Cervical Spine Injury

Aka: Cervical Spine Injury, C-Spine Injury, Cervical Spine Trauma, C-Spine Trauma

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II. Epidemiology

  1. Significant spinal cord injuries per year: 11,500
    1. Patients who die of their injuries: 6500
    2. New quadriplegic and paraplegic patients: 500
  2. Prevalence of morbidity in United States
    1. Paralysis or paresis in United States: 265,000 (in 2010)
    2. Males account for 80% of spinal cord injuries
  3. Mechanisms of Spinal Injury in United States
    1. Motor Vehicle Accident: 40%
    2. Violent crime: 26%
    3. Fall-related injury: 24%
    4. Sports Injury: 7-9%
      1. Ice Hockey (3 fold higher Incidence of c-spine injuries than football)
      2. Football (associated with the most catastrophic sports-related injuries)
      3. Wrestling
      4. Gymnastics
      5. Diving
  4. Underdiagnosed c-spine injuries are common in sports
    1. Feldick (2003) Clin Sports Med 22:445-65 [PubMed]

III. Associated Conditions: Spinal Injuries

  1. Vertebral Dislocation
    1. Cervical SpineVertebral dislocation
      1. High risk for neurologic deficit, Vertebral Artery injury
  2. Vertebral Fracture
    1. Cervical Vertebral Fracture: 50%
      1. See Cervical Spine Fracture
      2. Associated with a second non-contiguous Vertebral Fracture in 10% of cases
    2. Thoracic Vertebral Fracture: 16%
    3. Lumbosacral Vertebral Fracture: 33%
  3. Spinal cord injuries
    1. Epidural Hematoma
    2. Complete transection of the spinal cord (Complete Cord Syndrome)
    3. Partial spinal cord injuries
      1. Central Cord Syndrome
        1. Bilateral motor weakness (esp. upper extremity and esp. distal extremity)
        2. Variable sensory deficits
      2. Anterior Cord Syndrome
      3. Spinal Cord Hemisection (Brown-Sequard Syndrome, rare)
      4. Transient Cervical Cord Neuropraxia syndromes (diagnoses of exclusion)
        1. Stingers or Burners (Unilateral arm pain or Paresthesias lasting seconds to minutes)
        2. Transient Quadriplegia
  4. Other injuries
    1. Spinal Cord Injury without Radiographic Abnormality (SCIWORA, Pediatric Cervical Spine Injury)
    2. Cervical Ligamentous Instability
    3. Concurrent brain injury occurs in 25% of spinal injuries

IV. Associated Conditions: Neck Vascular Injury

  1. Vertebral Artery Injury
    1. See Vertebral Artery Injury in Blunt Neck Trauma
  2. Carotid Artery Injury
    1. See Carotid Artery Injury in Blunt Neck Trauma (includes CT Angiography criteria)
    2. Blunt neck injury may result in occult and initially masked major neck vascular injury
    3. Risk of Carotid Artery Dissection and thrombosis
    4. May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours

V. Evaluation: General

  1. Do not lose sight of primary ABC Management in focus on spine
    1. See Acute stabilization below
    2. Hypoxia (start Oxygen)
    3. Hypotension
  2. Avoid unnecessary motion
    1. Assign one person responsible for ensuring immobilization
    2. See Cervical Spine Immobilization
    3. Remove long board on EMS arrival maintaining spinal precautions (Log Roll)
    4. May leave sports protective equipment in place (typically radiolucent) during imaging if SCI high suspicion

