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					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
         The second vertebra is the most commonly injured accounting for 24% of fractures; the sixth and seventh vertebrae together account for
          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.
         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
          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.
         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
         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
          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
         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
          detecting injury.
Emergency department management
         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.
         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,
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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