Orthopedics Book


Cervical Spine Injury

Aka: Cervical Spine Injury, C-Spine Injury, Cervical Spine Trauma, C-Spine Trauma, Spinal Trauma, Spinal Injury
  1. See Also
    1. Cervical Spine Immobilization
    2. Pediatric Cervical Spine Injury
    3. Cervical Spine Imaging in Acute Traumatic Injury
    4. NEXUS Criteria
    5. Trauma Evaluation
    6. Vertebral Compression Fracture
  2. 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%
        1. Football
        2. Ice Hockey
    4. Underdiagnosed c-spine injuries are common in sports
      1. Feldick (2003) Clin Sports Med 22:445-65 [PubMed]
  3. Associated Conditions: Spinal Injuries
    1. Vertebral Dislocation
    2. Vertebral Fracture
      1. Cervical Vertebral Fracture: 50%
      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
        2. Anterior Cord Syndrome
        3. Spinal Cord Hemisection (Brown-Sequard Syndrome, rare)
        4. Neuropraxia (Stinger, Burner)
    4. Other injuries
      1. Spinal Cord Injury without Radiographic Abnormality (SCIWORA, Pediatric Cervical Spine Injury)
      2. Cervical Ligamentous Instability
  4. Associated Conditions: Neck Vascular Injury
    1. Blunt neck injury may result in occult and initially masked major neck vascular injury
      1. Risk of Carotid Artery dissection and thrombosis
      2. May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours
      3. See Neck Vascular Injury in Blunt Force Trauma for CT Angiography criteria
  5. Evaluation: General
    1. Do not lose sight of primary ABCs 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
  6. Evaluation: Acute Stabilization (Primary Survey)
    1. Airway
    2. Breathing
      1. High lesion: Ventilator dependent
      2. Lower lesion: Diaphragmatic breathing
    3. Circulation
      1. Spinal Shock
        1. Temporary flaccid paralysis
        2. Loss of segmental reflexes
      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
  7. Evaluation: Acute Stabilization: Additional Interventions
    1. Oxygen
    2. Two large bore IVs
    3. Nasogastric Tube
    4. Foley Catheter
  8. Evaluation: Immobilization
    1. See Cervical Spine Immobilization
  9. 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
    2. Exam without moving head or neck
      1. Assess peripheral strength and sensation
      2. Palpate the neck
        1. Focal Vertebral tenderness
        2. Asymmetric spasm
      3. Evaluate isometric neck strength
    3. Provocative maneuvers (perform only if exam above negative)
      1. Evaluate c-spine active range of motion
      2. Spurling Test (axial compression)
    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
  10. 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
      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
  11. Imaging
    1. See Cervical Spine Imaging in Acute Traumatic Injury
    2. See NEXUS Criteria
    3. 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%
    4. Pre-XRay
      1. Assistant stabilizes neck with collar removed
      2. Palpate for tenderness, swelling, or instability
      3. Reapply Cervical Collar
    5. Cases where a C-Spine Imaging is not needed
      1. See Cervical Spine Imaging in Acute Traumatic Injury (NEXUS Criteria)
    6. 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)
    7. 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]
    8. Neck angiography indications (CT angiography or MR angiography)
      1. C1-C3 Fracture in addition to other associated findings from blunt force Trauma
      2. See Neck Vascular Injury in Blunt Force Trauma for CT Angiography criteria
    9. 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
    10. 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
  12. Precautions: Cervical Collar (C-Collar)
    1. See Cervical Collar
  13. 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
  14. Management: Approach
    1. Consult Neurosurgery or Orthopedics
    2. Indications for continued Cervical Spine precautions (e.g. Aspen Cervical Collar, Miami-J collar)
      1. 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
      2. 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)
  15. 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
  16. Resources
    1. C-Spine Clearance (Regions Trauma)
      1. http://www.youtube.com/watch?v=NhjF9kDOcjE
  17. References
    1. Jang and Kaji (2013) Crit Dec Emerg Med 27(6): 2-9
    2. Orman and Swaminathan in Herbert (2015) EM:Rap 15(8): 1
    3. Cantu (2000) Semin Neurol 20(2):173-8 [PubMed]
    4. Ghiselli (2003) Clin Sports Med 22:445-65 [PubMed]
    5. Haight (2001) Physician SportsMed 29:45-62 [PubMed]
    6. Whiteside (2006) Am Fam Physician 74(8):1357-62 [PubMed]

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