Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation.

Airway management in the blunt trauma patient is complicated by the potential for causing or exacerbating an injury to the cervical cord if an unstable cervical fracture is present. The records of 987 blunt trauma patients who required emergent endotracheal intubation over a 5-year period were retrospectively reviewed to determine the incidence and type of cervical spine injury and the incidence of injury based on airway management. Sixty of the patients (6.1%) had a cervical fracture; 53 were potentially unstable injuries by radiographic criteria. Twenty patients had neurologic deficits prior to intubation. Twenty-six patients with unstable injuries were intubated orally, 25 nasally, and two by cricothyrotomy. One patient developed a neurologic deficit after nasotracheal intubation. Because of a possible selection bias in which severely injured patients were preferentially referred to this trauma center, the true incidence of cervical spine injuries may be lower than the 6.1% we found. The authors conclude that the incidence of serious cervical spine injury in a very severely injured population of blunt trauma patients is relatively low, and that commonly used methods of precautionary airway management rarely lead to neurologic deterioration.     

Evaluation of the acute cervical spine: a management algorithm. (Department of Surgery, University of Kentucky, Lexington, KY) J Trauma 2000;49:450–456.

A retrospective review was initiated of all trauma patients evaluated in a Level I trauma center the year before and after implementation of a new cervical spine protocol to determine the incidence of missed cervical injuries. An additional 6 months were reviewed to detect any missed injuries late in the study period. During the 2‐year study period, 4,460 patients presented to the emergency room with some form of cervical spine precautions. Blunt trauma comprised 90% of the study population. According to the protocol, approximately 45% required further cervical radiographs after presentation. In the preprotocol year, 77 of 2,217 (3.4%) patients were diagnosed with cervical spine injuries, 16 of 77 (21%) with multiple level injuries, and 25 of 77 (32%) with neurologic compromise. Three of 2,217 patient had missed cervical spine injuries on their initial evaluations. In the postprotocol year, 84 of 2,243 (3.4%) patients had cervical injuries, 25 of 84 (30%) with multiple levels of injuries and 28 of 84 (28%) with neurologic compromise. No patient evaluated during the protocol year was missed. All statistics between the two groups were not significant. Conclude the current protocol by risk stratifying patients on presentation is effective in assessing patients for cervical spine injuries. Comment by Gabor B. Racz, M.D. This is a retrospective review from a Level I trauma center a year before and after implantation of a cervical spine injury protocol. The comparison of outcomes before and after the protocol was rather similar in that the diagnosis of cervical spine injury in 77 of 2,217 patients, or 3.4% and 84 of 2,243 had cervical injuries again 3.4%. Prior to the initiation of the protocol, the first year had three cervical spine injuries missed, which were diagnosed later secondary to continued neck pain on reevaluation. There were no missed cases after the protocol. The evaluation and examination go hand in hand. More emphasis is placed on the clinical exam and plain multiple view x‐ray films and adherence to limiting the rigid collar to 6 h switching over to soft collar and developing more of a confidence in the clinical exam rather than to concentrate on the more expensive and time consuming radiological diagnostic procedures. The cervical algorithm does work and it is impressive that there were no missed injuries. It is recommended that physicians working in a Level I trauma center should go and review the algorithm in detail. The recommended practice is to rely on plain films first if there is persistent pain flexion and extension films and involvement of appropriate consultants in these patients who must be assumed to have cervical spine injury.     

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.     

Is the anteroposterior cervical spine radiograph necessary in initial trauma screening?

The usefulness of the anteroposterior (AP) radiograph of the cervical spine in contributing to the diagnosis of cervical spine injuries in the acute trauma patient was examined in a retrospective study. All cases of cervical spine fracture or dislocation seen at a level I trauma center over a 3-year period and at a rehabilitation center over a 10-year period were reviewed. The lateral radiograph, open-mouth odontoid radiograph, and AP radiograph of each case were sequentially examined by a neuroradiologist (blinded to the original diagnosis) to determine the contribution of each view in making a diagnosis of cervical spine injury. Results of these reviews showed that there were no cases of cervical spine injury evident on the AP view without an obvious corresponding abnormality on the lateral or open-mouth view. It was concluded that the AP view could be dropped from the initial screening radiographic study of the cervical spine in the trauma patient. Only an adequate lateral view and open-mouth odontoid view would then be necessary to initially evaluate the cervical spine in the trauma patient, and decisions to obtain further studies could be based safely on only the lateral and open-mouth views.     

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.     

Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma?

Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.     

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.     

Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging

Background: Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. Objectives: This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. Discussion: Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. Conclusion: With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.     

Subaxial cervical spine trauma

Subaxial cervical spine trauma is common and an often missed diagnosis. Accurate and efficient diagnosis and management is necessary to avoid devastating complications such as spinal cord injury. Several classification schemes have been devised to help categorize fractures of the subaxial spine and define treatment algorithms. The Subaxial Cervical Spine Injury Classification System (SLIC) is widely used and evaluates not only fracture morphology but also considers ligamentous injury and neurological status in surgical decision making. However, interobserver reliability is poor, which proves to be the defining pitfall of this tool. More modern classification systems have been developed, which aim to improve the interobserver reliability; however, further large-scale studies are needed for more definitive evaluation. Overall, treatment of subaxial cervical spine injuries should include a protocol with initial trauma evaluation, leading to expedient operative intervention if indicated. Surgical techniques include both anterior and posterior approaches to the cervical spine depending on fracture classification.     

