Maxillofacial trauma may be associated with occult cervical spine injury (CSI), particularly after low-impact mechanisms. Facial fractures influence airway management and operative planning. Delayed CSI carries risk of neurological morbidity and requires a high index of suspicion when symptoms evolve.

Description

A 34-year-old male presented after a low-impact fall with a left zygomatic fracture diagnosed on X-ray and was discharged with analgesia and follow-up. He reported no neck pain initially. Two weeks later, he re-presented with worsening neck pain, reduced range of motion, and increased analgesic requirements, without neurological deficit. CT cervical spine demonstrated a comminuted right occipital condyle fracture with posterior subluxation and atlantoaxial rotation. He was immobilised in full spinal precautions and admitted. Given cervical instability and maxillofacial injury, he underwent awake fibreoptic intubation with strict precautions and open reduction internal fixation of the zygomatic fracture. He remained neurologically intact. Following multidisciplinary discussion with a tertiary spinal service, he was managed conservatively in a Minerva collar and discharged with follow-up.

Discussion

Cervical spine injuries occur in a small but significant proportion of maxillofacial trauma and may be missed initially, particularly when facial injury dominates or mechanism appears low risk. Occipital condyle fractures are rare and may present with neck pain alone. Facial fractures may distract from occult injury, and initial assessment or X-ray may not exclude CSI. Worsening pain or increasing analgesic requirement should prompt re-evaluation and advanced imaging. Unrecognised cervical instability poses major risk during airway management; techniques minimising movement, including awake fibreoptic intubation, are essential. Early recognition and immobilisation prevent secondary neurological injury.