Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478

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Journal of Cranio-Maxillo-Facial Surgery

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Maxillofacial trauma e Underestimation of cervical spine injury

Waldemar Reich a, *, Alexey Surov b, 1, Alexander Walter Eckert a, 2
a
Department of Oral and Plastic Maxillofacial Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube Str. 40, 06120, Halle (Saale), Germany
b
Department of Diagnostic and Interventional Radiology, University Leipzig, Liebig Str. 20, 04103, Leipzig, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Undiagnosed cervical spine injury can have devastating results. The aim of this study was to analyse
Paper received 18 February 2016 patients with primary maxillofacial trauma and a concomitant cervical spine injury. It is hypothetised
Accepted 16 June 2016 that cervical spine injury is predictable in maxillofacial surgery.
Available online 24 June 2016
A monocentric clinical study was conducted over a 10-year period to analyse patients with primary
maxillofacial and associated cervical spine injuries. Demographic data, mechanism of injury, specific
Keywords:
trauma and treatments provided were reviewed. Additionally a search of relevant international literature
Adverse events
was conducted in PubMed by terms “maxillofacial” AND “cervical spine” AND “injury”.
Airway
Cervical spine
Of 3956 patients, n ¼ 3732 (94.3%) suffered from craniomaxillofacial injuries only, n ¼ 174 (4.4%) from
Diagnosis cervical spine injuries only, and n ¼ 50 (1.3%) from both craniomaxillofacial and cervical spine injuries. In
Maxillofacial this study cohort the most prevalent craniofacial injuries were: n ¼ 41 (44%) midfacial and n ¼ 21 (22.6%)
Trauma skull base fractures. Cervical spine injuries primarily affected the upper cervical spine column: n ¼ 39
(58.2%) vs. n ¼ 28 (41.8%). Only in 3 of 50 cases (6%), the cervical spine injury was diagnosed coinci-
dentally, and the cervical spine column was under immobilised. The operative treatment rate for
maxillofacial injuries was 36% (n ¼ 18), and for cervical spine injuries 20% (n ¼ 10). The overall mortality
rate was 8% (n ¼ 4). The literature search yielded only 12 papers (11 retrospective and monocentric
cohort studies) and is discussed before our own results.
In cases of apparently isolated maxillofacial trauma, maxillofacial surgeons should be aware of a low
but serious risk of underestimating an unstable cervical spine injury.
© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction et al., 2006). Sharp and blunt trauma to the head may lead to un-
suspected comorbidity of the cervical spine (Haug et al., 1991;
According to a recent national trauma report (German Trauma Kayser et al., 2006; Roccia et al., 2007). Possible symptoms of cer-
Society), the incidence of maxillofacial injuries in polytraumatised vical spine injury include local headache, occipital tenderness on
patients is relatively high (25.4%). Approximately 35% are primarily palpation, Horner syndrome, cranial nerve impairments, and brain
affected by complex midfacial fractures (Esmer et al., 2016); (stem) infarction (Brandt et al., 2006). The underestimation of or
otherwise, every 13th polytrauma patient (7.7%) presents a spinal general neglect of these signs can have devastating results, espe-
cord injury with neurologic deficit, including 7.2% with transient cially when they are associated with difficult airways or distracting
neurologic deficits, 27.5% with incomplete paraplegia, and 49.6% injury. In primarily isolated maxillofacial injuries energy may
with complete paraplegia or a complete lesion above C3 (Stephan inevitably be transmitted to other anatomical structures of the
et al., 2015). Furthermore, in 5e14% of all cases, a delayed diag- head and neck, which can also be involved in a variety of fractures.
nosis of lesions in multiply traumatised patients is evident (Pehle Some studies recognise certain patterns of force transmission and
dispersion to the cervical spinal column (Lewis et al., 1985; Jamal
et al., 2009; Mithani et al., 2009) or discuss causal relationship
between the location of first and second regions (Clayton et al.,
* Corresponding author. Tel.: þ49 345 557 5359; fax: þ49 345 557 5291. 2012). When maxillofacial surgeons are involved in the initial
E-mail addresses: waldemar.reich@medizin.uni-halle.de (W. Reich), alexey.
assessment of these cases, it is essential that they are aware of the
surov@medizin.uni-leipzig.de (A. Surov), alexander.eckert@uk-halle.de (A.W. Eckert).
1
Tel.: þ49 341 97 17400; fax: þ49 341 97 17409. possibility of cervical spine injury and initiate additional
2
Tel.: þ49 345 557 5237; fax: þ49 345 557 5291. diagnostics.

http://dx.doi.org/10.1016/j.jcms.2016.06.017
1010-5182/© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
1470 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478

The purpose of this study is to analyse the incidence of patients

with primary maxillofacial trauma who also present with signifi-
cant cervical spine injury in a single centre. It is hypothetised that
cervical spine injury is underestimated in maxillofacial surgery; in
this patient group, individual risk factors can predict the possibility
of concomitant cervical spine injuries, which may lead appropriate
imaging examinations and could prevent neurologic complications.

