Occult ligamentous injury of the cervical spine

Evaluating the cervical spine for injury is an essential part of the assessment of a traumatized patient. Clinical examination and radiographs are the traditional techniques used for this evaluation. Often, however, a reliable clinical examination is not possible because of head injury, altered mental status, or "distracting" injuries. In such cases, cervical spine injury that is not apparent on radiographs may be missed. This case report illustrates a purely ligamentous cervical spine injury resulting in cervical instability. We describe our method of screening for and evaluating these types of injuries using physician-controlled stretch, flexion, and extension examination under fluoroscopy.     

The radiology of cervical spine injury.

Cervical spine injury is a frequent sequelae of accidental trauma. Clinical evaluation often fails to raise adequate suspicion of an underlying injury. Radiologic assessment frequently reveals recognizable signs of damage ranging from fractures to joint and soft tissue injuries. This paper reviews the pathomechanics, clinical and radiologic features of the most common patterns of cervical spine injury.     

Utility of flexion–extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine

Detecting the presence of injuries to the cervical spine is an important component of the initial assessment of patients sustaining blunt trauma. A small proportion of cervical spine injuries consists of ligamentous disruption. Accurate detection of ligamentous injury is essential as it may result in sequelae including radiculopathy, quadriplegia and death. Flexion–extension (FE) radiography has traditionally been utilised for the detection of ligamentous injury in patients who have been cleared of bony injury. There are controversies surrounding the use of FE for alert patients with neck pain. There are studies that call into question the diagnostic accuracy of FE, the high proportion of inadequate FE images due to muscle spasm and the adverse effects of prolonged cervical collar immobilisation while awaiting FE. Other literature indicates that FE provides no additional diagnostic information following a multi‐detector helical computed tomography. This review evaluates the literature on the utility of FE for the detection of ligamentous injury and explores alternate strategies for clearing the cervical spine of ligamentous injury.     

Trauma radiology: Part V. Imaging of acute cervical spine trauma

Cervical spine injury constitutes a major cause of morbidity resulting from trauma. The consequences of a missed "significant" injury can be devastating for the patient and can create potential medical legal consequences for involved physicians. Multiple imaging modalities can be applied to imaging of the cervical spine after trauma, including radiography, computed tomography (CT), myelography, CT myelography and magnetic resonance imaging (MRI). Controversy exists concerning the appropriate number of radiographic views required for the screening assessment of cervical spine injuries. CT clarifies uncertain radiological findings, identifies subtle fractures in patients with neck pain or with neurological deficits but with normal radiographs, determines details of injury, and assists in operative planning. MRI has virtually replaced myelography and CT myelography in evaluating the traumatized cervical spine. MRI is more accurate than CT with intrathecal contrast in delineating epidural pathology, ligament injury, soft-tissue edema, and cord parenchymal injury. Information derived from MRI guides appropriate management and has value in predicting injury outcome. We consider indications for and relative merits of these various diagnostic modalities, and we describe imaging features of major patterns of cervical spine injury.     

Cervical spine curvature during simulated whiplash

OBJECTIVE: To develop a new method to describe cervical spine curvature and evaluate the potential for injury in the upper and lower cervical spine during simulated whiplash. DESIGN: A method was developed to integrate the upper and lower cervical spine rotations and describe the spine curvature. BACKGROUND: In vivo and in vitro whiplash simulations have documented the development of an S-shape curvature with simultaneous upper cervical spine flexion and lower cervical spine extension immediately following rear-impact. Investigators have hypothesized that the injury potential is highest during the S-shape phase. However, little data exist on the spine curvature during whiplash and its relation to spine injury. METHODS: A biofidelic model and a bench-top whiplash apparatus were used in an incremental rear-impact protocol (maximum 8 g) to simulate whiplash of increasing severity. To describe the spine curvature, the upper and lower cervical spine rotations were normalized to corresponding physiological limits. RESULTS: Average peak lower cervical spine extension first exceeded the physiological limits (P<0.05) at a horizontal T1 acceleration of 5 g. Average peak upper cervical spine extension exceeded the physiological limit at 8 g, while peak upper cervical spine flexion never exceeded the physiological limit. In the S-shape phase, lower cervical spine extension reached 84% of peak extension during whiplash. CONCLUSIONS: Both the upper and lower cervical spine are at risk for extension injury during rear-impact. Flexion injury is unlikely.     

Cervical Spine Injuries in Children, Part II: Management and Special Considerations

Background: The diagnosis and management of cervical spine injury is more complex in children than in adults. Objectives: Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. Discussion: Children have several common variations in their anatomy, such as pseudosubluxation of C2–C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. Conclusion: With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.     

The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department

Objective: To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome. Methods: This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in‐hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service. Results: The trauma registry identified 1721 trauma presentations during the 4‐month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long‐term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non‐compliant groups. Conclusions: Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.     

