Eur J OrthopSurgTraumatol (1999) 9:195-199 European Journalof Orthopaedic Surgery & Traumatology © Springer-Verlag 1999 Occult fracture-dislocation of the cervical spine A case report and review of the literature D.S. Korres, P.J. Papagelopoulos, H.G. Petrou, G2. Tzagarakis, P.G. Triantafyllidis, J. Tsarouchas and G. Koundis OrthopaedicDepartment,AthensUniversity, KATHospital,Athens, Hellenic Republic(Greece) Summary: Occult injuries of the cervical spine in certain patients may lead to misdiagnosis or delayed diagnosis and treatment. The authors present a patient with an occult cervical spinal fracture- dislocation and review the literature. A 37 year-old male was involved in a motor vehicle accident. At his admis- sion, the patient was alert and denied any pain in the cervical region, as well as neurologic symptoms. Physical exami- nation revealed painless range of motion of his neck and no sensory or motor deficits. Plain radiographs of the cervical spine showed unilateral dislocation of C4 on C5 vertebra with fracture of the left facet of C5 vertebra. Computed tomography scanning showed no neu- ral compression. Operative reduction, stabilization and arthrodesis of the spine were advised, but the patient refused operative treatment. One year after his initial injury, the patient presented with torticollis and no neurologic symptoms. Key words: Cervical spine -- Fracture dislocation -- Occult spine injury Code Mdary: 6112.1 Correspondence to: D.S. Korres Cervical spine injuries are common. They may result in local pain and neuro- logic disturbance in the upper and lower extremities. Detailed history and physi- cal examination are helpful and deter- mine the diagnosis. Radiographic exa- mination confirms the diagnosis in most of the cases. However, in some patients the history may be confusing and may lead to misdiagnosis or delayed diagno- sis of significant unstable cervical spinal injuries. The purpose of this paper is to describe a patient with an occult cervical spinal fracture-dislocation and review the literature. Case report A 37 year-old male, a mechanical engi- neer, was admitted to the Emergency Orthopaedic Service shortly after being involved in a motor vehicle accident. On admission the patient was alert, oriented and conscious. The patient denied any pain in the cervical region, as well as paresthesiae, dysthesia or weakness of the upper or lower extremities. On physical examination, there was a painless full range of motion of his neck. Neurologic examination showed no sensory or motor deficits. Deep ten- don reflexes were symmetrical and nor- mal. Plantar reflexes were down-going bilaterally. There was no tenderness on palpation of the spinous processes of the cervical spine. Because the patient was involved in a motor vehicle accident, and according to our hospital legal and insurance requirements, the patient underwent a complete radiographic eva- luation. Plain anteroposterior, lateral and oblique radiographs of the cervical spine showed unilateral dislocation of C4 on C5 vertebra with fracture of the left facet of C5 vertebra (Fig. 1a-c). Sub- sequent, computed tomography scan- ning confirmed the above findings and showed no neural compression (Fig. 2). The patient was put on Barton trac- tion of 4kg for one week. Operative reduction, stabilization and arthrodesis of the spine were advised, but the patient refused and signed himself out of the hospital. One year after the initial injury the patient presented with torti- collis and no neurologic symptoms. Flexion-extension lateral radiographs showed the subluxation at C4-C5 level with no further changes since the initial injury. Discussion Early detection and accurate manage- ment of cervical spine injuries are important for prognosis [1, 13, 19, 25] However, detection of such injuries may be difficult in certain patients [7, 16]. These are patients with an altered men- tal status, loss of consciousness, or other associated injuries [z, 3, 5, 7, 16, i7, 19, zl]. Patients with an occultcervical spi-