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A 20-year-old man was returning from a “night on the town” when he drove his car into a garbage truck.

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On arrival in the ED, the patient appeared intoxicated. He was hemodynamically stable. He had a forehead contusion. The neurological examination was normal, as was examination of the chest, abdomen and extremities.

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His lateral cervical spine radiograph is shown in Figure 1.

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  • Are there any abnormalities?

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The initial lateral view was interpreted as negative for an acute injury. However, the inferior portion of C7 was not seen. In addition, the patient’s positioning was rotated; the left and right lateral masses are widely separated.

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The patient was maintained in spinal immobilization and the lateral view was repeated with greater traction on the patient’s arms (Figure 2).

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Although this second view did not show C7, the injury is now more easily seen. The injury, however, was visible on the initial lateral view.

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The second lateral radiograph more clearly reveals the patient’s injury, although the injury was, in fact, visible on the first lateral view.

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Although a definite fracture is difficult to detect, there is indirect evidence that a fracture is present, i.e., malalignment of the upper cervical spine. The C2 vertebral body shows slight anterior displacement (anterolisthesis) relative to C3 (asterisk in Figures 3 and 4). This displacement is easier to see in the second radiograph (Figure 3).

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Slight anterior displacement of the C2 vertebral body relative to C3 may be normal, especially with supine cross-table lateral radiographs in which the neck is slightly flexed. However, a second radiographic finding indicates that this C2 anterolisthesis is abnormal.

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The spinous process of C2 is displaced slightly posteriorly. This is determined by drawing a line through the C1–C3 spinolaminar junctions: the posterior cervical line (PCL) (lines in Figures 3, 4, and 5). Normally, the C1, C2, C3 spinolaminar junctions are within 2 mm of a straight line. In this patient, the C2 spinolaminar junction is displaced 3 mm posterior to the PCL (arrowheads in Figures 3 and 4). Because the anterior part of C2 is displaced anteriorly, and the posterior part of C2 is displaced posteriorly, the neural arch of C2 must be fractured.

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