Background:

DRJ

Dent Res J

Dental Research Journal

1735-3327 2008-0255

Medknow Publications Pvt Ltd

India

DRJ-11-336

10.4103/1735-3327.135885

Original Article

When to suspect head injury or cervical spine injury in maxillofacial trauma?

Rahman

Sajjad A

Chandrasala

Soumithran

Department of Oral and Maxillofacial Surgery, Dr. Z A Dental College, AMU, Aligarh, India Government Dental College, Department of Oral and Maxillofacial Surgery, Kozhikode, Kerala, India

Address for correspondence:Sajjad Rahman, Department of Oral and Maxillofacial Surgery, Dr. Z A Dental College, AMU, Aligarh, India sajjad_ar@rediffmail.com

May–Jun 2014

11 3 336 344

2014

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background:

The global status report of the World Health Organization (WHO) on road safety suggested that India is leading in road traffic accidents in the world. According to the report on road accidents in India in 2010 by the Transport Research Wing, Ministry of Road Transport and Highways, New Delhi, Kerala ranked third in accidents per lakh population and second in persons injured per lakh population. As the face, brain, and cervical spine are in close proximity with one another, associated injuries can be suspected. The aim of this study was to determine the relationship between the severity of head, cervical spine, and facial injury and incidence of facial injury in patients with head and/or cervical spine injury.

Materials and Methods:

A prospective cohort study was conducted over a period of one year. The study population included all patients having computed tomography (CT)-demonstrable head injury, radiographic evidence of cervical spine injury, and associated head or cervical spine injury with facial injury. Data were analyzed using the chi-square test using statistical package SPSS. A P value less than 0.05 was considered statistically significant.

Results:

Of 124 patients, 59 (47.6%) had facial injuries. As severity of head injury increased, the number of facial injuries decreased. Statistically, no significant association between facial and head injury was seen. A statistically significant association between dentoalveolar involvement and cervical spine injury was seen (P < 0.001). The proportion of injuries in patients with cervical spine injuries alone was significantly lower in the frontal (P = 0.001) and orbital (P = 0.004) regions and higher in the mandibular region (P = 0.010).

Conclusion:

Midface injuries were more commonly associated with head injuries. Decreased facial involvement leads to increased severity of head injury. Simple injuries of the cervical spine were more commonly associated with facial injuries.

Cervical spine injury head injury maxillofacial injury

[TAG:2]INTRODUCTION [/TAG:2]The study of trauma has a very important role these days. Due to the increase in economic strength of our society, the number of people owning different varieties of vehicles has increased, resulting in an increased number of automobiles on our roads. Further, due to bad roads and nonadherance of traffic rules, road traffic accidents has emerged as one of the principle causes of morbidity and mortality. As the face is the most exposed part of the body, it is very prone to sustaining injuries during these accidents. Frequently, patients having facial injuries have other associated injuries especially to the brain and cervical spine. Several studies suggest that facial fracture dissipates a lot of force during trauma, in effect protecting the brain. <xref ref-type="bibr" rid="ref1">1</xref> , <xref ref-type="bibr" rid="ref2">2</xref> In contrast to this, the literature also suggests that facial fracture increases the risk of brain trauma. <xref ref-type="bibr" rid="ref3">3</xref> Frequently, it is also thought that cervical spine injury should be considered in a maxillofacial trauma patient until proved otherwise. Recently, Jamal et al. <xref ref-type="bibr" rid="ref4">4</xref> in their study also supported this belief. Further, some studies suggest no association between facial and cervical spine injuries. <xref ref-type="bibr" rid="ref5">5</xref> , <xref ref-type="bibr" rid="ref6">6</xref> Others show a small but real possibility of the face being injured in cervical spine injuries. <xref ref-type="bibr" rid="ref7">7</xref> , <xref ref-type="bibr" rid="ref8">8</xref> , <xref ref-type="bibr" rid="ref9">9</xref> Likewise, association of head injury with facial injury has been emphasized. <xref ref-type="bibr" rid="ref10">10</xref> , <xref ref-type="bibr" rid="ref11">11</xref> , <xref ref-type="bibr" rid="ref12">12</xref> , <xref ref-type="bibr" rid="ref13">13</xref> The global status report of the World Health Organization (WHO) on road safety <xref ref-type="bibr" rid="ref14">14</xref> suggests that India has one of the highest road traffic accidents in the world. Also, in the report on road accidents in India 2010 by the Transport Research Wing, Ministry of Road Transport and Highways, New Delhi, Kerala ranked third in the number of accidents/100,000 population and second in the number of persons injured/100,000 population. <xref ref-type="bibr" rid="ref15">15</xref> Hence, a study to consider any association between head, cervical spine, and facial injury is pertinent. The present study was planned for this purpose. </sec> <sec> <title>Materials and methods

The aims and objectives were to determine the incidence of facial injury in patients presenting with head injury and cervical spine injury and the relationship between the severity of head and cervical spine injury and facial injury.

