertebrobasilar insufficiency and recovered full neurological function. Repeat MRA in six patients showed no evidence of recanalisation. Conclusion: VAI was more common in unifacet dislocations, emphasising the effect of a rotation force predisposing to vascular injury. We recommend early diagnosis of vertebrobasilar insufficiency. Future anterior cervical surgery in patients with VAI should be undertaken with caution

Cervical extrication collars are frequently used in pre hospital stabilization and in the definitive treatment for lesions of the cervical spine. The control of extensionflexion, lateral bending, and rotation given to individual segments is variable with different designs. Objective: To highlight the patient satisfaction and reported pain perception with immobilization of cervical injury with the extrication collar. Method: We present prospective cohort of fourteen patients with median age of 28 years with suspected C-spine injury waiting for CT scan. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. They were treated with extrication collar immobilization. The initial diagnosis was made by supine cross-table lateral radiograph and then by computed tomographic scan as early as possible. All had no apparent neurologic deficit attributed to the C-spine at admission. Results: All reported increased level of pain despite administering adequate analgesia. Most patients reported increased pain at the pressure point of the collar. Conclusion: These cases demonstrate the limitations of current management techniques of suspected cervical fractures in unreliable trauma patients and highlight the lack of appropriate orthosis for cervical immobilization in our institution

We have reported that most of lower cervical cord injury patients had either improved or remained the same neurology following early operative stabilization done in our hospital. However, a few patients deteriorated with ascending paralysis in acute stage. Purpose of this paper is to present such cases and discuss the outcomes. Methods: 1) We have analyzed 10 pts of acute lower cervical cord injury who had deteriorated neurologic symptom ascending above C4 and complicated with respiratory quadriplegia. They accounted for 3.7 % out of 271 patients with bony injury. 2) They were 8 males and 2 females, aged 17~76, injury type C5/6 fracture-dislocation (Fx/Dx) in 4, C6/7 Fx/Dx in 4, C7/T1 in 1, and one C5 flexion tear drop Fx. 3) 2 patients were treated conservatively and 8 had operative reduction and fusion with careful technique. Results: 1) All patients had complete quadriplegia. 2) 3 pts could not wean out of ventilator and other 2 of them eventually died. 3) Paralysis started to ascend in 3 days after injury needed ventilator in 24 hours thereafter. 4) 2 out of 10 patients underwent an excessive distraction being treated conservatively. 8 patients had operative fixation for bony injuries, 7 of them obtained solid spine with single operation, but one had redislocated in a few days after the operation and received restabilisation surgery. Conclusion: 1) There are a few patients of acute lower cervical injury with complete quadriplegia deteriorated neurology ascending paralysis with respiratory distress. 2) Comparing to other cases an operative treatment would not a cause of such neurologic deterioration. 3) In most cases paralysis of diaphragm was passing symptom, but quite a few patients(1%) could not wean off ventilator. 4) Cause of ascending paralysis in such injury could not be identified definitely, therefore careful observation and prompt treatment such as tracheotomy should be recommended

Purpose: The decision of whether or not an injury to the sub-axial cervical spine needs operative management often hinges on the stability of the spine. The posterior Ligamentous Complex (PLC) is one of the primary soft tissue stabilizers of the cervical spine. Fat-saturated T2-wieghted MRI sequences are able to demonstrate soft tissue injury to the cervical spine. No studies to date have assessed the ability of MRI to accurately and reliably demonstrate PLC disruption in the sub-axial cervical spine.

Method: Forty-nine consecutive patients aged 14–85 years presenting to the two participating institutions with injury between C3 and T1 who required posterior surgery as part of their management were prospectively enrolled in the study. All patients had radiographs, CT, and MRI scans preoperatively, which were reviewed by a Neuroradiologist, and the treating surgeon separately. Their posterior intraoperative findings were then recorded by the treating surgeon and his assistant. Statistical analysis included Spearman’s rank order correlation, and Cohen’s kappa score.

Results: There was a moderate level of agreement between the radiologist’s interpretation of the preopera-tive MRI and the surgeon’s intraoperative findings for the supraspinous and intraspinous ligaments, (kappa.49 & .48 respectively). A fair level of agreement was found for the ligamentum flavum, left and right facet capsules, and the cervical fascia (kappa scores.31,.30,.30,.39 respectively).

