Title: Evaluation and Management of Acute Cervical Spine Trauma
Authors: Laura Pimental MD and Laura Diegelmann MD
A high index of suspicion should be maintained by all providers involved in the care of trauma patients and c-spine injury should be
assumed until ruled out clinically or with radiographs.
The determination of fracture stability or instability is significant in guiding 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
another 39%.(Goldberg, Mueller et al. 2001)
Risk factors for c-spine injury include older age (patients > 65 years old have twice the risk with a mortality rate of 24% in this age group)
and having associated moderate to severe head trauma (4 times more likely to have c-spine injury).(Lowery DW 2001; Damadi, Saxe et al.
The trauma patient with an initial Glasgow Coma Scale (GCS) of 8 or lower has the highest risk of unstable c-spine injury.(Holly, Kelly et al.
General vertebral anatomy consists of an annular body, vertebral arch, symmetric pedicles, laminae, superior and inferior articular
surfaces, transverse processes, and a single posterior spinous process. Figure 1
The first cervical vertebra (the atlas) supports the head at the atlantooccipital joint where 50% of neck flexion and extension occurs.(Gray
1973) Figure 2
The second cervical vertebra (the axis) forms the base where the atlas pivots to allow head rotation. Figure 2
C2-C7 are supported by intervertebral discs and a complex network of ligaments. Figure 3
The main blood supply consists of a single anterior and two posterior vessels originating from the vertebral arteries which run
longitudinally the length of the cord.
Clinically the spinal column should be considered as 2 parallel columns with the vertebral bodies and disc forming the anterior column
supported by the longitudinal ligaments. The posterior column is comprised of the spinal canal and cord, pedicles, transverse processes,
facets, laminae, and spinous processes all of which are supported by the ligamentum flavum and interspinous ligaments.
Axial compression injury can result in the Jefferson fracture (unstable burst fracture of the atlas) which is diagnosed by open-mouthed
odontoid view which shows displacement of the lateral masses of C1 compared to C2. Figure 4
Multiple or complex mechanisms may result in odontoid fracture and may be 1 or 3 types. Type I is an avulsion of the tip of the dens
above the transverse ligament. Type II (most common) is localized to the base of the dens. 10% are associated with transverse ligament
injury which makes them very unstable. Figure 5 Type III extends into the body of C2, are mechanically unstable, and best treated in a
halo brace. Figure 6
Flexion mechanism may lead to 2 types of unstable fractures including the flexion teardrop fracture (most common at C5 and often
associated with spinal cord injury) Figure 7 and the bilateral facet dislocation.(Davenport M 2008) Figure 8
Extension mechanism can lead to a Hangman’s fracture (fracture of the pedicles of the axis) which is unstable because of location but
spinal cord injury is uncommon here. Figure 10
The extension teardrop fracture at C2 is also a common potentially unstable fracture from this mechanism although neurologic injury
here is usually not severe. Figure 11
Vertebral artery injury can complicate as many of 17% of cervical spine fractures.(Taneichi, Suda et al. 2005)
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 should be done with the use of manual in-line immobilization (MILI) as described by Crosby.(Crosby 2006)
Cord level findings include neurologic deficits that correlate with the level of injury resulting in weakness or paralysis below the lesion.
Partial cord syndromes:
o Anterior cord syndrome results from compression of the anterior spinal artery, direct anterior cord compression or compression
from fragments from a burst fracture and manifests as complete motor paralysis with loss of pain and temperature perception
distal to the lesion
o Posterior cord syndrome is rare and most often seen in Brown-Sequard syndrome which is characterized by paralysis, loss of
vibration sense and proprioception ipsilaterally with contralateral loss of pain and temperature sensation. Causes include
hemisection of the cord from penetrating trauma or lateral fracture fragments.
o Central cord syndrome is characterized by weakness in the upper extremities (and mostly distal upper extremities) more than
the lower extremities. The cause is damage to the corticospinal tract from a hyperextension injury in someone with underlying
stenosis or spondylosis.
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).
o The NLC states that c-spine imaging is necessary for all trauma patients unless all 5 of the following are true: the patient is alert,
is not intoxicated, has no posterior midline tenderness, has no neurologic indications of injury, has no distracting injuries (e.g.
long bone fracture, severe burn or laceration).
o The CCR poses 3 questions to help determine the need for x-rays and considers that the c-spine may be cleared without
additional imaging if there are no high risk factors (older than 65 years, “dangerous” mechanism of injury) and there are low
risk factors (low velocity injury, delayed symptoms, no posterior midline tenderness) that allows for safe evaluation of range of
motion (patient can activity rotate the neck 45 degrees to the right and left).
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.(Stiell IG 2003)
Emergency department management
After initial assessment and airway management, it is critically important to aggressively manage hypotension in cord injured patients as
the low blood pressure is associated with worse outcome likely due to decreased cord perfusion.(Hadley M 2007) Goal for optimal cord
perfusion is 85 to 90 mm Hg.
The use of prednisone is controversial with conflicting reports of efficacy in the literature and with risk of medical complications. (Bracken,
Collins et al. 1984; Bracken, Shepard et al. 1990; Bracken, Shepard et al. 1997; Hadley M 2007)
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.(Hadley M 2007)
Understanding acute cervical spine trauma means understanding the anatomy and pathophysiology involved.
Imaging plays an important role in diagnosing and determining the severity of these injuries.
Treatment must start from the moment of injury and be adjusted after imaging to prevent morbidity and mortality in these trauma
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