A prospective cohort study design was adopted to assess the incidence of facial trauma in patients sustaining head or cervical spine injury.

Study population

The study population consisted of all patients admitted in the Department of Neurosurgery-Head Injury Intensive Care Unit and Department of Surgery having computed tomography (CT)-demonstrable head injury and patients admitted in the Department of Orthopedics having radiographic evidence of cervical spine injury. It also included patients having associated head or cervical spine injury along with facial injury, reporting in the Department of Oral and Maxillofacial surgery.

Patients who did not have X-ray and CT proved injury and patients who died were excluded from the study. All patients included in the study had CT of head if head injury was present and X-ray of the cervical spine if cervical spine injury was present. Findings of CT and X-rays were reported from the same unit of the Radiology Department of the Medical College.

This study was conducted from January 2008 to January 2009.

A standard form was designed to record age, sex, and etiology of injury, and associated features of head or cervical spine injury and facial injury of the patient.

Head injuries were classified as mild, moderate, and severe according to the Glasgow Coma Scale (GCS) score.

Cervical spine and facial injury were classified as simple and severe. Demonstrable straightening of the cervical spine in the radiograph was considered simple. All other injuries like luxation, subluxation, or dislocation were considered severe. Facial injuries involving only soft tissue were called as simple and any injury involving bone or dentoalveolar segment were considered severe. Available CT, magnetic resonance imaging (MRI), and X-ray findings were also recorded. Data were analyzed by chi-square test; P values less than 0.05 were considered statistically significant. The statistical package SPSS (SPSS Inc., Chicago, IL, USA) was used for all analyses.

[TAG:2]RESULTS [/TAG:2]During the study period, a total of 124 cases were assessed of which 59 patients (47.6%) had facial injuries.

Age, sex, and etiology

Maximum patients were seen in the age range of 21 to 40 years in all the groups Figure 1. In all the groups, males outnumbered females. Genderwise, there was no significant difference in the proportion of patients with facial injuries Table 1.{Table 1} Figure 1

Different types of injuries and age groups (n = 124), HI: head injury; CI: Cervical injury

Figure 1

Overall, maximum cases were of road traffic accidents followed by falls Table 2. There was one case of sports injury and eight cases had other etiological causes. Among patients with facial injuries, the proportion of those with injuries from light motor vehicles and heavy motor vehicles were higher as compared to pedestrian, assault, fall, and other injuries.{Table 2}

Different clinical features of head injury were assessed in the study like skull fracture, contusion, subdural hematoma (SDH), extradural hematoma (EDH), and so on. Statistically, no significant association of facial injuries was seen with any of the clinical features. However, SDH (P = 0.018) and cerebrospinal fluid otorrhea (CSF-O) (P = 0.048) was significantly less prevalent among cases with facial injuries Table 3.{Table 3}

Severe facial injuries were more common in all the three groups. There was no significant association between type of injury and type of facial injury (P = 0.229).

Soft and hard tissue were both involved in majority of the patients (n = 35; 59.32%). Involvement of soft tissue was seen in 19 patients (32.2%) and dentoalveolar involvement was seen in 11 (18.64%) patients. Statistically, a significant association between dentoalveolar involvement and cervical spine injury alone was seen (P < 0.001) Table 4.{Table 4}

The maxilla was the region most commonly involved, followed by frontal, orbital, zygomatic, mandible, and nasal regions. The proportion of injuries in patients with cervical spine injuries alone was significantly lower in the frontal (P = 0.001) and orbital (P = 0.004) regions, whereas its proportion was significantly higher in the mandibular region (P = 0.010) Table 5.{Table 5}

Statistically, a negative association between subluxation and facial injuries was seen (P = 0.032). For fracture and dislocation of the spine, no significant association could be seen. No case of luxation was reported in the present study Table 6.{Table 6}

Among patients with cervical spine injury alone, the incidence of simple injuries was significantly higher among patients with facial injuries; however, no such association was seen among patients with head injury along with cervical injury. Overall, no significant positive association between facial injury and severe cervical injury was seen (P < 0.001) Table 7.{Table 7}

It was noticed that as severity of head injury increased as per the GCS score, the number of facial injuries decreased Table 8.{Table 8}

Subluxation was seen in the C4-C5 region in 50% of the patients. Dislocation and fractured spine were seen mostly in the C5 region of the cervical spine.