Conclusion: MRI has a high sensitivity (78.6% to 100%) for detecting cervical PLC injury but a low specificity (53.6% to 75%). On its own MRI is not a useful tool for diagnosing cervical spine PLC injury. The clinician should be aware of the relatively high rate of false positive PLC injury diagnosis with MRI.

Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries

Aim of Study. To highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. Study Method. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. Conclusion. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries

Background. A cautious outlook towards neck injuries is the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce the unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries. Methods. This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs done for suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results. 14 patients were included in the high risk category according to the Canadian Cervical Spine rule. 100 patients were assessed according to the low risk category. If the Canadian Cervical Spine rule was applied, there was a significant reduction in cervical spine radiographs (p<0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radiograph. 2/100 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied. Conclusion. Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and cost benefits

Background: A cautious outlook towards neck injuries has been the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce the unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries. Methods: This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs done for suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results: 14 patients were included in the high risk category according to the Canadian Cervical Spine rule. 100 patients were assessed according to the low risk category. If the Canadian Cervical Spine rule was applied, there was a significant reduction in cervical spine radiographs (p< 0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radiograph. 2/100 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied. Conclusion: Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and cost benefits

Introduction Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation is often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3. Methodology The MND(SE) Hospital databases were used to identify all casualties admitted with either a “cervical” or “Neck” injury. The databases covered the period from March 2003 until February 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries. Results 46 casualties were admitted and all were British except 2, who were Iraqi. 33 casualties were returned to their unit for duty or discharged at the airhead on return to the UK. Twelve casualties required hospital treatment. There were 3 serious cervical spine injuries over the study period which included one Hangman’s fracture of C2, one flexion compression injury of C5 and one unifacetal dislocation. All casualties were neurologically intact. Conclusions 3 casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a halo was flown out from the UK. Recommendations All unstable cervical spine fractures should be stabilised with a halo vest prior to transfer from Role 3. Halo rings and vests should be available at Role 3 facilities

The August 2013 Spine Roundup. 360 . looks at: SPECT CT and facet joints; a difficult conversation: scoliosis and complications; time for a paradigm shift? complications under the microscope; minor trauma and cervical injury: a predictable phenomenon?; more costly all round: incentivising more complex operations?; minimally invasive surgery = minimal scarring; and symptomatic lumbar spine stenosis

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today’s global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties. We retrospectively reviewed hospital charts and autopsy reports of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention and cause of death was recorded. During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 (7%) actually survived to reach hospital. Four subsequently died from injuries within 72 hours. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation, however this patient died as result of a co-existing head injury. Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life threatening conditions

The posterior ligament complex (PLC) in the cervical spine comprises the posterior longitudinal ligament, ligamentum flavum and ligamentum nuchae, the latter homologous with the supraspinous and interspinous ligaments at other levels of the spine. In determining instability, evaluation of the PLC is an essential part of the assessment of cervical spine injuries. Disruption of the PLC occurs following flexion injuries, both in compression and in distraction, and following extension injuries with compression. PLC disruption, diagnosed when clinical examination reveals localised posterior spinal tenderness and/or a widened interspinous gap, is confirmed on standard and dynamic flexion-extension radiographs and MRI. This paper is a retrospective review of 162 patients treated for cervical injuries between 1997 and 2001. There were 83 (51%) distraction flexion, 37 (23%) compression flexion, 18 (11%) compression extension, 17 (10%) vertical compression, six (4%) distraction extension and one (1%) lateral flexion injuries. In 79 patients with pure ligamentous instability, an interspinous stabilisation procedure was performed, using a titanium cable. When associated fractures occurred with PLC disruption, neurologically intact patients were managed conservatively with traction followed by a spinal brace. Patients with a neurological deficit underwent surgery. Using delayed dynamic flexion-extension views and MRI, PLC disruption was diagnosed late in nine flexion distraction injuries without facet dislocation. At follow-up, flexion-extension views showed that all PLC disruptions with associated fractures had stabilised. There were two broken cables in patients who underwent surgery. Patients with cervical instability following trauma may be treated non-operatively when there are associated fractures, while patients with pure ligamentous instability should undergo fusion. Further, to exclude occult PLC disruption, all cervical injuries should be reviewed on flexion-extension views once the paraspinal muscle spasm has settled