2. Materials and methods

A retrospective monocentric study was conducted over a 10-

year period to analyse patients with primary maxillofacial and
major cervical spine injuries. Craniomaxillofacial (CMF) and cervi-
cal spine (CS) injuries that included the following ICD-10 codes
(German modification, version 2015) were included: S02.0 (cranial
vault), S02.1 (skull base), S02.2 to S02.4 (nasal pyramid, orbita,
zygoma), S02.6 (mandible), S12.0 to S12.25 (cervical spine fractures
from C1 to C7), and S12.7 (multiple cervical spine fractures). For
that reason, first the incidence of CMF injuries and respectively, the
incidence of CS injuries were calculated. In this study, only patients
suffering from both types of injuries were included (study cohort).
Patient charts were reviewed to determine demographic data, the
mechanism of injury, the specific trauma and the treatments Fig. 1. Monocentric trauma population suffering from head and neck fractures
over a 10-year period and study cohort. (a) Among all head and neck fractures,
received. The study was performed according to the Declaration of
n ¼ 3732 patients suffered from craniomaxillofacial (CMF) injuries only, n ¼ 174 from
Helsinki. Descriptive statistical analyses were performed using cervical spine (CS) injuries only, and n ¼ 50 patients (study cohort) suffered from a
Microsoft Excel. combination of both injuries (Figure 1b). (b) Maxillofacial and cervical spine fractures
Additionally a literature search was conducted in PubMed by were prevalent in n ¼ 22 patients (44%; isolated maxillofacial injuries n ¼ 16, multiple
maxillofacial injuries n ¼ 6), cranial vault/skull base and cervical spine fractures
terms “maxillofacial” AND “cervical spine” AND “injury” OR
(associated with facial soft tissue lesions) in n ¼ 17 (34%), and craniomaxillofacial and
“trauma” aiming to discuss own results. Only original articles cervical spine fractures in n ¼ 11 of 50 patients (22%; isolated maxillofacial injuries
reporting patients with blunt cervical spine injury were included. n ¼ 8, multiple maxillofacial injuries n ¼ 3).
Review manuscripts, articles referring case reports, paediatric pa-
tients, dental injury, temporomandibular joint dysfunction and
penetrating injuries were excluded. Articles were also excluded cervical vertebra was affected (C0/C1, C0/C5/C6, C1/C2, C1/C7, C2/
when no abstract was available. C6, C3eC5, C4/C6, C5/C6, C6/C7).
A cervical spine CT scan was the imaging method of choice.
3. Results Additional MRI was performed in 5 cases: two discoligamentous
lesions (C0/C1, C6/C7) and respectively, one case of subdural
Over the 10-year study period (01/2005e11/2015) at a single bleeding (atlanto-occipital junction), bilateral abducens nerve
trauma centre of 3956 trauma patients, n ¼ 3732 (94.3%) suffered paresis and arteria spinalis anterior syndrome. In n ¼ 3 of the 50
from craniomaxillofacial injuries only, n ¼ 174 (4.4%) from cervical presented cases (6%), the cervical spine injury was diagnosed
spine injuries only, and n ¼ 50 (1.3%) from both (cranio)maxillo- coincidentally to the maxillofacial injury, and the cervical spine
facial and associated cervical spine injuries (Fig. 1a, Table 1). Among column was under immobilised. In other 47 patients primary
3732 craniomaxillofacial injuries, n ¼ 3359 (90%) had isolated cervical spine or polytrauma CT imaging systematically cleared
fractures, and n ¼ 373 (10%) had multiple fractures. The average the questionable CS injuries based on specific circumstances,
yearly distribution of maxillofacial fractures was n ¼ 125 (34%) mechanism of injury and clinical signs. Consequently, the
zygomatic, n ¼ 119 (32%) mandibular, n ¼ 72 (19%) nasal, n ¼ 41 calculated prevalence of cervical spine injuries diagnosed on
(11%) orbital, and n ¼ 15 (4%) other fractures. midface CT scans each year was 0.3, and the calculated preva-
Craniomaxillofacial and cervical spine fractures were reported lence of cervical spine injuries diagnosed on cervical spine or
in n ¼ 11 of 50 patients (22%; isolated maxillofacial injury n ¼ 8, polytrauma CT scans each year was 4.7. During the same period
multiple maxillofacial injuries n ¼ 3), cranial vault/skull base and and at the same trauma centre, the following CT imaging ex-
cervical spine fractures (associated with facial soft tissue lesions) aminations were performed per year: n ¼ 82 polytrauma CTs,
were reported in n ¼ 17 (34%), and maxillofacial and cervical spine n ¼ 32 cervical spine CTs and n ¼ 9 midface CTs (external im-
fractures were prevalent in n ¼ 22 patients (44%; isolated maxil- aging was not considered).
lofacial injury n ¼ 16, multiple maxillofacial injuries n ¼ 6). Clinical The operative treatment rate for maxillofacial injuries was 36%
signs of CMF injuries and CS injuries are presented in Table 2. In this (n ¼ 18) and that of cervical spine injuries was 20% (n ¼ 10; Table 3
study cohort (Fig. 1b), n ¼ 17 patients met the polytrauma criteria and Fig. 5). Unlike the patients treated conservatively (CMF injury:
(34%). The average age of 29 male and 21 female patients was 56.2 according to known principles of craniomaxillofacial surgery, CS
years. Based on clinical and radiological examination the most injury: soft cervical collar for 6 weeks and overlapping physio-
prevalent CMF injuries were as follows (Fig. 2a): n ¼ 41 (44%) therapy), in the first patient group CMF fractures were displaced,
midfacial fractures, n ¼ 21 (22.6%) skull base fractures and n ¼ 16 associated with functional impairment (i. e. diplopia, malocclusion)
(17.2%) soft tissue lesions. The CF injuries mostly affected the upper or open. Regarding the surgically treated CS injuries, clinical and
cervical spine column (Fig. 2b): C0eC2 n ¼ 39 (58.2%) vs. C3eC7 mainly radiologic examination were determining. A displacement
n ¼ 28 (41.8%). Seven patients had an unstable spine injury, and and/or instability or narrowing of the spinal canal were verified. In
cerebrocranial injuries of different severity were found in 28 pa- each case the individual treatment decision was determined in the
tients (Figures 3 and 4). In 9 of 50 cases (18%), more than one interdisciplinary trauma board.
 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478 1471