Comparing the incidence of fractures in different bones of the cranium, it was found that the most frequently fractured bone was the temporal bone followed by the frontal bone Figure 2. Figure 2

Regions of skull fracture (n = 47)

Figure 2

Discussion

0Head injury and facial injury

Injuries affecting the maxillofacial region are complex, especially because of the proximity of vital structures like the cranium containing the brain and cervical spine. In many cases, head injury accounts for a significant portion of mortality and morbidity. Keenan et al. ³and Martin et al. ¹⁶found facial fracture to be highly associated with head injury. Many studies ⁷, ¹¹, ¹⁷indicated that the frequency of neurologic injuries associated with facial fracture was as high as 82%. Recently, Mulligan et al. ¹⁸found 21.7% incidence of facial fractures in head injury patients. In this study, we found that the frequency of maxillofacial injury was 48.48% in patients with some sort of head injury. If we consider a combination of cervical spine injury and head injury, the frequency of facial injury was 47.58%.

In almost all studies, there is a male predominance ¹⁰, ¹⁹, ²⁰, ²¹, ²²and we also found that males are involved in over 80% of the cases Table 1. In patients having facial injury including the entire group, we see that the male-to-female ratio is nearly 9:1. Perhaps this is because in a country like India having a male-dependent society, the movement of males outside their homes is more; hence, there is a greater likelihood of them sustaining trauma.

The age of patients ranged from 13 to 90 in our series. Most of the patients fell in the range of 21-40 Figure 1. Keita et al. ²²in their series in Mali studied maxillofacial trauma and found that most of the patients were young, with a mean age of 27 years. This pattern is similar to almost all other studies studying the relationship between facial fracture and concomitant neurological injuries. ¹⁰, ²⁰, ²¹, ²³, ²⁴, ²⁵

Light motor vehicles were the most frequent cause of injury, accounting for 59.32% Table 2. This finding is similar to Subhasraj et al. ²⁴who studied maxillofacial injuries and reported an incidence of 62 and 23 % involving two wheelers and four wheelers, respectively. Keita et al. ²²found 93% road traffic accidents as the cause of maxillofacial injuries. This can be attributed to local conditions like bad roads and lack of restraints, and so on. Recent trends in the western world have been toward a reduction in road traffic accident cases and increased maxillofacial fracture cases because of sports injuries and interpersonal violence. ²⁶This is perhaps because of the respect for traffic rules and application of restraint while driving. In an Indian setting with bad roads and lack of respect for traffic rules especially in smaller cities and towns, road traffic accidents seems to be the most common cause for maxillofacial injuries.

In our study group, severe injury of the facial region was seen in all three groups of patients. This indicates that the involvement of bony tissues of the face is most of the time associated with head injury or cervical spine injury. The maxilla (61%) is the region most frequently involved Table 5. This is followed by frontal, orbital, zygomatic, mandible, and nasal region. In the study by Pappachan and Alexander, ¹⁰involvement of zygoma was the most frequent. In the series by Sinclair et al., ²⁷association between facial fracture and head injury was 85%. They also found maxillary bone involvement to be more common. Recently, Mithani et al. ²⁸found that midface fractures were associated with basilar skull fractures and several intracranial injuries. They looked for an association between unilateral midface and head injury and bilateral midface and head injury and suggested that concomitant injuries should be investigated closely with distinct types of facial fractures.

The cranial bone most frequently fractured was the temporal bone (39%) followed by the frontal bone (30%) Figure 2. Compared to the study by Haug et al., ²⁹in which frontal bone involvement was 38% and temporal bone 22%, we had a slightly lesser involvement of the frontal region and greater involvement of the temporal bone. In the study conducted by Pappachan and Alexander, ¹⁰temporal bone involvement was 18.52%. Further, it was noticed that when the temporal bone was fractured, the most common region of hard tissue involvement was the zygomaticomaxillary complex.

