Title: Evaluation and Management of Acute Cervical Spine Trauma
Authors: Laura Pimental MD and Laura Diegelmann MD
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.
Careful evaluation and aggressive management of c-spine injured patient improves outcomes and reduces complications associated with
these devastating injuries.
The second vertebra is the most commonly injured accounting for 24% of fractures; the sixth and seventh vertebrae together account for
Risk factors for unstable cervical spine injury include older age (> 65 years), associated head trauma, and initial Glasgow Coma Scale (GCS)
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
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.
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 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
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.
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