VI. Evaluation: Acute Stabilization (Primary Survey)

  1. Airway
    1. Secure airway if Advanced Airway indications
    2. Endotracheal Intubation with inline stabilization is safe in C-Spine Injury
      1. Variable support for Video Laryngoscopy over Direct Laryngoscopy
      2. Robitaille (2008) Anesth Analg 106(3): 935-41 [PubMed]
      3. Turkstra (2005) Anesth Analg 101(3): 910-5 [PubMed]
  2. Breathing
    1. High lesion: Ventilator dependent
    2. Lower lesion: Diaphragmatic breathing
  3. Circulation
    1. Spinal Shock
      1. Temporary (<24 hours) Flaccid Paralysis and hyporeflexia/areflexia below the level of injury
      2. Autonomic Dysfunction also occurs
      3. Incomplete Spinal Cord Injury may mimic complete injury when Spinal Shock is present
      4. Bulbocavernosus Reflex (S2-S4) is absent in Spinal Shock and present in severed spinal cord
        1. Anal sphincter contraction in response to one of following triggers
          1. Slight traction of Foley Catheter
          2. Compressing/Squeezing glans penis or clitoris
    2. Spinal Neurogenic Shock
      1. Hypotension (Systolic Blood Pressure <90 mmHg)
      2. Paradoxical Bradycardia
        1. Heart Rate 60-80 despite low Blood Pressure
      3. Skin warm, dry, and with normal color
        1. Despite Hypotension
    3. Occult Hemorrhage
  4. Disability
  5. Exposure
  6. Perform Secondary Survey
    1. See Trauma Secondary Survey

VII. Evaluation: Acute Stabilization: Additional Interventions

  1. Oxygen
  2. Two large bore IVs
  3. Nasogastric Tube
  4. Foley Catheter

VIII. Evaluation: Immobilization

  1. See Cervical Spine Immobilization

IX. Evaluation: Cervical Spine

  1. General
    1. Immobilize the spine and image if any concerns
    2. Requires stepwise approach
      1. If one step is abnormal, halt exam until imaging
      2. Primary, Secondary Trauma Survey takes precedence
    3. Observe for findings on history or exam suggestive of primary injury
      1. Direct Contusion
      2. Axonal stretch
      3. Spinal compression from Vertebral bone fragments, Hematoma or intervertebral disc
      4. Ischemia due to spinal artery compression
  2. Exam without moving head or neck
    1. Assess peripheral strength and Sensation
      1. Evaluate isometric neck strength
      2. Focal examination deficits can isolate the lesion level
        1. See Motor Exam
        2. See Sensory Exam
        3. See Cervical Spine Anatomy
    2. Palpate the neck
      1. Focal Vertebral tenderness (midline Vertebral pressure applief with thumbs)
      2. Facet tenderness (2-3 cm lateral from midline)
      3. Asymmetric spasm
      4. Neck deformity
    3. Evaluate for anterior and lateral neck findings
      1. Focal tenderness
      2. Deformity
      3. Ecchymosis
      4. Muscle spasm
      5. Focal edema
  3. Provocative maneuvers (perform only if exam above negative)
    1. Evaluate c-spine active range of motion
    2. Spurling Test (axial compression)
    3. Instability
  4. Interpretation
    1. All Steps Negative: Patient may be moved
    2. Any Step Positive: Complete Spine Immobilization
      1. Transport to emergency department for imaging
      2. Re-evaluate primary and Secondary Survey above

X. Exam: Distinguishing Upper from Lower Motor Neuron Injury

  1. Upper Motor Neuron Lesion (lesion proximal to the spinal cord anterior horn cells)
    1. Hyperreflexia
    2. Clonus
    3. Motor Spasticity
    4. Increased Muscle tone
    5. Babinski Sign positive
    6. Muscles without atrophy (normal Muscle mass)
  2. Lower Motor Neuron Lesion (lesion distal to the spinal cord anterior horn cells)
    1. Motor Weakness
    2. Muscle Atrophy
    3. Muscle Fasciculations
    4. Deep Tendon Reflexes decreased

