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.     

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.     

Application of clinical criteria for ordering radiographs to detect cervical spine fractures

OBJECTIVE: The aim of the study was to determine if spinal-immobilized patients met clinical criteria for x-rays and which clinical criteria were associated with cervical fractures. METHODS: This was a prospective, observational analysis of clinical findings and radiograph results for patients transported to the emergency department in spinal immobilization by emergency medical services. The presence of altered mentation, distracting injury, cervical spine tenderness, neck pain, neurologic deficit, and palpable deformity was recorded for each subject. RESULTS: Of the 2044 subjects enrolled in the study, 1367 subjects received radiographs and 50 had cervical spine fractures. Sixty percent of subjects met some clinical criteria for radiograph ordering. Cervical spine tenderness and neurologic deficit were the only clinical criteria statistically associated with fractures. All subjects with fractures met 1 or more of the clinical criteria for radiographs. CONCLUSION: Cervical spine radiographs were ordered for a significant number of patients who did not meet the clinical criteria. However, omission of any one of the criterion other than palpable deformity would have potentially resulted in a missed fracture. Strictly following the criteria would have significantly reduced the number of cervical spine radiographs taken.     

Outcome of Trauma Patients Immobilized by Emergency Department Staff,but Not by Emergency Medical Services Providers: A Quality Assurance Initiative

Abstract

Background. Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. Methods. This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report. Results. The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. Conclusions. In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.     

Does the National Emergency X-ray Utilization Study make a difference?

OBJECTIVE: To assess whether the introduction of the National Emergency X-ray Utilization Study guidelines in a UK emergency department reduced the number of patients having cervical spine radiographs and altered the accuracy of diagnosis of cervical spine injury. METHODS: This was a prospective, observational study. The number of patients with recent neck injury who had cervical spine radiographs taken was assessed for 3 months before and three months after the introduction of the National Emergency X-ray Utilization Study guidelines to an urban emergency department in the UK. The number of injuries missed by emergency department doctors during the two 3-month periods was also recorded. RESULTS: Prior to using the guidelines, 252 of 715 patients (35%) were X-rayed and when using the guidelines, 268 of 706 patients (38%) were X-rayed. No significant difference was observed between the rates of X-ray in the two groups (P=0.288). No injuries were missed by emergency department doctors either before or after the introduction of the guidelines. CONCLUSION: Introduction of the National Emergency X-ray Utilization Study guidelines to a UK emergency department did not reduce the number of patients having cervical spine radiographs after neck trauma and had no effect on the pick-up rate for cervical spine injuries.     

Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT

Several recent studies report the sensitivity of computed tomography (CT) to be far greater than that of traditional plain film radiographic studies for evaluation of cervical spine fractures and spinal cord pathology. Nevertheless, plain films continue to be the standard screening examination. CT is used only if fractures are demonstrated or suspected on plain film survey. Recently, three patients with significant head and neck trauma (all three patients had intracranial hemorrhage) had cervical spine evaluation by computed tomography and standard plain film views. CT demonstrated significant C1-C2 fractures, while plain films were completely normal in all three cases. Prospectively studying the next 50 patients with significant head trauma, we added a few more slices to the routine head scan protocol to cover the first three cervical vertebrae. This added very little time or cost to the procedure. The additional CT images demonstrated four upper cervical fractures that could not be seen on plain films, even in retrospect. Our findings suggest that routine inclusion of the upper cervical spine with head CT is appropriate in the evaluation of patients with significant head trauma as defined by intracranial hemorrhage or skull fracture.     

Spinal cord injury syndrome with motor sparing in the absence of all sensation

This paper describes the anatomic basis for the unusual presentation in a spinal cord injured subject of preservation of motor power in the absence of all sensation. The patient was examined at four hours, and daily thereafter, after a motorcycle accident in which he was thrown over the handle bars. He had trace ankle dorsi and plantar flexors, but light touch, pin, position, and vibratory sensation were absent below the level of C4 bilaterally. There was no physical evidence to differentiate whether he suffered a flexion or extension injury. Cervical spine films showed no evidence of fracture or dislocation, but anterior and posterior osteophytes involving C3 to C4, C4 to C5, and C5 to C6 were present. Magnetic resonance imaging showed evidence of cervical cord edema at C3 to C4 with possible hemorrhage and severe spinal stenosis at C3 to C4 and C4 to C5. This patient received a compression injury with resulting classic anterior spinal artery syndrome. Because of his spinal stenosis with a decreased anterior-posterior (AP) diameter of the canal, the posterior circulation was also compromised. The extensive pial anastomotic network provided relative sparing of the most peripheral components of the lateral corticospinal tracts. This case report demonstrates a unique clinical picture that cannot be anatomically classified by current American Spinal Injury Association (ASIA) standards as central cord syndrome. It can be explained by the lamination of the ascending and descending tracts in relation to the vascular supply of the cervical cord in conjunction with the narrowing of the AP diameter of the canal due to spinal stenosis.     