Emergency department intubation of trauma patients with undiagnosed cervical spine injury

Objectives: Some trauma patients have an undiagnosed cervical spine injury but require immediate airway control. This paper reports an emergency department''s (ED) experience with these patients. In particular, is there a worse neurological outcome? Methods: A retrospective study over 6.5 years, based on prospectively collected data from the Royal Perth Hospital trauma registry. Patients with a cervical spine injury were identified and clinical data were abstracted. The primary outcome measure was evidence of exacerbation of cervical spine injury as a result of intubation by ED medical staff. Results: 308 patients (1.9%) of the 15 747 trauma patients were intubated by ED medical staff. Thirty seven (12%) were subsequently verified to have a cervical spine injury, of which 36 were managed with orotracheal intubation. Twenty five (69%) survived to have a meaningful post-intubation neurological examination. Fourteen (56%) of these 25 patients had an unstable cervical spine injury. Ninety per cent of all ED intubations were by ED medical staff. No worsening of neurological outcomes occurred. Conclusions: Every ninth trauma patient that this ED intubates has a cervical spine injury. Intubation by ED medical staff did not worsen neurological outcome. In the controlled setting of an ED staffed by senior practitioners, patients with undiagnosed cervical spine injury can be safely intubated.     

Incidence of cervical spine injuries in association with blunt head trauma

To establish an incidence of cervical spine injuries in significant blunt head trauma and to evaluate the necessity of using cervical radiography, all consecutive cases of blunt head trauma admitted to the trauma service over a 7-month period were reviewed. Two hundred twenty-eight charts were reviewed for demographic information, circumstance of injury, complaints and physical findings referable to the cervical spine, presenting level of consciousness, severity of head injury, and cervical spine radiographic findings. Only three patients were found to have cervical spine injuries, for an incidence of 1.7%. Of the 122 alert and asymptomatic patients, none had cervical spine injury. The patient population was defined, yet the very low incidence of cervical spine injuries associated with blunt head trauma in this study precludes any identification of predictors. Nevertheless, the results suggest that alert and asymptomatic patients can be spared cervical spine radiography.     

General principles governing radiological examinations in cervical spine injuries

A review of the general principles governing radiological procedures in cases of acute trauma to the cervical spine, depending on the patient's clinical status, and on the location and nature of the injury. Various X-ray techniques are presented that can be used to attain better differentiation of the sequelae of spinal injury, along with a general assessment of the clinical value of certain other examinations, such as computer tomography and magnetic resonance, in terms of their suitability in cases of acute trauma to the cervical spine.     

Evaluation of pediatric cervical spine injuries.

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.     

A Cryptic Cause of Cardiac Arrest

Background

RIPPLY2-associated spondylocostal dysostosis is a rare disorder that leads to segmentation defects of the vertebrae. These vertebral defects can result in severe instability of the cervical spine, leading to cardiac arrest after only minor whiplash injury.

Transient cervical neurapraxia associated with cervical spine stenosis

A 43 year old woman presented with a history of a hyperextension cervical injury resulting in transient quadriplegia. Cervical spine radiography revealed developmental spinal stenosis and magnetic resonance imaging demonstrated underlying spinal cord oedema secondary to contusion, with a herniated disc at C3-C4. The Torg ratio may be used to aid the initial diagnosis of cervical spine stenosis. Indications for operative treatment of these patients are controversial and these patients should receive further expert assessment.     

Management of suspected cervical spine injuries--the paediatric perspective

Paediatric cervical spine immobilisation and management is one of the most difficult tasks to master in the paediatric trauma population. The Royal Children's Hospital--Melbourne has admitted 54 patients with diagnosed cervical spine injuries since January 1999. The management of such patients admitted to acute care facilities with suspected cervical spine injuries is inconsistent and at times sub-optimal. Management controversies centre around, application of cervical collars, clearance of the c-spine, patient movement and general care principles. In an endeavour to address these issues, the Royal Children's Hospital Trauma Service, in conjunction with the Emergency Department developed cervical spine guidelines. Teams consulted in the formulation of these guidelines included, Emergency Department, Intensive Care Unit, Orthopaedics, Neurosurgery, Radiology and General Surgery. These guidelines were developed as a clinical tool to guide management and standardise the approach of care for these patients. Specifically, the guidelines address: immobilisation of the paediatric cervical spine; radiology; clearing the cervical spine of injury; suspected or proven cervical spine injury; guidelines for times to fitting Philadelphia collar; ongoing care.     

The unstable occult cervical spine fracture: a review.

The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and management on the patient's eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. The existence of patients with an unsuspected cervical spine fracture who have few, if any, symptoms and/or signs of an injury to the cervical spine is a valid concern and a dilemma for the practicing physician. Thus the principle of the occult unstable cervical spine fracture, which has been established as the standard of care, has major significance and implications. Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature.     

Emergency department evaluation and treatment of pediatric orthopedic injuries

Orthopedic injuries in children are unique in terms of the mechanisms of injury, pathophysiology, and healing. This article reviews the pediatric fracture patterns and common pediatric injuries or complaints seen in the emergency department, with an emphasis on management in the emergency department. Additionally, the approach to pediatric cervical spine injuries and child abuse will be described as it pertains to the emergency physician.     

