A considerable variety of fractures and dislocations follow trauma between the occiput and the first thoracic vertebra. Most are caused by car accidents, with falls and sports accidents next in frequency.1–3 Half of all patients present with neurological problems.4 Early diagnosis is important. The cervical fracture is often combined with another spinal fracture and therefore the entire vertebral column must be X-rayed.5 Plain radiographs are the first way in which diagnosis is established. Multidirectional CT is particularly advantageous in patients with facet injuries. CT seems to add most additional information in laminar or posterior column injuries, fractures of the vertebral body or in atlantoaxial subluxations.6 Fractures of the axis are common. In 14–17.5% of all fractures of the cervical spinal column the lesion lies at the axis.7 Most frequent are odontoid fractures. They are classified as type I – avulsion of the tip of the odontoid process, type II – fracture through the base and type III – fracture through the vertebral body.8,9 These are followed in frequency by those of the vertebral body, the pedicle or the lateral mass. Less common is hangman’s fracture – a bilateral fracture through the pars interarticularis of the axis. Neurological damage is not frequent in odontoid and hangman’s fractures but quite common in the other miscellaneous fractures of the axis.10 Dislocations of the atlas are not uncommon and may lead to serious neurological damage.11 Fractures of the atlas are rare and seldom cause neurological problems. In order of frequency the following fractures are found: bilateral fracture of the posterior arch, comminuted fracture of the ring of the atlas – traumatic spondylolisthesis or Jefferson’s fracture, and unilateral fracture of the lateral mass.12 Most fractures in the cervical spine occur below C2. They range from fractures of the articular process to fractures of the vertebral body, lamina, spinous process and pedicle. Fractures are commonly classified in six groups depending (in order of frequency) on the forces that have acted on the cervical spine: compressive flexion, distractive flexion, compressive extension, vertical compression, distractive extension and lateral flexion.13 Neurological problems most often occur when the fracture is combined with luxation.14,15 Pathological fractures following a minor injury or a sudden effort give rise to the same clinical picture but the history is much less indicative and may even be misleading. If neurological injury is present, the diagnosis of a probable fracture or dislocation is made more simple. This is a fracture of one or more spinous processes in the lower cervical or upper thoracic spine (mostly C7, sometimes C6 or T1).16 A traction fracture may occur as the result of strong muscular force from the trapezius transmitted to the spinous processes through the musculature. It happens suddenly. A crack is felt followed by severe pain at the base of the neck and between the shoulders. The same event may occur in motor vehicle accidents where a strong flexion force is applied to the neck, and thus also in whiplash injuries.17,18 Primary bone tumours are uncommon. They represent only 0.4% of all tumours and cervical localization accounts for only 4.2% of the primary bone tumours of the spine. This is very much less than in the thoracic or lumbar spine.19 The symptoms may vary and include local heat, tenderness, neuralgic pain, root palsy, torticollis-like limitation of neck movements20 and myelopathy, although early in development the symptoms may mimic ordinary soft tissue lesions. Severe pain at night is often a hallmark of neoplasm.21 The presence of one or more inconsistencies during history and/or functional examination is a warning sign and puts the examiner on guard (see Box 1). It is again mainly the clinical approach that suggests a serious disorder. Radiography – usually the first additional examination – is not always helpful, as it appears that more than 30% of the cancellous bone of the vertebral body must be destroyed before a plain X-ray becomes positive.22–24 More refined imaging such as CT scan, technetium scan, angiography and MRI confirms the diagnosis. A radiograph and CT scan of the chest or abdomen may be necessary in patients with unknown primary sites. The most common benign neoplasms affecting the cervical spine are, in order of frequency: osteoid osteoma, osteoblastoma, haemangioma, aneurysmal bone cyst, eosinophilic granuloma, giant cell tumour and osteochondroma. They can be found at any level, except C1, and are most common at C2, C4 and C7 levels.25–28 This is the most frequent benign tumour in the cervical spine20 and appears in young adults, mostly males.29,30 It affects the cervical spine less frequently than the lumbar spine and is located in the pedicles and vertebral arches.31 This tumour affects the cervical spine as frequently as it does the thoracic spine. It is more common in the lumbar spine.25 Young adults – males more frequently – are affected and the posterior elements of the vertebra are involved, which may lead to radiculopathy and myelopathy. This occurs most often in women in their fourth decade.33 It is common and usually has an asymptomatic development – one-quarter of all cases are in the cervical spine. This is seen most frequently in