Evaluation of Cervical Spine Trauma: Maintaining an Index of Suspicion

Introduction: In older individuals, falls can have dangerous consequences. Of specific concern are falls that result in trauma to the cervical spine and head. Injuries in this area can be difficult to detect, as patients may present with signs and symptoms that are consistent with multiple conditions. It is imperative for physical therapists to maintain an index of suspicion when evaluating patients who have experienced a trauma, utilizing sound clinical reasoning to best serve patients. Case Description: A 70-year-old man who fell playing hockey presented to physical therapy with a three-week history of upper cervical pain and headache following the fall. His primary care provider ordered plain cervical spine radiographs, ruling out gross fracture and instability. Upon examination, the physical therapist had concerns for undetected upper cervical instability based on clinical findings and refers the patient back to the primary provider for further diagnostic imaging. Differential Diagnosis: Odontoid fracture and resultant upper cervical instability, along with cervicogenic headache, post-concussive syndrome, and cervical spondylolisthesis. Patient outcome: Additional open-mouth and flexion/extension stress views indicate no present fracture of the odontoid process and mild-moderate cervical anterolisthesis, respectively. The patient was cleared for physical therapy intervention, including manual therapy to the cervical spine. After two physical therapy sessions the patient’s symptoms are decreased by 90%. Discussion: When evaluating a patient with neck pain and headache after a fall, it is imperative to maintain suspicion of undetected cervical spine injury. Conditions like odontoid fracture and cervicogenic headaches may present with similar clinical findings, and if incorrectly diagnosed, may have dangerous consequences for the patient. As a primary care provider, a physical therapist needs to be able to understand clinical findings and utilize diagnostic imaging and medical referral when necessary.