Hidden cervical spine injuries in traffic accident victims with skull fractures.

We studied 22 cervical spines from traffic accident victims with fatal craniocerebral injuries (19 male victims and three female victims; mean age, 26 years). Two had parietal fractures, 20 had skull base fractures (seven ring fractures), and 16 had severe polytrauma. The spines with all soft tissues were frozen in situ and removed. Fine-focus specimen radiograms were taken in special views and evaluated by an expert orthopedic radiologist. The specimens were then cryosectioned, and all injuries were recorded at submillimeter intervals on high resolution film. Ten radiological fracture diagnoses were incorrect; six were false positive, and four were false negative. In the upper cervical spine, only one of 10 gross ligamentous disruptions was suspected on the radiograms. In the lower cervical spine, 198 lesions were missed on the radiograms: 77 facet joint and ligamentum flavum injuries, 77 uncovertebral, and 22 disc lesions. In two adolescents, eight cartilaginous end-plate avulsions of the discs were found. At second-look evaluation, only four of the 245 unrecognized bone and discoligamentous lesions were detected on the radiograms. All spines were injured. Multiple-level soft-tissue injuries were common.