Contusion (52%) and subarachnoid hemorrhage (52%) were the most common injuries seen in patients having head injury followed by skull fracture (47.47%).

In neurologic injuries, various studies have shown that concussion is more frequently associated with facial fracture. ³, ¹⁰, ¹⁹, ²², ³⁰Keenan et al., ³in a case control study, found more concussion (9%) than intracranial injury (4%). In this study, facial injuries were mostly seen in patients having subarachnoid hemorrhage followed closely by skull fracture and then contusion Table 3.

In this study, we observed that when the severity of head injury increased as per the GCS score, the number of facial injuries decreased Table 8. This may mean that facial injury dissipates forces so that a less serious cranial injury would be sustained by the victim. Similar findings were reported by Lee et al. ¹They suggested that facial bones act as a protective cushion for the brain, explaining the fact that injuries that crush the facial bones frequently cause no apparent brain damage. Chang et al. ²suggested that the maxilla, together with the neighboring bones, is capable of absorbing considerable impact force, thus protecting the brain from direct collision. They further concluded that there should be a direct correlation between the severity of maxillary fracture and that of the initial head injury. Other investigators like Davidoff et al., ³⁰and Keenan et al. ³found facial fracture to be highly associated with traumatic brain injury. Mulligan et al. ¹⁸also found increased number of head injury (71.5%) patients in their series of 2.7 million trauma cases having combined facial fracture and cervical spine fractures.

The mandible was involved in only 17 cases (28.81%) out of the total injuries seen in the series Table 5. If we compare this to the total number of head injury patients, it decreases to 17.17%. The mandible was involved in three cases (5.5%) of the total skull fractures (n = 54) in our series. This is in contrast to other investigators who found a significant association of mandibular fracture with cranial injury. ¹⁹, ²¹, ²³, ²⁷In patients having head injury associated with facial injury (n = 48), the region most commonly involved was the middle third of the face; the lower third was less frequently involved. This is similar to the observation of Haug et al. ¹⁹, ²⁹that midfacial fractures had more than twice the chance of sustaining cranial fractures and neural injuries.

Cervical spine injury and facial injury

In this study, 41 patients had cervical spine injuries (isolated cervical spine and combined with head injury). Of this, 19 (46.34%) patients had some sort of facial injury Table 7. Most of the literature describes the incidence of cervical spine injury in association with injury to the facial skeleton ranging from 0.3 to 19.3%. ⁵, ¹², ²³, ³¹, ³², ³³, ³⁴Most of these studies looked for cervical spine injuries in maxillofacial-injured patients. Our study looked for the incidence of maxillofacial injuries in a group of cervical spine injury patients and we found quite a high association; almost 46.34% had some sort of facial injury. This is in contrast to what McCabe and Angelos ⁷concluded. This is also higher compared to the study by Lewis et al., ³¹in which they found 19.6% incidence of facial injury. Hills and Deane ⁵concluded that there is a lack of significant correlation between maxillofacial and cervical spine injuries.

In our series, 53.65% of the patients belonged to the age group of 31-60 years. We also noticed that patients with a facial injury in association with both cervical spine and head injury were usually young, mostly younger than 40 years Figure 1.

The male-to-female ratio was approximately 5:1 in overall cervical spine-injured patients. But if we consider patients with facial injury also, this ratio increases to 8.5:1 Table 1.

Road traffic accidents were the most common cause of cervical spine injury Table 2. In patients having concomitant facial injury, this was the most common cause. But when we assess cervical spine injury where the etiology is a fall, the percentage of facial injuries is only 13.33%. Hence, we can conclude that in patients having cervical spine injury on account of road traffic accidents, facial injuries were more common.

Majority of the conscious patients (n = 25) with facial injury (75%) presented with simple injuries to the cervical spine. But in patients with severe injury to the cervical spine, the percentage with facial injury was only 19% Table 7. Hence, we noted that when severity of cervical spine injury increases, the incidence of facial injury decreases.

Assessment of fully alert trauma patients has shown that possible cervical spine injuries can be satisfactorily screened by etiology, patient symptoms, and physical examination. However, in patients in whom reliable examination and symptoms are missing, there is a difficulty. This can lead to delayed diagnosis either because of the effects of the head injury or other concomitant injury. Recently Jamal et al. ⁴suggested that cervical spine injury is present in a maxillofacial trauma patient until proved otherwise. Of 41 cervical spine injury patients, 41.02% of patients in our series had concomitant head injury.

