The most common cause of cervical injury is indirect trauma; ie, trauma to the head or trunk.1 Since the cervical spine is the most mobile segment of the spinal column, forming a bridge between the head and the rigid trunk, it is very vulnerable to injury. Among the more frequent causes are: automobile accidents, diving accidents, faUs and sports injuries.2 Dance injuries to the cervical spine are apparently rare.
Recently we encountered a case of serious cervical injury that occurred during break dancing and resulted in quadriplegia.
A 24-year-old man was admitted to Queens Hospital Center for the evaluation of a neck injury. About two hours prior to admission, while break dancing with his brother, the patient landed on the top of his head. Apparently he was doing a back flip with the help of his brother; his brother held his hand in cradle manner, while the patient stepped on his brother's hands, flexed his knee and was boosted into the flip. Immediately after falling, he was unable to move any extremity, there was no loss of consciousness, and he denied a history of head or neck injury.
Examination revealed an awake, alert and oriented man of medium build. There was a scalp swelling on the vertex of the head measuring 5 cm in diameter. There were no visible external injuries on the anterior surface of the trunk or extremities. Cranial nerve function was nonrial. He was quadriplegic except for minimal movement in both biceps and triceps. Sensation to all modalities was absent below C-4 dermatome. There were no deep tendon reflexes except for a minimal right biceps jerk. Sphincter tone was absent.
Fig. 1: Cervical spine, lateral view, showing compression fractures of vertebral bodies of C-5 and C-6.
Cervical spine x-ray films revealed compression fractures of the bodies of C-5 and C-6 with widening (fanning) of the interspinous space of C-5 and C-6 (Fig. I). The computerized tomography (CT) of the cervical spine revealed multiple fractures in the region of C-5 and C-6. There were bilateral fractures of the laminae of this level; and the midportions of the vertebral bodies of C-5 and C-6 were also fractured. The spinal canal was compressed both anteriorly and posteriorly at the level of C-5, where there was a widened, fractured vertebral body and displaced, fractured laminae (Fig. 2).
Gardner- Wells tongs were applied and decompressive cervical laminectomy and spinal fusion were performed about eight hours after initial.4 Operation revealed initially an interspinous ligament that was grossly torn and disrupted at the level of C-5 and C-6 and paraspinal muscles around this area were severely contused. The laminae of C-5 and C-6 were fractured bilaterally. A free segment of a fractured laminae of C-5 appeared to "float" over the dura. Decompressive laminectomy of C-5 was performed. The dura underneath the laminae appeared free from any gross disruption. Stabilization was secured using iliac bone grafts and stainless steel wire loops around the spinous processes of C-4 and C-7. Five pounds of skull traction were maintained throughout the procedure. Postoperative course was uneventful; no significant neurological improvement occurred. One week later, he was transferred to another institution.
Injuries to professional ballet dancers are usually due to repetitive stress and tend to involve the lower extremities.3-5 Varying types of fractures of the lower extremities,3-5 as well as joint abnormalities, have been described.4,7 Actual injury caused by direct trauma during dancing is rare, but occasionally occurs during an accidental fall.5 Cervical injuries are usually minor in nature.6
Redmond et al8 reported a case of cervical injury in a previously healthy young boy who did head banging during disco dancing. Redmond's patient developed insidious onset of quadriparesis, probably due to a shearing vascular injury of the spinal cord. This assumption was based on normal cervical spine x-ray films, with widening of the cervical spinal cord on myelography. Serious cervical injury has been reported to occur during exercise on a trampoline.9
Break dancing is a rhythmic body movement occasionally associated with acrobatic type "stunts" (windmills, back spins, head spins, flips, etc); and usually performed to music with a strong beat. It has been gaining in popularity among teenagers for the past decade. A number of physical injuries resulting from break dancing have recently been reported. These include fractures of the clavicle and of the extremities,10 scrotal injury," hair loss due to head spinning,12 cervical injury (subluxation) due to head spinning13 and spinal cord injury.14
The fall that our patient had was probably caused by poor coordination with his partner. Initial vertical compression on the head probably caused "buckling" of the cervical spine which led to compression fractures of the vertebral bodies. A similar mechanism has been previously described by Sanees Jr et al.15 The laminar fractures could have been caused by a combination of "shearing" and "expanding" forces exerted by the vertebral bodies against the relatively stationary posterior elements of spine. Primarily, the vertebral fractures probably lead serious direct spinal cord injury in this patient.
Fig. 2: Computerized tomography at the level of C-5 showing bilateral laminar fractures addition to fracture of vertebral body. Narrowing of spinal canal also demonstrated.
1. Babcock JL: Cervical spine injuries, diagnosis and classification. Arch Surg 1976; 111:646-651.
2. Carter RE Jr: Etiology of traumatic spinal cord injury: sialics of more than 1,100 cases. Tex Med 1977; 73:61-65.
3. Schneider HJ, King AV, Branson JL, et al: Stress injuries and developmental changes of lower extremities in ballet dancers. Radiology 1974; 113:627-632.
4. Miller EH, Schneider HJ, Bronson JL. et al: A new consideration in athletic injuries. The classical ballet dancer. Clin Orthop 1975; 111:181-191.
5. Teitz CC: Sports medicine concerns in dance and gymnastics. Pediatr Clin North Am 1982; 29:1399-1421.
6. Nixon JE: Injuries to neck and upper extremities of dancers. Clin Sports Med 1983; 2:459-472.
7. Graharae R, Jenkins JM: Joint hypermobility - Asset or liability? A study of joint mobility in ballet dancers. Ann Rheum Dis 1972; 31:109-111.
8. Redmond J, Thompson A. Hutchinson M: Acute central cervical cord injury due to disco dancing. Br Med J 1983; 286:1704.
9. Evans RJ: Tetraplegia caused by gymnastics. Br Med J 1979; 2:732.
10. Goscienski PJ. Luevanos L: Injury caused by break dancing. JAMA 1984; 252:3367.
11. Wheeler RE, Appell R: Differential diagnosis of scrotal pain after break dancing. JAMA 1984; 252:3366.
12. Copperman SM: Hazards of music and dancing. NY State J Med 1984; 84:442.
13. Ramirez B. Masella P. Piscina B, et al: Breaker's neck. JAMA 252:3366-3367.
14. Leung AKC: Hazards of break dancing. NY Stale J Med 1984; 84:592.
15. Sanees A Jr, Myklebust JB. Maiman OJ. et al: The biomechanics of spinal injuries, in Bourne JR (ed): Critical Reviews in Biomedical Engineering. Boca Raton, Rorida. CRC Press. Inc. 1984. pp 1-76.