Injuries of the Upper Cervical Vertebrae

According to many researchers, injuries to the upper cervical vertebrae constitute the majority of birth injuries in newborns. This is due to the anatomical features of this section of the spine, including increased elasticity of the joint-ligament apparatus and a loose, wide capsule, which makes the cranio-vertebral joint potentially unstable. The anatomical and physiological features, combined with the rather traumatic nature of the birth processes, especially when complicated by rough obstetric interventions—make this area particularly vulnerable. The presence of receptors in the joint capsules and ligaments explains the sharp pain syndrome, forced posture of the infant, torticollis (twisted neck), and protective hypertonus of the paravertebral neck muscles.

To understand the mechanism of vertebral artery injury during childbirth and its clinical significance, it is important to consider that the vertebral artery and vein, intertwined with the nerve (Frank’s nerve), pass through a narrow bony canal of the transverse processes. In the upper cervical vertebrae, the artery forms two bends, making it especially vulnerable even during normal head turns during birth. Traction of the fetus by the neck significantly worsens this injury. This is very important because the vertebral artery supplies blood to the brainstem and the cervical part of the spinal cord, where even slight hemodynamic changes can lead to widespread ischemia. Clinically, this manifests as myatonic syndrome in older children.

Given the particular importance of this section of the spine, the question of timely diagnosis and adequate treatment of this patient group is especially relevant. Alongside clinical neuro-orthopedic examination, X-ray imaging remains popular due to its accessibility and informativeness. However, even significant changes in this area are not always accompanied by radiological signs, and practicing orthopedists and neurologists may not always diagnose them.

In the newborn pathology department, from January to December last year, 380 children up to 3 months old were treated. Of these, 138 were clinically diagnosed with combined brain and spinal cord injury at the cervical spine level. Considering the clinical signs of spinal cord damage in segments C1-C2 (the site of the pyramidal decussation), namely hypertonus of upper and lower limb muscles, tremor, positive Babkin’s sign, spontaneous Moro reflex—which help differentiate upper cervical spinal cord lesions from lesions in lower segments C3-C6—we identified this pathology in 87 children.

To confirm the clinical diagnosis, we performed spondylography. Radiographic signs of cranio-cervical joint damage were found in all. It is known that even minimal vertebral dislocation can involve the vertebral arteries. This can lead to compression of the artery in the bony canal of the transverse processes, which undoubtedly results in spinal cord ischemia with all its consequences.

Treatment tactics depended on the severity and progression or regression of clinical symptoms and the severity of radiological abnormalities.

For all children with birth injuries to the cervical spine, we recommend immobilization with a cotton-gauze collar worn for 2-3 months until the child’s natural muscular corset formed. Cranial traction was applied daily for 7-9 seconds.

All children underwent physiotherapy: transverse electrophoresis with spasmolytics (euphyllin and papaverine), and paraffin therapy on the cervical spine. Neck muscle massage was avoided to prevent further dislocation of injured vertebrae.

In almost all children, gradual regression of neurological symptoms was observed after the comprehensive neuro-orthopedic treatment. However, 3 children (with subluxation of C1-C2 and atlas block) showed no positive dynamics. Under general muscle-relaxant anesthesia (fluothane), they underwent one-stage repositioning using the Risser-Guther method, followed by immobilization with a Schantz collar. After this, there was a complete regression of pathological symptoms.

Conclusions:

• Birth injuries of the cervical spine remain predominant among newborn pathologies.
• Among cervical spine injuries, damage to the cranio-cervical junction predominates due to its anatomical and functional features that make it most vulnerable during birth.
• Characteristic clinical symptoms of C1-C2 spinal cord injury, besides pain, forced posture, neuromuscular torticollis, and protective hypertonus of paravertebral muscles (also typical of lower cervical segment pathology), include hypertonus of upper and lower limbs, tremor, Babkin’s sign, and spontaneous Moro reflex.
• Radiological examination confirms the clinical diagnosis.
• The most common radiological sign of birth trauma to the cranio-cervical junction is subluxation in the median atlanto-axial joint.
• Early diagnosis allows timely comprehensive pathogenetic neuro-orthopedic treatment, leading to regression of pathological symptoms.
• In cases without positive dynamics, orthopedic one-stage repositioning removes the etiopathological factor and leads to disappearance of pathological symptoms.