Title: Evaluation and Management of Acute Cervical Spine Trauma Authors: Laura Pimental MD and Laura Diegelmann MD Key points Cervical spine injury in trauma patients is associated with a high morbidity and mortality rate and requires early recognition and careful evaluation which begins at the site of the accident by pre-hospital providers and continues throughout the hospital course. Imaging is important to differentiate stable and unstable injury and to guide treatment. Clinical conclusions Careful evaluation and aggressive management of c-spine injured patient improves outcomes and reduces complications associated with these devastating injuries. Section Highlights Introduction The second vertebra is the most commonly injured accounting for 24% of fractures; the sixth and seventh vertebrae together account for 1 another 39%. Risk factors for unstable cervical spine injury include older age (> 65 years), associated head trauma, and initial Glasgow Coma Scale (GCS) 2, 3 of 8 or lower. Anatomy The cervical spine consists of seven vertebra, the spinal cord, intervertebral disc (C2-C7), supporting ligaments, and neurovascular structures. Figure 1-3 The atlas is the first cervical vertebra sitting underneath the occipital bone (atlantooccipital joint) where 50% of neck flexion and 4 extension occur. The axis is the second cervical vertebra and allows head rotation at its articulation with the atlas. A single anterior and two posterior vessels originate from the vertebral arteries and supply the spinal cord. Pathophysiology Axial compression injury can result in the Jefferson fracture (unstable burst fracture of the atlas). Figure 4 Multiple or complex mechanisms may result in odontoid fracture and may be 1 or 3 types. Figures 5-6 5 Flexion mechanism may lead to 2 types of unstable fractures including the flexion teardrop fracture and the bilateral facet dislocation. Figures 7-8 Extension mechanism can lead to a Hangman’s fracture which is a fracture of the pedicles of the axis. Figures 10-11 Spinal cord injury without radiographic abnormality (SCIWORA) SCIWORA is defined as the presence of a spinal cord injury on magnetic resonance imaging (MRI) in the absence of a fracture or subluxation on computerized tomography (CT) or plan radiography. Spinal and Neurogenic shock Spinal shock is the temporary loss of reflexes and sensorimotor function below the level of cord injury. Neurogenic shock is the hemodynamic instability that occurs in high spinal cord injury (cervical and T1-T4). It manifests as hypotension, bradycardia, and hypothermia. Prehospital Management Prehospital management is based in the assumption that an injured patient has a spinal cord injury until proven otherwise. Essential steps of the first responder include surveying the scene, securing the ABCs, performing a secondary survey to determine the extent of the injuries, and following standard immobilization procedures for transport to the hospital. Emergency department evaluation Initial clinical assessment should be structured and should assume cervical spine injury until the spine is cleared clinically or radiographically as appropriate. Airway management must be carefully performed without allowing excess motion of the cervical spine. Typically this is done with the 6 use of manual in-line immobilization (MILI). Cord level findings include neurologic deficits correlate with the level of injury resulting in weakness or paralysis below the lesion. Figure 12 Partial cord syndromes include anterior cord syndrome, posterior cord syndrome, and central cord syndrome. Cervical spine imaging There are two different guidelines that have been developed to help determine the need for cervical spine imaging in trauma patients: the NEXUS Low Risk Criteria (NLC) and the Canadian C-Spine Rule (CCR). A prospective cohort study found the CCR to be more sensitive (99.4% versus 90.7%) and specific (45.1% versus 36.8%) than the NLC for 7 detecting injury. Emergency department management 8 Hypotension must be aggressively managed to maintain the goal of 85 to 90 mm Hg which is optimal for spinal cord perfusion. The use of prednisone is controversial with conflicting reports of efficacy in the literature and with risk of medical complications. Disposition Early consultation with a spine or neurosurgeon is critical to optimal management of c-spine injuries. Critical care consultation and admission to the intensive care unit are indicated for unstable c-spine fracture or cord injury as these patients frequently suffer from hypotension, cardiac instability, hypoxemia, and pulmonary dysfunction for 7-14 days. Key References 1. Goldberg W., Mueller C., Panacek E., Tigges S., Hoffman J.R., and Mower W.R., Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med, 2001. 38(1): p. 17-21. 2. Damadi A.A., Saxe A.W., Fath J.J., and Apelgren K.N., Cervical spine fractures in patients 65 years or older: a 3-year experience at a level I trauma center. J Trauma, 2008. 64(3): p. 745-8. 3. Lowery DW W.M., Browne BJ, et al, Epidemiology of cervical spine injury victims. Ann Emerg Med, 2001. 38(1): p. 12-16. 4. Gray H., Osteology, in Gray's Anatomy. 1973, Lea & Febiger: Philadelphia. p. 95-286. 5. Davenport M M.J., Belavel E, et al, Fracture, cervical spine. eMedicine Specialties, Emergency Medicine, Trauma, and Orthopedics, 2008. 6. Crosby E.T., Airway management in adults after cervical spine trauma. Anesthesiology, 2006. 104(6): p. 1293-318. 7. Stiell IG C.C., McKnight RD, et al, The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med, 2003. 349(26): p. 2510-2518. 8. Hadley M W.B., Grabb P, et al., Guidelines for the management of acute cervical spine and spinal cord injuries. American Association of Neurological Surgeons: Section on Disorders of the Spine and Peripheral Nerves. 2007, Rolling Meadows IL.
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