XI. Findings: Occult Spinal Cord Injury Findings in Neurologically Impaired

  1. Cervical Spine Injury
    1. Respiratory weakness (C4 Injury or higher)
    2. Extremity weakness (without facial weakness)
    3. Hypotension with Bradycardia (Neurogenic Shock)
    4. Body Temperature Lability
  2. Thoracolumbar Spine Injury (T1-L2 injuries may affect spinal sympathetic Neurons with hemodynamic effects)
    1. Lower extremity weakness (with facial or upper extremity weakness)
    2. Hypotension with Tachycardia
    3. Labile Blood Pressures
  3. References
    1. Killu and Sarani (2016) Fundamental Critical Care Support, p.133-49

XII. Imaging

  1. Indications
    1. See Cervical Spine Imaging in Acute Traumatic Injury
    2. See NEXUS Criteria
    3. See Canadian C-Spine Rule
  2. General Rules
    1. When in doubt leave Cervical Collar on
    2. Image entire spine when Vertebral Fracture found
      1. Incidence of more than one spinal Fracture: 10-15%
  3. Pre-XRay
    1. Assistant stabilizes neck with collar removed
    2. Palpate for tenderness, swelling, or instability
    3. Reapply Cervical Collar
  4. Cases where a C-Spine Imaging is not needed
    1. See Cervical Spine Imaging in Acute Traumatic Injury (NEXUS Criteria)
  5. Cervical C-Spine XRay Indications
    1. Younger, otherwise healthy patients
      1. No focal exam findings but who cannot be cleared with NEXUS Criteria alone
    2. Indications for CT C-Spine instead of XRay (most cases in which C-Spine Imaging is required)
      1. Focal findings (e.g. neurologic or significant localized c-spine tenderness)
      2. Older patients or those with altered baseline Cervical Spine Anatomy (e.g. prior surgery, DJD)
  6. C-Spine CT Indications
    1. C-Spine CT is the first-line study in significant Trauma (esp. if other CT imaging, such as CT Head, is obtained)
    2. C-Spine XRay poorly shows Vertebrae (esp. C7-T1)
    3. C-Spine XRay abnormal
    4. C-Spine XRay negative but symptoms suggest injury
    5. CT Cervical Spine alone with axial slices <3mm has 100% NPV for unstable Cervical Spine Injury
      1. May someday obviate need for C-Collar or MRI in obtunded patients (follow local guidelines)
      2. Patel (2015) J Trauma Acute Care Surg 78(2): 430-41 [PubMed]
  7. Neck angiography indications (CT angiography or MR angiography)
    1. C1-C3 Fracture in addition to other associated findings from blunt force Trauma
    2. Risk of Vertebral Artery injury
    3. See Neck Vascular Injury in Blunt Force Trauma for CT Angiography criteria
  8. MRI Cervical Spine Indications
    1. Precaution
      1. Highly sensitive for Ligamentous Injury, but non-specific for significance
    2. Acute neurologic findings (e.g. Central Cord Syndrome) findings despite negative CT Cervical Spine
    3. Cervical Ligamentous Instability suspected (SCIWORA)
    4. Obtunded patients
    5. Patient should remain in Cervical Collar (e.g. Aspen collar)
      1. Until MRI Cervical Spine can be performed or
      2. C-spine cleared at follow-up based on resolved symptoms and signs
  9. Imaging Modalities
    1. C-Spine CT
      1. First line for most adults (see above)
    2. Cervical Spine XRay
      1. Primarily for pediatric Cervical Spine evaluation (see above)
    3. MRI Cervical Spine
      1. Indicated on follow-up if findings suggestive of ligamentous instability (see below)
      2. Patient should remain in collar (Miami-J or Aspen) until follow-up imaging if instability suspected
    4. Flexion and Extension view Cervical Spine XRay
      1. Historically used for evaluating ligamentous instability at 2 weeks
      2. However, not recommended due to low efficacy and need for prolonged use of collar until imaging
    5. Other imaging in Trauma
      1. CT Head (often obtained in combination with Cervical Spine CT)
      2. CT Chest (may reconstitute for Thoracic Spine CT) or Chest XRay
      3. CT Abdomen and Pelvis (may reconstitute for Lumbar Spine CT) or Pelvis XRay