Table 1
Overview of patients with maxillofacial and cervical spine injuries (n ¼ 50). Among all craniomaxillofacial injuries (n ¼ 3782), an association with cervical spine injury was
found in 50 cases (1.3%). Twenty-four out of 3383 patients (0.7%) had isolated maxillofacial injuries, and 26 out of 399 patients (6.5%) had combined maxillofacial injuries.
Otherwise, among all cervical spine injuries (n ¼ 224), n ¼ 50 patients (22.3%) required craniomaxillofacial trauma therapy. The average inpatient treatment duration was 12
days (minimum 0, maximum 67 days). Polytrauma patients n ¼ 17 (34%), (þ) exitus letalis n ¼ 4 (8%), (?) mechanism of injury unknown., (*) soft tissue lesion, (**) Anderson-
D'Alonzo type (Anderson and D'Alonzo, 1974), (***) Jefferson type (C1 ring fracture).

n Year Craniomaxillofacial Cervical Craniomaxillofacial Gender Mechanism Craniocerebral Maxillofacial injury Cervical spine
injury only spine and cervical spine of injury injury e CCI (ICD10 S02.2 nasal injury (ICD10 S12.0
(n per year) injury only injury (n per year) (ICD10 S02.0 pyramid, S02.3 orbital Atlas, S12.1 Axis S12.21
(n per year) cranial vault, floor, S02.4 C3, S12.22 C4, S12.23 C5,
S02.1 skull base) zygoma/maxilla, S12.24 C6, S12.25 C7)
S02.6 mandible)

1. 2005 m Polytrauma S02.0, S02.1 S02.4 S12.1

2. 2005 f Polytrauma S02.2, S02.4 S12.23
2005 361 14 2
3. 2006 mþ Polytrauma S02.0, CCI III S12.0
4. 2006 mþ Polytrauma CCI III S02.2 S12.1 (II**)
5. 2006 f ? S02.0 S12.1
2006 367 12 3
6. 2007 m Polytrauma S02.4 S12.1
7. 2007 m ? S02.4 S12.22
2007 348 15 2
8. 2008 m ? S02.4 S12.25
9. 2008 m ? S02.4 S12.24, S12.25
10. 2008 m Polytrauma S02.67 S12.0, S12.25
11. 2008 f Polytrauma S02.1 S12.1 (III**)
12. 2008 m Polytrauma S02.1 S12.1
13. 2008 f ? S02.2 S12.0
2008 340 4 6
14. 2009 mþ Polytrauma S02.4 S12.0 (III***, unstable)
15. 2009 fþ ? S02.1 S02.2 S12.1 (II**, unstable)
16. 2009 f S02.1 S12.1
2009 309 16 3
17. 2010 m Polytrauma S02.1 S12.24, S12.25
18. 2010 f ? S02.4 S12.24, S12.25
19. 2010 m Fall S.02.4 S12.1
20. 2010 m ? S02.1 S12.1
2010 311 17 4
21. 2011 f ? S02.2, S02.4 S12.24
22. 2011 m ? S02.2 S12.1
23. 2011 m MVC, moped S02.1 S12.0
24. 2011 f Polytrauma S02.0 S01.43, S01.54* S12.0
25. 2011 f Fall S02.1 S02.4 S12.1, S12.22, S12.23
26. 2011 m Polytrauma S02.1 S12.25
27. 2011 m ? S02.1 S12.0
28. 2011 m Fall S02.61, S02.62, S12.22, S12.24
S02.65
2011 349 15 8
29. 2012 f ? CCI II S02.2 S12.0
30. 2012 m MVC, S02.0, S02.1 S02.2, S02.4 S12.1
Polytrauma
31. 2012 m ? S02.4 S12.24
32. 2012 m ? S02.2 S12.22
33. 2012 m MVC S02.2, S02.60, S12.24, S12.25
S02.63
2012 332 19 5
34. 2013 m ? S02.2 S12.0, S12.1
35. 2013 m Fall S02.0 S.02.4 S12.25
36. 2013 f Fall S02.4, S02.65, S12.25
S02.68, S02.69
37. 2013 f Bicycle S02.1 S02.2 S12.0
2013 327 19 4
38. 2014 f ? S02.2 S12.0
39. 2014 f Polytrauma S02.1 S12.25
40. 2014 m ? S02.1 S12.1
41. 2014 m Polytrauma S02.1 S12.0
2014 362 18 4
42. 2015 m ? S02.1 S12.1
43. 2015 m ? S02.1 S12.1 (II**)
44. 2015 f Polytrauma S02.0, S02.1 S02.4 S12.23, S12.24
45. 2015 f ? S02.1 S12.0
46. 2015 m ? S02.1 S12.23
47. 2015 f Fall, alcohol S02.0 S02.61 S12.0
48. 2015 f ? S02.2 S12.24
(continued on next page)
1472 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478