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.     

Clinical outcomes of magnetic resonance imaging in blunt cervical trauma

Objectives: To determine whether MRI of the cervical spine resulted in a change in management of patients with blunt trauma and normal plain X‐ray (XR)/CT of the cervical spine. Methods: An explicit chart review was conducted of patients seen at a Level 1 trauma centre over a 1 year period. Clinical details were extracted from the charts of patients with blunt trauma who had a normal plain XR and CT scan of the cervical spine and who underwent cervical spine MRI. A comparison of clinical details was made between those with a normal/abnormal MRI secondary to the acute injury. Results: One hundred and thirty‐four patients met entry criteria. Discharge non‐operative management of the cervical spine was associated with a change in management by the MRI result (P < 0.0001) where MRI of the cervical spine occurred a median of 3 days (interquartile range 0–4.5, range 0–137) after the injury. The MRI occurred before discharge 90% of the time in both groups. Operative management occurred in three patients and was delayed until after first outpatient review in two patients. Conclusions: An abnormal MRI after normal plain XR and CT cervical spine studies resulted in a change in non‐operative management at discharge. Early MRI resulted in one patient receiving surgery before discharge. No unstable injuries were detected by MRI that were not evident on plain XR or CT cervical spine.     

Incidence and significance of injuries on secondary CT imaging after initial selective imaging in blunt trauma patients

ObjectiveIt is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients.MethodsThis was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system. Inclusion criteria: age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management.Results537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient).ConclusionWhile a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.     

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 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.     

Assessment and management of a child with suspected acute neck injury

Any child presenting at an emergency department after trauma, such as road traffic accidents, falls, sports and head injuries, should be assessed for risk of injury to the cervical spine. The aim of this article is to provide an overview of the assessment and nursing management of a child with a suspected cervical spine injury. Basic anatomy is covered along with neck injury assessment, how to measure a cervical collar correctly, safe immobilisation, and communication.     

The management of patients with spinal cord injury

Few diseases or injuries have greater potential for causing death or having a devastating impact on a person's quality of life than cervical spine trauma. All patients admitted to hospital after significant trauma must therefore be assumed to have a potentially unstable spinal fracture until it is proven otherwise, to prevent their sustaining further injury owing to inappropriate management. It is vital that nurses are familiar with the signs and symptoms of such injuries and aware of the appropriate management techniques.     

Delayed Subluxation of an Occult Traumatic Odontoid Fracture in an Elderly Patient

The issue of whether a traumatic but occult cervical spine fracture can exist has generated significant debate in emergency medicine. The profound clinical and legal implications of missing an unstable cervical spine injury are well known to the emergency care provider. An elderly patient who satisfies all of the rigorous criteria for this type of injury is discussed. The patient experienced delayed subluxation of her acute odontoid fracture during a flexion/extension examination completed in the ED, with resultant development of cervical discomfort. Elderly victims of trauma with an appropriate mechanism of injury should be suspected of subtle or occult neck injuries.     

Missed cervical dissociation-recognizing and avoiding potential disaster

Complete cervical disruptions are high-energy injuries often associated with polytrauma and spinal cord injury. Because these injuries disrupt all anterior and posterior stabilizers, they result in a highly unstable spine, and the injuries are usually apparent on screening radiographs. Patients with these injuries must be identified and protected during the multiple diagnostic and surgical procedures they may require during their initial evaluation and treatment. Emergency procedures must be carefully prioritized relative to other life-threatening injuries; formal evaluation of the cervical spine may be carried out before, after, or in stages around other urgently indicated procedures. Until the cervical spine is cleared, careful observation of precautions can avoid disasterous complications in even the most unstable situation. A case of complete cervical disruption in a neurologically intact, hemodynamically unstable patient is presented for discussion. For polytraumatized patients with cervical dissociation, combined anterior and posterior stabilization is the treatment of choice.     

Spinal trauma

The practice of spinal immobilization has existed since the 1960s under the premise that trauma victims with cervical spine injuries may suffer neurologic injury if moved without stabilization consisting of a rigid cervical collar and long spine board. Because of this assumption, it is of particular importance to assess for movement of the cervical spine with and without spinal immobilization. Over time, the on-field management of athletes with a mechanism consistent with spinal cord injury (SCI) has evolved and produced protocols that can be considered standard of care. Attempts to find evidencebased research to verify the necessity of a rigid collar and long spine board as the only option in athletic medicine for suspected SCI is difficult. As changes occur in the Emergency Medical Services standards, there will be opportunities to see how their processes relate to athletes and the rationale for immobilization on the field of play. Going forward, there could very well be a significant change in the approach to and management of the athlete down on the field of play with a suspected spinal cord injury.     

The radiographic evaluation of spinal trauma

The authors describe a systematic approach to the radiographic evaluation of spinal trauma, discussing cervical spine anatomy, the mechanism of injury, and classification of injuries, and then discuss several specific injuries of the cervical and thoracolumbar spine and their radiographic evaluation.