Clinical presentation of a traumatic cervical spine disc rupture in alpine sports: a case report

Abstract

Isolated non-skeletal injuries of the cervical spine are rare and frequently missed. Different evaluation algorithms for C-spine injuries, such as the Canadian C-spine Rule have been proposed, however with strong emphasis on excluding osseous lesions. Discoligamentary injuries may be masked by unique clinical situations presenting to the emergency physician. We report on the case of a 28-year-old patient being admitted to our emergency department after a snowboarding accident, with an assumed hyperflexion injury of the cervical spine. During the initial clinical encounter the only clinical finding the patient demonstrated, was a burning sensation in the palms bilaterally. No neck pain could be elicited and the patient was not intoxicated and did not have distracting injuries. Since the patient described a fall prevention attempt with both arms, a peripheral nerve contusion was considered as a differential diagnosis. However, a high level of suspicion and the use of sophisticated imaging (MRI and CT) of the cervical spine, ultimately led to the diagnosis of a traumatic disc rupture at the C5/6 level. The patient was subsequently treated with a ventral microdiscectomy with cage interposition and ventral plate stabilization at the C5/C6 level and could be discharged home with clearly improving symptoms and without further complications. This case underlines how clinical presentation and extent of injury can differ and it furthermore points out, that injuries contracted during alpine snow sports need to be considered high velocity injuries, thus putting the patient at risk for cervical spine trauma. In these patients, especially when presenting with an unclear neurologic pattern, the emergency doctor needs to be alert and may have to interpret rigid guidelines according to the situation. The importance of correctly using CT and MRI according to both - standardized protocols and the patient's clinical presentation - is crucial for exclusion of C-spine trauma.

Figure 1

An MRI was obtained in the emergency department for detection of disco-ligamentous injuries. This figure shows T2 weighted transversal and sagittal MRI images. The scan revealed a traumatic extradural rupture of the intervertebral disc between C5 and C6 with ventral myelocompression but without disruption of the dorsal longitudinal ligament

Figure 2

The CT scan shows the small teardrop fracture at the ventral base plate of C5. The ruptured disc cannot be clearly identified.

Figure 3

After identification of the injury the patient was transferred to the operating room. This figure shows the postoperative image after discectomy, cage interposition and ventral stabilization. The implants are in correct position.