Table 1 (continued )

n Year Craniomaxillofacial Cervical Craniomaxillofacial Gender Mechanism Craniocerebral Maxillofacial injury Cervical spine
injury only spine and cervical spine of injury injury e CCI (ICD10 S02.2 nasal injury (ICD10 S12.0
(n per year) injury only injury (n per year) (ICD10 S02.0 pyramid, S02.3 orbital Atlas, S12.1 Axis S12.21
(n per year) cranial vault, floor, S02.4 C3, S12.22 C4, S12.23 C5,
S02.1 skull base) zygoma/maxilla, S12.24 C6, S12.25 C7)
S02.6 mandible)

49. 2015 f MVC, S02.61, S02.65 S.12.1

polytrauma
50. 2015 f Fall S02.0 S02.2, S02.4 S12.1
2015 326 25 8
S 3956 3732 (94.3%) 174 (4.4%) 50 (1.3%)
(100%)

Table 2
Clinical signs of craniomaxillofacial and cervical spine injuries. Maxillofacial and cervical spine fractures were prevalent in n ¼ 22 patients (isolated maxillofacial injury
n ¼ 16, multiple maxillofacial injuries n ¼ 6), neurocranial and cervical spine fractures in n ¼ 17 (associated with facial soft tissue lesions), and craniomaxillofacial (CMF) and
cervical spine (CS) fractures in n ¼ 11 of 50 patients (isolated maxillofacial injury n ¼ 8, multiple maxillofacial injuries n ¼ 3).

Injury Clinical signs

CMF Headache, nausea, vomiting, amnesia, deep soft tissue lazeration in the cranial, frontal, occipital, midfacial, (sub)mental, or (sub)mandibular region,
(periorbital) haematoma, epistaxis, orbitopalpebral emphysema.
Intraoral bleeding, mouth floor haematoma, dysphagia and dyspnoea.
Known diversity of maxillofacial fracture signs (nasal deviation, malocclusion etc.).
Increasing complexity of soft tissue and bony injuries associated with impaired consciousness, amnesia etc. is present in polytraumatised patients.
CS Associated clinical signs indicating possible CS injury: painful and limited neck mobilisation (examination of all 6 degrees of freedom), upper/lower
paravertebral or posterior midline neck tenderness on palpation (alert patient).
Especially in cases of impaired consciousness as well as dementia or other communication barriers clinical examination of the cervical column was
not adequately possible (prehospital immobilisation by a cervical rigid collar!).

The average overall inpatient treatment duration was 12 days

(minimum 0, maximum 67 days). The mortality rate within the first
18 days was 8% (1 patient died preoperatively, and 3 patients died
postoperatively).
Other than one patient presenting an arteria spinalis anterior
syndrome and another with bilateral abducens nerve paresis
(suspected brain stem contusion, spinal cord injury without
radiologic abnormality (Boese and Lechler, 2013) associated with
dens axis fractures, there were no spinal cord injuries with
neurological deficits.
The literature search in PubMed yielded only 12 international
papers which met the abovementioned inclusion criteria. The re-
ported studies were mostly of monocentric retrospective design.
The reviewed time period ranged from 2 to 10 years, the study
cohort from 123 to more than 1.3 million patients, and the preva-
lence of concomitant CS injuries from 0.6 to 60%. The largest na-
tional cohort presented the following over-all prevalences of head
injuries, cervical spine injuries, or both with isolated and multiple
craniomaxillofacial fractures: head injuries 25.6%, maxillofacial
fractures 11.3% and cervical spine injuries 4.5% (Mulligan and
Mahabir, 2010). The distribution of maxillofacial trauma in that
study was as follows: involvement of nasal pyramid in 25%, malar
bone/upper jaw in 23.2%, frontal/temporal bone in 20.5%, mandible
in 16.9%, orbital floor in 14.3%. The findings are presented in detail
in Table 4 and discussed below in front of own results.