We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years in a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data were acquired by analysis of the national spinal unit database, hospital inpatient enquiry (HIPE) system, chart and radiographic review. Mean age was 74 years (range 66-93yrs). The male to female ratio was 2.1: 1(M=72, F=35). The mean follow-up was 4.4 years (1-9 years) and mean in-hospital stay was 10 days. The mechanism of injury was a fall in 75 and a road traffic accident (RTA) in the remaining 32 patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. Outcome was assessed using the Cervical Spine Outcomes Questionnaire (CSOQ) from Johns Hopkins School of Medicine. Functional outcome scores approached pre-morbid level in almost all patients. Functional disability was more marked in the patients with neurological deficit at the time of injury. Outcome of the injury is related to the increasing age, co-morbidity and the severity of the neurological deficit. Injuries of the cervical spine are a not infrequent occurrence in the elderly and occur with relatively minor trauma. Neck pain in the elderly patient should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilisation

Purpose. Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine injury following relatively minor trauma. The authors present a retrospective review to determine the characteristics, treatment and outcome following cervical spine injury in these patients. Methods. Retrospective analysis of case notes and images of patients with AS admitted to the Spinal Injury Unit over a 10-year period. Results. Thirty-nine patients were identified. Records were available for 31 patients at the time of this analysis. The median age was 62 years (range 37-84). The male:female ratio was 7:1. Mechanisms of injury included falls (72%) and RTAs (7%), while 14% were unable to recall an injury. Alcohol was involved in 20% of the cases. Fracture through an ankylosed disc in the mid to low cervical spine was the commonest injury. Concomitant non-contiguous bony injury was seen in 2 patients. More than half (55%) were Grade E on ASIA impairment scale (AIS), while 14% were Grade A and 31% Grade D. Two patients required skull traction. Most patients were successfully treated by external immobilisation. Halo crown and jacket was the most common orthosis used. Twelve patients underwent surgical stabilisation. The mean duration of external immobilisation in the non-surgical group was 13 weeks (range 10-32), whereas following surgery it was 6 weeks (range 2-8). Adequate radiological evidence of fusion was seen in all 22 patients for whom this information was available at a median of 22 weeks (range 12-32). Patients with AIS Grade A and E were unchanged at discharge, while 4 patients in AIS Grade D improved to E. Conclusion. External immobilisation with halo in an effective first-line therapy in achieving fusion and stability. Surgical stabilisation can be reserved as a second-line treatment

Purpose. Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine injury following relatively minor trauma. The authors present a retrospective review to determine the characteristics, treatment and outcome following cervical spine injury in these patients. Methods. Retrospective analysis of case notes and images of patients with AS admitted to the Spinal Injury Unit over a 10-year period. Results. Thirty-nine patients were identified. Records were available for 31 patients at the time of this analysis. The median age was 62 years (range 37-84). The male:female ratio was 7:1. Mechanisms of injury included falls (72%) and RTAs (7%), while 14% were unable to recall an injury. Alcohol was involved in 20% of the cases. Fracture through an ankylosed disc in the mid to low cervical spine was the commonest injury. Concomitant non-contiguous bony injury was seen in 2 patients. More than half (55%) were Grade E on ASIA impairment scale (AIS), while 14% were Grade A and 31% Grade D. Two patients required skull traction. Most patients were successfully treated by external immobilisation. Halo crown and jacket was the most common orthosis used. Twelve patients underwent surgical stabilisation. The mean duration of external immobilisation in the non-surgical group was 13 weeks (range 10-32), whereas following surgery it was 6 weeks (range 2-8). Adequate radiological evidence of fusion was seen in all 22 patients for whom this information was available at a median of 22 weeks (range 12-32). Patients with AIS Grade A and E were unchanged at discharge, while 4 patients in AIS Grade D improved to E. Conclusion. External immobilisation with halo in an effective first-line therapy in achieving fusion and stability. Surgical stabilisation can be reserved as a second-line treatment