children and young adults, mostly females (under 30 years old).35 Twenty-five per cent of spinal aneurysmal bone cysts are located in the cervical spine.28 It is a destructive tumour and is mostly localized in the neural arch but may also invade the vertebral body. As it expands, it may lead to root pain and even to compression of the spinal cord. Excision and/or curettage and stabilization with bone grafts are indicated.36 The fracture may heal spontaneously. However, when the flattening is significant, neurological symptoms may follow; these are reversible when treatment is started without delay. Open biopsy, followed by immobilization and irradiation may be necessary.37,38 This is more frequent in the sacrum and the lumbar spine but may also affect the cervical spine. It seems to occur in younger patients (between 20 and 40 years old), especially women.39 It leads to destruction of the vertebral body and can later involve the posterior part of the vertebra. It may cause pain in the neck but can also give rise to radicular symptoms. The primary malignant tumours represent 6.3% of all primary bone tumours of the spine and occur mainly from middle age on, much more frequently in men than in women. They are found at all levels, except C1.26 The treatment of choice is radiation and/or systemic chemotherapy. The outlook is poor. This is an uncommon, locally invasive, slow-growing malignant neoplasm that arises from the vertebral or suboccipital remnants of the embryonic notochord. In 33–38% it occurs in the upper cervical vertebrae, especially C2, and is found most often in men aged between 50 and 70 years.41,42 The tumour often extends anteriorly into the soft tissues and may then result in dysphagia, upper respiratory obstruction and Horner’s syndrome.43 Posterior extension may be accompanied by neurological complications, such as epidural spinal cord compression or cervical radiculopathy.44,45 This is a myeloma (plasma cell neoplasm) in a single vertebral body. The patient is over 60 years and complains of slowly progressing neck pain with muscle spasm. The prognosis is much more favourable than in patients with multiple myeloma.46 Collapse of the vertebral body and cord compression may result. Secondary deposits are the most common malignant tumours of the cervical spine, although this part of the vertebral column is the least affected, occurring in 8–20% of patients with known metastatic disease.47 Breast, lung, prostate, colon, kidney and thyroid are the most frequent sites of primaries.48 Metastases in the spine may pass unnoticed for a considerable time and are sometimes discovered during routine radiography. In symptomatic cases, pain is the earliest and most prominent feature in 90%.49 Localized pain that starts spontaneously and becomes gradually worse, especially at night, is the most common picture of spinal metastases. It is axiomatic that a cancer patient who develops neck pain harbours a spinal metastasis until proven otherwise. If a patient presents with neck pain but has a history of a primary tumour, for example breast cancer, even a long time ago, metastases must be taken into consideration. Tumour-related pain is predominantly nocturnal or early morning pain and generally improves with activity during the day. This pain may be caused by inflammatory mediators or tumour stretching the periost of the vertebral body.50 The clinical features differ depending on whether the lesion is localized at the upper cervical spine (C1-C3), the lower cervical spine (C4-C7) or the upper thoracic spine (T1-T3).51 If vertebral metastases are suspected, further investigations are arranged. Plain radiographs are often ordered as the first test to evaluate a patient with cancer who has neck pain, but are relatively poor screening tests for metastases. Visualization of a radiolucent defect on plain radiographs requires a 30% destruction of the vertebral body. Additionally, metastatic tumour often infiltrates the bone marrow of the vertebral body without destroying the cortical bone. Bone scan (99mTc-MDP) is more sensitive than plain radiographs for detecting spinal metastases. The advantage of bone scan is the ability to screen the entire skeleton with a single image. However, the sensitivity is not 100%: patients with rapidly progressive, destructive tumours may not be detected and bone scan is relatively insensitive for multiple myeloma and tumours confined to the bone marrow.52 It also has a low specificity for tumour: fractures, degenerative disease, and benign disorders of the spine (Schmorl’s nodes, haemangioma) all may be positive.53 Since MRI is widely available, it has become the most sensitive and specific modality for imaging spinal metastases. Sagittal screening images of the entire spine reveal bone, epidural and paraspinal tumour. The extent and degree of spinal cord compression can be readily appreciated.54
Non-mechanical disorders
Pathology
Osseous disorders
Fractures and luxations
Fractures and dislocations of the atlantoaxial complex
Fractures of the lower cervical spine
Clay-shoveller’s fracture
Bony tumours
Benign tumours
Osteoid osteoma
Osteoblastoma
Haemangioma
Aneurysmal bone cyst
Eosinophilic granuloma
Giant cell tumour
Malignant tumours
Multiple myeloma
Chordoma
Solitary plasmacytoma
Metastases
Upper thoracic metastases
disorders: Pathology