4. Discussion

Monocentric and nationwide studies indicate that cervical spine

Fig. 2. Distribution of maxillofacial and cervical spine injuries in 50 consecutive injuries are prevalent in 0.8e11% of maxillofacial trauma patients,
patients. In 9 cases, two and more cervical vertebral fractures were involved (C0/C1, depending to the study cohort (Table 4). From a traumatologic-
C0/C5/C6, C1/C2, C1/C7, C2/C6, C3eC5, C4/C6, C5/C6, C6/C7). Of 50 patients, 7 patients orthopaedic point of view, patients with cervical spine injuries
had an unstable spine injury, and 28 presented with an additional craniocerebral present in 6.3e19.3% significant maxillofacial trauma (Lewis et al.,
injury of several severity (Tables 1 and 3). (a) Distribution of craniomaxillofacial in-
juries with predominately midfacial fractures (n ¼ 41). (b) Cervical spine level injuries,
1985; Jamal et al., 2009).
primarily involving the upper cervical spinal column (n ¼ 39): C0 n ¼ 6, C1 n ¼ 14, C2 The relevance of this issue is evident as presented in Fig. 1b.
n ¼ 19, C3eC7 n ¼ 28. Namely, in the majority of our study cohort (n ¼ 33; 66%)
 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478 1473

Fig. 3. Severe de
collement of the submandibular tissue associated with a critical airway and cervical spine injury in a 49-year-old woman. Without securing the airway, there
is a serious risk of glossoptosis and dyspnoea (while swallowing or in horizontal position), which is a special challenge during the preclinical period. (a) Preoperative clinical aspect
following fiberoptic intubation and CT examination. (b) Caudal view of the submandibular wound under manual head fixation and neck distraction, which was continued during

collement of the submandibular soft tissue associated with
soft tissue closure (concerning other means of intraoperative stabilisation see injured sagittal sutura in Fig. 4a). (c) De
disinsertion of the mouth floor muscles anteriorly and on the left side, indicating a trauma resulting from high kinetic energy (distracting injury).

Fig. 4. Native CT scan of the head and cervical spinal column. (a) Coronal CT section of the injured sagittal sutura with haematosinus frontalis on the left side. (b) Axial CT section
showing an unstable C1 ring fracture (Jefferson type 3): atlas arch, massa lateralis.

maxillofacial surgeons were substantially involved in the in- aware of the possibility of cervical spine injury. There is a significant
hospital treatment. possibility of a delayed in-hospital diagnosis of some lesions in
multiple trauma patients, although this is extremely rare in cases of
blunt spine injuries (Pehle et al., 2006). Several authors have found
4.1. Blunt cervical spine injury that the probability of a blunt cervical spine injury obviously rises
with increasing maxillofacial trauma complexity (Hackl et al.,
Especially during prehospital medical aid, the risk of under 2001a,b; Roccia et al., 2007; Mithani et al., 2009; Mulligan and
immobilisation of the injured cervical spine column should be Mahabir, 2010). Because maxillofacial surgeons are not typically
considered. Paterek et al. (2015) reported a 0.3% frequency of that involved in cervical spine pathologies in cases of apparently iso-
condition (under immobilisation), which is exactly concordant with lated maxillofacial trauma, there may be a risk of underestimating
our own results. As maxillofacial surgeons are regularly involved in an occult blunt cervical spine injury. Familiarity with the
the initial assessment of trauma patients, it is essential that they are
 1474
Table 3
Overview of surgically treated patients with maxillofacial and cervical spine injuries (n ¼ 18). m: male; f: female; MVC: motor vehicle collision; F: fall (þ) specific circumstances: syncope, stairs, ladder, alcohol, vertigo; B:
bicycle; ICB: intracranial bleeding; SAB: subarachnoidal bleeding; !: cervical spine injuries diagnosed coincidentally (one other case was treated non-operatively); C0eC2: upper cervical spine; C3eC7: lower cervical spine
(Reinhold et al., 2006; Schueller-Weidekamm, 2008); L: lumbar spine; (þþ) spinal cord injury without radiologic abnormality: SCIWORA (Boese and Lechler, 2013). #: see Figs. 3e5.

W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478

Gender Mechanism Maxillofacial trauma Cervical spine trauma Craniocerebral trauma, etc. Imaging Therapy, maxillofacial trauma Therapy, cervical spine
of injury trauma