It was seen that the proportion of injuries in patients with cervical spine injuries alone was significantly lower in the frontal (P = .001) and orbital (P = .004) regions, whereas its proportion was significantly higher in the mandibular region (P = .010) Table 5. It was also seen that the midface and lower face was involved in almost equal proportion when they were associated with cervical spine injury. Elahi et al. ³⁵found that a combined facial fracture pattern, involving multiple facial regions, accounted for the greatest number of cervical spine injuries in their series. Further, in our study, it was noted that of four cases of severe cervical spine injury, the lower third of the face was involved, and the involvement of the upper cervical spine (C1-C4) was seen in severe injury associated with the lower third. This finding is consistent with those of Lalani and Bonanthaya ⁸and Lewis et al. ³¹who concluded that when the lower third of the face is involved, injuries to the upper cervical spine are seen.

In this study, subluxation was seen in the C4-C5 region in 50% of the patients. Dislocation and fractured spine were seen more than 50% of the times in the C5 region, which is considered as the most mobile portion of the cervical spine. This is in agreement with the studies of Davidson and Birdsell ³²and Hackl et al. ⁹Statistically, a negative association between subluxation and facial injury was seen (P = .032) in this study.

In the facial injury group, soft and hard tissue both were involved in majority of the patients (n = 35; 59.32%). Involvement of soft tissue was seen in 19 patients (32.2%); dentoalveolar involvement was seen in 11 (18.64%) patients. Statistically, a significant association between dentoalveolar involvement and cervical spine injury alone was seen (P < 0.001) Table 4. This is in contrast to the study Bayles et al. ³⁶who found no significant association between cervical spine trauma and isolated mandibular trauma. However, our finding further stresses the point that when the lower third of the face is involved, cervical injury should be ruled out. As a result, it has long been advocated that as patients with facial trauma are at a higher risk of cervical spine trauma, they should undergo cervical spine radiography as a routine investigative procedure. ⁹, ³⁶, ³⁷

Conclusion

In our series, approximately 50% of the patients had some facial injury. Though overall there was no significant association between the three types of injuries in this study, it appears that motor vehicle accident patients suffer injuries in which multiple forces from different directions act at the same time on the patient. Hence, when examining the road traffic accident patient, a high level of care should be practiced so that significant injuries to other head and neck regions may not be missed.

Lee

Wagner

Lee

Suh

Lee

The impact absorbing effects of facial fractures in closed head injury.Analysis of 210 patients

J Neurosurg 1987 66 542 7

Chang

Chen

Noordhoff

Chang

Maxillary Involvement in central craniofacial fractures with associated head injuries

J Trauma 1994 37 807 11

Keenan

Brundage

Thompson

Maier

Rivara

Does the face protect the brain.A case-control study of traumatic brain injury and facial fractures?

Arch Surg 1999 134 14 7

Jamal

Diecidue

Qutub

Cohen

The pattern of combined maxillofacial and cervical spine fractures

J Oral Maxillofac Surg 2009 67 559 62

Hills

Deane

Head Injury and Facial Injury.Is their increased risk of cervical spine injury?

J Trauma 1993 34 549 53

William

Jehle

Cottington

Shuffiebarger

Head, Facial and Clavicular Trauma as a predictor of Cervical Spine injury

Ann Emerg Med 1992 21 719 22

McCabe

Angelos

Injury to the Head and Face in patients with cervical spine injury

Am J Emerg Med 1984 2 333 5

Lalani

Bonanthaya

Cervical Spine Injury in Maxillofacial Trauma

Br J Oral Maxillofac Surg 1997 35 243 5

Hackl

Fink

Hausberger

Ulmer

Gassner

Incidence of combined Facial and Cervical injuries

J Trauma 2001 50 41 5

Pappachan

Alexander

Correlating facial fractures and cranial injuries

J Oral Maxillofac Surg 2006 64 1023 9

Luce

Tubb

Moore

Review of 1000 major facial fracture and associated injuries

Plast Reconstr Surg 1979 63 26 30

Schultz

Facial Injuries from Automobile Accidents- A study of 400 consecutive cases

Plast Reconstr Surg 1967 40 415 25

Goodisson

MacFarlane

Snape

Darwish

Head injury and associated maxillofacial injuries

N Z Med J 2004 117 U1045

Murali

krishnan

Available from: http: //www

html [Last accessed on Apr ] . 9] . Available from: http: //wwwdwde/dw/article/0,,5519345,00html [Last accessed on 2010 Apr 29]

Available from: http:

//www

morth

pdf [Last accessed on June ]. 9]. morthnicin/writereaddata/mainlinkFile/File761pdf [Last accessed on 2013 June 29]

Martin RC 2 n

Spain

Richardson

Do facial fractures protect the brain or are they a marker for severe head injury?

