Sequential Cranial and Overlooked Cervical Spine Injuries Due to Head Trauma: A Billiard-Like Mechanism.

A 55-year-old male construction worker presented with multiple fractures after falling downstairs and striking his forehead on a concrete wall, an incident preceded by consuming approximately 50 g of alcohol. Initial evaluation revealed a contaminated 7 cm forehead laceration and a depressed frontal bone fracture, with no neurological deficits or intracranial bleeding on computed tomography (CT), leading to discharge with follow-up instructions despite mild intoxication. The next day, neck pain prompted further imaging, uncovering a complex injury pattern: frontal bone fracture, occipital base fracture, C1 anterior arch fracture, and C4 vertebral body and spinous process fractures, with magnetic resonance imaging (MRI) excluding intervertebral disc injury. Conservative management with a Philadelphia collar for two months, followed by a soft collar for three months, and teriparatide to aid bone healing resulted in the patient returning to work symptom-free after six months. Follow-up imaging at one year (CT) showed no displacement and partial bone healing, while a three-year MRI confirmed no posttraumatic complications. This case illustrates a rare sequential fracture pattern from head trauma, resembling a billiard-like chain reaction where indirect axial force cascades through the frontal bone, occipital base, and cervical spine. Alcohol likely delayed pain recognition by elevating the pain threshold, highlighting the need for comprehensive cervical imaging in head trauma patients - especially those with intoxication or altered consciousness - to prevent missed diagnoses and ensure timely intervention.