1. m MVC Centrolateral midface Dens axis [C2] Skull base, ICB CT Osteosynthesis Osteosynthesis
2. m Fþ Lateral midface, open Dens axis Anderson type II [C2] CT ! Osteosynthesis Osteosynthesis
3. f Fþ Lateral midface, comminuted Dens axis Anderson type II [C2] ICB parietal, radius, L1eL4 CT Osteosynthesis Osteosynthesis
(Proc. transversi)
4. f# MVC Soft tissue only, severe Atlas Jefferson type [C1] ICB frontal, SAB bilateral, skull, CT ! Osteosynthesis, tracheostomy Osteosynthesis
olecranon
5. f F Central midface Atlas Jefferson type, dens axis – CT Osteosynthesis Osteosynthesis
Anderson type II [C1eC2]
6. f F Centrolateral midface, open Atlas Gehweiler type I [C1] – CT Osteosynthesis Non-operative
7. m MVC Mandible, multiple C6 (arch), C7 (Proc. transversi) [C6eC7] Acetabulum CT Osteosynthesis Non-operative
8. f B Lateral midface, comminuted Condylus occipitalis [C0] SAB, subcapsular liver haematoma, CT Osteosynthesis Non-operative
Galeazzi fracture
9. f F Centrolateral midface Atlas and dens axis [C1eC2] Skull, aorta dissection Stanford type CT Osteosynthesis Osteosynthesis
A, internal carotid artery dissection
10. f Fþ Centrolateral midface Dens axis and C6 [C1, C6] Multiple SAB, T4 and T11 CT Osteosynthesis, tracheostomy Osteosynthesis
11. m MVC Centrolateral midface, C5 (Proc. transversi) [C5] Skull base, ICB, haematopneumothorax, CT Osteosynthesis, tracheotomy, Non-operative
mandible liver capsula, hip luxation, tibia, fibula VP-Shunt etc.
12. m F Orbita, mandible C7 (Proc. transversi) [C7] CT Osteosynthesis Non-operative
13. f MVC Only soft tissue Dens axis Anderson type II [C2] Ribs, medial femoral condylus CT Osteosynthesis Osteosynthesis
14. f Bþ Central midface C3eC5 (Proc. spinosi) [C3eC5] Sinus frontalis (anterior and CT Cranialisation frontal sinus, Non-operative
posterior wall) septorhinoplasty
15. f Fþ Lateral midface Condylus occipitalis, C5eC6 [C0, C5eC6] T1eT2 (Proc. transversi) CT Osteosynthesis Non-operative
16. f Fþ Mandible Atlas [C1] SAB, skull CT Osteosynthesis Non-operative
17. f MVC Mandible Dens axis Anderson type I [C2] Abducens nerve paresis bilaterally CT Osteosynthesis Osteosynthesis
resulting from brain stem contusion þþ,
contusion of lung, liver, spleen, uterus
and kidney
18. f Fþ Le Fort II, nasal pyramid Dens axis Anderson type II [C2] – CT Osteosynthesis Osteosynthesis
 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478 1475

Fig. 5. Posterior intercorporal spondylodesis e conventional postoperative X-ray in two planes. (a). Postoperative conventional X-ray examination (CT scan here not shown)
following posterior intercorporal spondylodesis (C1eC2). Reference lines on the lateral radiogram for evaluation of the cervical spinal column (Ardekian et al., 1997): anterior
vertebral body line (1), posterior vertebral body line (2), spinolaminary line (3), processus spinosi line (4). (b) Atlanto-axial fusion according to Gallie with a corticospongious block
from the iliac crest and wiring (Gallie, 1939) combined with transarticular screw osteosynthesis according to Magerl (Magerl and Seemann, 1986; Kandziora et al., 2010a).

Table 4
Cervical spinal injuries in maxillofacial trauma patients e comparison of literature with own results. In maxillofacial trauma cases, energy may be transmitted to the
cranial base and cervical spine column. In patients with isolated maxillofacial trauma, 28.7e79.9% have neurocranial injuries; in multiple maxillofacial trauma cases,
65.5e88.7% have neurocranial injuries (Mithani et al., 2009; Mulligan and Mahabir, 2010). (?) unknown.

Authors/year of publication Period Patients with Study cohort Study design Isolated maxillofacial trauma
(years) maxillofacial associated with cervical
injuries (total n ¼ ) spine injuriesa

 Haug et al., 1991  ?  563  Monocentric  ?  2.0% (n ¼ 11)

 Beirne et al., 1995  ?  582  Monocentric  Prospective cohort study  1.0% (n ¼ 6)
 Ardekian et al., 1997 (mandible)  ?  424  Monocentric  Retrospective cohort study  2.6% (n ¼ 11)
 Bayles et al., 1997 (mandible)  10  1382  Monocentric  Retrospective cohort study  0.6% (n ¼ 8)
 Lalani and Bonanthaya, 1997  2  536  Monocentric  Retrospective cohort study  3.0% (n ¼ 16)
 Merritt and Williams, 1997  10  1750  Monocentric  Retrospective cohort study  1.8% (n ¼ 27)
 Roccia et al., 2007  10  2482  Monocentric  Retrospective cohort study  0.8% (n ¼ 21)
 Elahi et al., 2008  10  709  Monocentric  Retrospective cohort study  1.8e5.7% (2e21)
 Mithani et al., 2009  7  4786  Monocentric  Retrospective cohort study  9.7% (n ¼ 461)
 Mulligan and Mahabiri, 2010  4  >1.3 x 106  National (USA)  Retrospective cohort study  4.9e8.0% (n  338)
 Mukherjee et al., 2015  6  714  Monocentric  Retrospective cohort study  2.2% (n ¼ 16)
 Presented own results  10  3383  Monocentric  Retrospective cohort study  0.7% (n ¼ 24)