创伤性颈椎损伤内固定置入相关临床试验注册项目分析

背景：创伤性颈椎损伤不容忽视,如果不及时有效救治,伤及脊髓会产生瘫痪的风险。目的：通过中国临床试验注册中心,北美临床试验注册中心以及汤森路透WebofScience数据库进行相关检索,对创伤性颈椎相关临床试验注册项目及发表文献进行文献计量学分析。方法：①使用关键词“颈椎”在中国临床试验注册中心进行临床试验项目检索,得到颈椎创伤相关临床试验项目。②使用关键词“Cervicalvertebra”,“Trauma”或“cervicalspine”,“Trauma”在北美临床试验注册中心进行临床试验项目检索,得到的注册项目有22项。③使用关键词“Neckvertebra”,“cervicalvertebra”,“vertebraecervicales”,“cervicalspine”,“C．spine”,“Trauma”在汤森路透WebofScience数据库对创伤性颈椎损伤相关文献进行检索,时间范围2003至2012年。结果与结论：①中国临床试验注册中心关于颈椎创伤的临床试验注册项目仅有5项,北美临床试验注册中心关于颈椎创伤的临床试验注册项目有22项。中国临床试验注册中心明显少于北美临床试验注册项目。北美临床试验注册中心相关颈椎创伤的临床试验注册项目分布于3个州,17个国家。主要分布在美国。②创伤性颈椎临床试验注册项目多为干预性研究,干预措施多涉及内固定物。暂时没有诊断性试验研究进行临床试验注册。2003至2012年在汤森路透WebofScience数据库中关于创伤性颈椎损伤已发表文献多达1597篇。美国发文量占总数比重最大,为46．84％。中国发文量占所有文章的1．94％。高被引文章主要分布于JournalofTrauma-InjuryInfectionandCriticalCare（《创伤一损伤感染和危重护理学杂志》）杂志上。④中国临床试验注册中心关于颈椎创伤相关临床试验注册单位2003至2012年在汤森路透WebofScience数据库中未发表文章。北美临床试验注册中心关于颈椎创伤相关临床试验注册最多的单位是OttawaHospitalResearchInstitute（渥太华医院研究所）发表文章4篇;发文量最多的单位是UniversityofBritishColumbia（英国哥伦比亚大学）发表文章30篇,多集中在2009年和2012年。同时这两个单位合作的关于颈椎创伤的文章也进行了临床试验注册,注册号为NCT00290875。     

Active Retropharyngeal Hemorrhage from an Acute Thyrocervical Artery Injury: A Rare Complication of Hyperextension Cervical Spine Injury

Background: Acute vascular injury is uncommon after cervical spine injury. We describe a recent case of active retropharyngeal bleeding from the thyrocervical artery after an acute cervical spine injury. Objectives: The case illustrates an unusual vascular injury diagnosed by 64-slice multidetector computed tomography (MDCT) and managed successfully by emergency transcatheter embolization. Case Report: A 65-year-old woman presented to the Emergency Department after a fall. MDCT scans of the cervical spine revealed a fracture of C5 and a large prevertebral hematoma. Subsequent MDCT carotid angiography revealed active bleeding from a branch of the right thyrocervical trunk. Superselective catheterization into the right thyrocervical trunk confirmed this as the source vessel. A 3-mm coil was deployed without complication. Conclusion: This case illustrates an unusual arterial injury in the context of cervical spine trauma and how, as endovascular services become more accessible out of hours, the management of patients with acute arterial injury is increasingly a multidisciplinary team effort. Early recognition by the emergency physician of potential vascular injury and prompt referral for appropriate imaging will expedite treatment and improve clinical outcome.     

Compression cervical spine cord injury in patients with posterior cranial fossa tumors operated on in the sitting position: two cases with different outcomes

The paper describes two cases of posterior cranial fossa pathology, operated on in the sitting position on the operating table. In one case, symptoms of cervical spine injury caused by undiagnosed preoperative cervical spine pathology emerged in a female patient in the early postoperative period. In the other case, cervical spine pathology was diagnosed before surgery and evoked potentials were monitored to prevent possible cervical spine injury in the sitting position during an operation.     

Evaluation and management of acute cervical spine trauma

The evaluation and management of cervical spine injuries is a core component of the practice of emergency medicine. This article focuses on evaluation and management of blunt cervical spine trauma by the emergency physician. Pertinent anatomy of the cervical spine and specific cervical spine fractures are discussed, with an emphasis on unstable injuries and associated spinal cord pathology. The association of vertebral artery injury with cervical spine fracture is addressed, followed by a review of the most recent literature on prehospital care. Initial considerations in the emergency department, including cervical spine stabilization and airway management, are reviewed. The most current recommendations for cervical spine imaging with regard to indications and modalities are covered. Finally, emergency department management and disposition of patients with spinal cord injuries are reviewed.