Am Surg 2002 68 477 81

Down

Boot

Gorman

Maxillofacial and associated injuries in severely traumatized patients: Implications of a regional survey

Int J Oral Maxillofac Surg 1995 24 409 12

Mulligan

Friedman

Mahabir

A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures

J Trauma 2010 68 587 92

Haug

Savage

Likavec

Conforti

A review of 100 closed head injuries associated with facial fractures

J Oral Maxillofac Surg 1992 50 218 22

Ugboko

Odusanya

Fagade

Maxillofacial fractures in a semi-urban Nigerian teaching hospital.A review of 442 cases

Int J Oral Maxillofac Surg 1998 27 286 9

Van Beek

Merkx CA.Changes in the pattern of fractures of the maxillofacial skeleton

Int J Oral Maxillofac Surg 1999 28 424 8

Keita

Doumbia

Diani

Diallo

Coulibaly

Timbo

Head and neck injuries: 184 cases in Mali

Med Trop (Mars) 2010 70 172 4

Haug

Prather

Indresano

An epidemiologic survey of facial fractures and concomitant injury

J Oral Maxillofac Surg 1990 48 926 32

Subhashraj

Nandakumar

Ravindran

Review of maxillofacial injuries in Chennai, India: A study of 2748 cases

Br J Oral Maxillofac Surg 2007 45 637 9

Hogg

Stewart

Armstrong

Girroti

Epidemiology of maxillofacial injuries at Trauma hospitals in Ontario, Canada, between 1992 and 1997

J Trauma 2000 49 425 32

Gassner

Tuli

Hächl

Rudisch

Ulmer

Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries

J Craniomaxillofac Surg 2003 31 51 61

Sinclair

Schwartz

Gruss

MacLellan

A retrospective review of the relationship between facial fractures, head injuries, and cervical spine injuries

J Emerg Med 1988 6 109 12

Mithani

St-Hilaire

Brooke

Smith

Bluebond-Langner

Rodriguez

Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: Analysis of 4786 patients

Plast Reconstr Surg 2009 123 1293 301

Haug

Adams

Conforti

Likavec

Cranial fractures associated with facial fractures: A review of mechanism, type, and severity of injury

J Oral Maxillofac Surg 1994 52 729 33

Davidoff

Jakubowski

Thomas

Alpert

The spectrum of closed head injuries in facial trauma victims: Incidence and Impact

Ann Emerg Med 1988 17 6 9

Lewis

Manson

Morgan

Cerrulo

Meyer PR

Facial injuries associated with cervical Fractures- recognition, patterns and management

J Trauma 1985 25 90 3

Davidson

Birdsell

Cervical Spine injury in patients with facial skeletal trauma

J Trauma 1989 29 1276 8

Oller

Merdith

Rutledge

Thomason

Clancy

Moylan

The relationship between face or skull fractures and cervical spine and spinal cord injury-a review of 834 patients

Accid Anal Prev 1992 24 187 92

Mace

Emergency evaluation of Cervical Spine Injuries- CT versus Plain Radiograph

Ann Emerg Med 1985 14 973 5

Elahi

Brar

Ahmed

Howley

Nishtar

Mahoney

Cervical Spine Injury in Association with Craniomaxillofacial Fractures

Plast Reconstr Surg 2008 121 201 8

Bayles

Abramson

McMohan

Reichman

Mandibular Fractures and Associated Cervical Spine Fracture, a rare and Predictable Injury.Protocol for Cervical Spine Evaluation and Review of 1382 cases

Arch Otolarygol Head Neck Surg 1997 123 1304 7

Hackl

Hausberger

Sailor

Ulmer

Gassner

Prevelence of Cervical Spine Injury in Patients with Facial Trauma

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001 92 370 6