XIII. Precautions: Cervical Collar (C-Collar)

  1. See Cervical Collar

XIV. Evaluation: Post-imaging (if negative or not indicated)

  1. See Cervical Spine Evaluation above
  2. Remove Cervical Collar
  3. Evaluate for midline tenderness
  4. Patient demonstrates active range of motion only!
    1. Nod yes and no
    2. Touch ears to Shoulder
    3. Rotation to sides
  5. Full and painless active range of motion
    1. Leave off Cervical Collar, evaluation complete
  6. Painful or limited range of motion
    1. Apply Aspen Cervical Collar, Miami-J collar or similar
    2. Follow-up with neurosurgery or othopedic spine
    3. Follow-up imaging
      1. Outpatient MRI or
      2. Flexion-extension view C-Spine XRay in 2 weeks

XV. Management: Approach

  1. Systematic acute stabilization is paramount (see above)
    1. See ABC Management
    2. See Trauma Evaluation
    3. Goal mean arterial pressure (MAP) >85 mmHg
  2. Consult Neurosurgery or Orthopedics
  3. Manage Cervical Spine Fracture and Evaluate for Stability
    1. See Subaxial Injury Classification Scale (SLIC)
  4. Indications for continued Cervical Spine precautions (e.g. Aspen Cervical Collar, Miami-J collar)
    1. See Cervical Spine Fracture
    2. See Spinal Cord Syndrome
    3. Intoxicated patients until coherent enough to clear Cervical Spine range of motion
      1. High risk mechanism may warrant MRI (e.g. diving accident, high speed MVA)
      2. Re-examine once sober
      3. Post-imaging evaluation as above, and if positive, apply Aspen or Miami-J collar and follow-up
      4. Herbert et. al. in Herbert (2016) EM:Rap 16(1): 15-6
    4. MRI Cervical Spine within 72 hours (see indications above)
      1. Findings suggestive of cervical instability
      2. Focal neurologic deficit suspicious for Cervical Spine origin (despite negative CT Cervical Spine)
      3. Persistent midline tenderness (if clears prior to MRI, may clear with post-imaging protocol as above)

XVI. Management: Disproven therapies (listed for historical purposes only)

  1. Methylprednisolone (high dose)
    1. Prior protocol that is no longer recommended
      1. Controversial - initial studies showing efficacy
      2. Local expert Consultation is recommended
    2. Dosing
      1. Bolus: 30 mg/kg over 15 minutes and wait 45 minutes
      2. Maintenance: 5.4 mg/kg/h for 23 hours IV
    3. Efficacy
      1. As of 2013, benefits appear to be minimal and it is not routinely used
      2. Initial studies showed significantly improved motor and sensory outcomes
        1. Without significant complication
        2. Sensory improvement only if given in first 8 hours

XVII. Resources

  1. C-Spine Clearance (Regions Trauma)
    1. http://www.youtube.com/watch?v=NhjF9kDOcjE
  2. CanadieEM
    1. https://canadiem.org/a-boring-guide-to-spinal-cord-syndromes/

XVIII. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Jang and Kaji (2013) Crit Dec Emerg Med 27(6): 2-9
  3. Kalsi, Kaufman and Hudson (2018) Crit Dec Emerg Med 32(10): 3-10
  4. Orman and Swaminathan in Herbert (2015) EM:Rap 15(8): 1
  5. Cantu (2000) Semin Neurol 20(2):173-8 [PubMed]
  6. Ghiselli (2003) Clin Sports Med 22:445-65 [PubMed]
  7. Haight (2001) Physician SportsMed 29:45-62 [PubMed]
  8. Whiteside (2006) Am Fam Physician 74(8):1357-62 [PubMed]

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