Multiple maxillofacial traumata

associated with cervical
spine injuriesa

 Hackl et al., 2001a and 2001b  4  3083  Monocentric  Retrospective case control study  6.7% (n ¼ 206)
 Elahi et al., 2008  10  914  Monocentric  Retrospective cohort study  8.9% (n ¼ 81)
 Mulligan and Mahabir, 2010  4  >1.3 x 106  National (USA)  Retrospective cohort study  7.0e10.8% (n  774)
 Presented own results  10  399  Monocentric  Retrospective cohort study  6.5% (n ¼ 26)

Maxillofacial and neurocranial

trauma associated with cervical
spine injuriesa

 Elahi et al., 2008  10  123  Monocentric  Retrospective cohort study  60% (n ¼ 74)
 Mulligan and Mahabir, 2010  4  >1.3 x 106  National (USA)  Retrospective cohort study  2.8e5.8% (n  232)
(isolated maxillofacial trauma)  dito  dito  dito  dito  5.8e10.1% (n  620)
 Mulligan and Mahabir, 2010
(multiple maxillofacial trauma)
a
From the orthopaedic-traumatologic view and according to a monocentric study of 701 patients with cervical spine injuries, 6.3% (n ¼ 44) also presented with facial
fractures (Jamal et al., 2009). In another group of 907 patients, 2.1% (n ¼ 105) also had facial fractures (Hackl et al., 2001a,b). Furthermore, in a multicentre study of 982
patients, 19.3% (n ¼ 190) also had a facial injury (Lewis et al., 1985).
1476 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478

appropriate diagnostic algorithm is therefore generally required in protocol. In 60%, CT scans were the imaging method of choice,
all involved disciplines who treat head and neck injuries. Fortu- whereas in 8%, a contraindicated dynamic diagnostic method was
nately, we did not find any persistent neurologic deficiencies in any used (Theologis et al., 2014). As Tan et al. (2014) reported, a high-
of the three initially under immobilised cases in the reviewed study quality CT has 100% sensitivity and specificity for detecting unsta-
cohort. ble fractures. A recent systematic review concluded that the rigid
International literature referring to this issue is mostly based on cervical collar can be removed in blunt trauma patients when
data from monocentric retrospective studies and focuses on pa- negative CT findings are documented (Patel et al., 2015).
tients with isolated maxillofacial fractures (Table 4). In such constellation the consequences for the maxillofacial
It is obviously in all studies that the prevalence of CS injuries is surgeons or anaesthesiologists etc. are easing of difficult airway
increasing with CMF trauma complexity: isolated maxillofacial management and traumatologic procedure in the head and neck
injury (0.6e9.7%), multiple maxillofacial injuries (6.7e10.8%), CMF region as well as reduction of the overall treatment duration and
injuries (2.8e60%). The distribution of maxillofacial trauma in the mortality risk (see below “Therapy for cervical spinal injuries”).
largest national cohort (Mulligan and Mahabir, 2010) of more than
1.3 million trauma patients (injury of nasal pyramid in 25%, malar 4.3. Biomechanics of the cervical spinal column
bone/upper jaw in 23.2%, frontal/temporal bone in 20.5%, mandible
in 16.9%, orbital floor in 14.3%) is comparable with own results The physiological kinematics and fracture dynamics of the cer-
(injury of malar bone/upper jaw in 21.5%, nasal pyramid in 16.1%, vical spinal column are highly complex (Bogduk and Mercer, 2000)
orbital floor in 6.5%, mandible in 6.5%, frontal/temporal bone in and are characterised by discoligamentous soft tissues and
9.7%). In both studies, it is evident that CS injuries were most degenerative, iatrogenic bony (fusion) and traumatic changes
frequently associated with midfacial fractures. We found mostly (Yoganandan et al., 2001). For a clinical understanding of injury
upper CS injuries, which are visible on midface CT scans. patterns, it is helpful to consider the following factors in addition to
In the next passage the questions “When extended imaging of the mechanisms of injury:
the complete cervical spine column is indicated within initial
assessment?” and “What is the appropriate radiologic technique?”  age (younger patients suffer from ligamentous and the elderly
are discussed. suffer from bony lesions; Kandziora et al., 2010b and 2010c)
 position of the head in relation to the cervical spinal column
4.2. Risk factors and diagnostic imaging in cervical spinal injuries during the trauma (force vector as a result of compression,
distraction, rotation, shear, or combinations; Cusick and
Leidel et al. (2005) describe an evidence-based diagnostic Yoganandan, 2002; Jauch et al., 2015)
approach to suspected cervical spine injury. In accordance with  the development of the neck muscles (Bogduk and Yoganandan,
literature, appropriate diagnostic imaging in this context is guided 2001)
by several risk factors associated with a possible cervical spine  stiffening of the cervical spine column as a result of spondylosis,
injury (see Table 5). Alert patients who have been completely rheumatism or previous interventions (Cusick and Yoganandan,
examined and who do not have sensorimotor deficiencies should 2002)
be cleared using conventional X-ray (three-view, low-risk patients).  bone quality (Schueller-Weidekamm, 2008).
When the mentioned risk factors are present (high-risk patients),
cervical spine CT scans are particularly convenient (Saltzherr et al., As presented in Tables 1 and 3 complex injuries might not be
2009); however, when the risk factors are associated with maxil- limited to cases of high-kinetic energy trauma (Jamal et al., 2009).
lofacial injuries and difficult airway management, CT scans can be a Under certain conditions, such injuries are not localised to the
challenge (Figs. 3 and 4), and immobilisation with a rigid cervical craniofacial region but involve the cervical spinal column, espe-
collar should be considered. The MRI is the imaging method of cially in elderly patients and injuries arising from everyday situa-
choice for patients with sensorimotor deficiencies or suspected tions. The biomechanics of the cervical spine in cases of minor and
discoligamentous lesions (Saltzherr et al., 2009; Sanchez et al., major injuries are in detail discussed by Bogduk and Yoganandan
2005; Schuster et al., 2005; Tan et al., 2014; Patel et al., 2015). (2001) and Cusick and Yoganandan (2002).
Five patients in our study required this approach. A recent study analysed 1255 cervical spine fractures and
In a recent multicentre questionnaire study, only 57% of 191 determined that MVC (OR 1.6), age <40 years (OR 1.8), fall (OR 2.1),
level 1 trauma centres maintained a cervical spine clearance Injury Severity Score >15 (OR 7.6), and pelvic fractures (OR 9.2) are

Table 5
Risk factors for blunt cervical spinal injuries and imaging. In the literature, there is an agreement that specific mechanisms of injury, circumstances, and
predisposing factors are predictors for blunt cervical spine injuries in association with maxillofacial trauma (see Table 4). These risk factors are useful for
initiating the radiological diagnostic work flow (Cusick and Yoganandan, 2002; Leidel et al., 2005; Sanchez et al., 2005; Schuster et al., 2005; Ong et al.,
2006; Schueller-Weidekamm, 2008; Saltzherr et al., 2009; Tan et al., 2014; Theologis et al., 2014; Jauch et al., 2015; Patel et al., 2015).

Risk factors for cervical spinal injuries Convenient diagnostic imaging

 Distracting injury above the clavicle, which includes Low-risk patients

isolated and multiple CMF injuries  X-ray in three-views:
 Mechanism of injury with transmitted a. p., lateral, dens axis
compression/rotation/hyperflexion/hyperextension  Preconditions are:
and shear to CS alert patient with a complete physical exam
 High-force accidents High-risk patients
 Elderly patients  3D diagnostics, especially in cases with mentioned risk factors
 Stiff spinal column (spondylosis etc.)  CT head and neck/polytrauma (contrast agent)
 Osteopenia (elderly patients)  MRI in cases with primary discoligamentary lesions and sensorimotor deficiencies
 Impaired consciousness, intoxication (optimum value e posttraumatically or 2e3 weeks later)
 Dementia, difficulty communicating  Evaluation of vascular structures (contrast agent)
 Cervicalgia, painful and limited neck mobilisation
 Posterior midline neck tenderness on palpation
 W. Reich et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1469e1478 1477

significant predictive factors for a major trauma. According to that complications resulting from concomitant cervical spine injury,
study, isolated maxillofacial or craniocerebral injuries alone are not and appropriate imaging can be performed following
considered risk factors for cervical spine fractures (Clayton et al., intubation.
2012). There is no causality between the two types of injuries, but 6. Craniofacial injuries complicated by cervical spine injuries are
there is a predictable pattern of injuries in both alert patients and associated with significant mortality (8%).
those who are obtunded (Lewis et al., 1985; Bayles et al., 1997; Ong
et al., 2006; Mithani et al., 2009) as a result of MVC, especially in
younger patients, or falls, especially in elderly patients. Thus, facial Conflict of interest statement
trauma is complicated by cervical spine injuries, though they are All authors confirm no conflict of interest.
rarely detected in patients with isolated facial injury (Table 4). In
this study cohort, only 34% (n ¼ 17) of 50 patients met the poly-
Financial support
trauma criteria.
None.

4.4. Therapy for cervical spinal injuries Sources of support in form of grants
On behalf of all authors of this manuscript we declare that there
Various operative and non-operative treatment modalities to is no financial or personal relationship with other individuals or
address injuries of the craniocervical junction, and the upper and organizations that could inappropriately influence this work.
lower cervical spine have been developed and meet accepted
standards (Kayser et al., 2006; Reinhold et al., 2006; Schueller-
Acknowledgements
Weidekamm, 2008; Kandziora et al., 2010a-2010c). In our study,
cervical spine injuries were treated operatively in 20% of 50 cases
We thank all members of the team and American Journal Ex-
(C0eC2, C7) with no associated neurologic complications.
perts (AJE) for helpful English language support (certificate verifi-
In the elderly, the treatment of cervical spine injuries is signif-
cation key: 9ECD-64F4-E327-4E24-9681). In addition authors
icantly associated with complications, particularly a high rate of
thank Matthias Gerlach (University hospital Halle, finance and
non-union (in cases of non-operative treatment) or morbidity and
controlling) for his kind support in data acquisition.
mortality (in cases of operative treatment; Delcourt et al., 2015),
that require prolonged inpatient hospital stays and rehabilitation,
which can last several weeks. Nevertheless, in the present study, References
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