Clearance of cervical spines in adult trauma patients.

Clearing the cervical spine in adult trauma patients must be done cautiously and methodically. Practitioners must be able to recognize abnormalities not only in the patient's neurological examination but also on the radiographic views obtained. A missed cervical spine injury can be a significant and catastrophic error. Nurse practitioners in the emergency department, as well as those working on an inpatient trauma service, should be confident in their ability to manage the cervical spine in the adult trauma patient population.     

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.     

Spine problems in emergency department patients: Does every patient need an x-ray?

Two hundred adults with spine problems were evaluated by one examiner in a community hospital emergency department. A patient was considered to have a spine problem requiring evaluation if presenting with pain in the neck or back not obviously caused by a process outside of the spine (eg, back pain in a patient with renal colic); if there was known or suspected trauma to the neck or back; or if the clinical setting suggested spinal tumor, infection, metabolic bone disease, or ankylosing spondylitis. Of the 200 patients, 143 were studied by x-ray films. Six patients (6 of 143, or 4%) had x-ray abnormalities that mandated specific treatment. Fifty-two of the 57 patients not receiving x-ray studies were followed up at 2 months. Thirty-three of these patients (63%) had no x-ray studies interim and had improved greatly. Nineteen (37%) had been studied radiographically in the interim, but no abnormality requiring specific treatment was found in any patient. Emergency physicians should be aware that x-ray studies of the spine have low utility for patients whose histories and examinations are benign, that especially for women lumbosacral x-ray studies involve high gonadal radiation exposure, and that selected patients can be managed without x-ray studies and still be satisfied recipients of adequate medical care.     

Spinal Cord Injury With a Narrow Spinal Canal: Utilizing Torg’s Ratio Method of Analyzing Cervical Spine Radiographs

A 65-year-old inebriated mancrashed his car and presented with spinal shock and neurogenic shock from a cervical spinal cord injury without cervical spine fracture or dislocation. The lateral cervical spine radiography was initially read as normal, except for degenerative disk disease; however, Torg’s ratio method of analyzing cervical spinal canal sagittal width indicated the spinal canal was congenitally narrow. Magnetic resonance imaging confirmed this and showed bulging and herniation of multiple invertebral disks between C2 and C7. This case illustrates the value of using Torg’s ratio method of analyzing lateral cervical spine radiographs. Although Torg’s method has not been prospectively validated, it may be useful to identify patients at risk for cervical spinal cord injuries without fractures or dislocations. An abnormal Torg’s ratio may be the only clue to the fact that the patient is at higher risk of spinal cord injury when the patient’s history or examination is questionable because of head injury, drug intoxication, or therapeutic sedation and paralysis.     

颈椎前路减压并发脊髓损伤的高危因素回顾分析

目的探讨颈椎前路减压加重脊髓损伤的危险因素.方法对颈椎前路减压并发脊髓损伤加重11例回顾分析.结果所有病例颈椎椎管、椎体矢径比值均＜0.7,椎管横断面狭窄率在C4～5、C5～6间隙＞40%.结论一旦脊髓损伤加重,早期后路扩大半椎板减压是一种可选择的治疗方法.     

Anterior spinal cord syndrome after initiation of treatment with atenolol

Anterior spinal cord syndrome is a rare condition with a variety of precipitating factors. Patients typically complain of weakness or paralysis of the extremities, often accompanied by pain, but frequently without a history of trauma. A 48-year-old man presented to the emergency department complaining of neck pain and inability to move his legs in the absence of trauma. Several hours prior he had seen his private physician and was given a dose of atenolol for elevated blood pressure. He had not previously been on medications for hypertension. His neurological examination revealed bilateral paralysis of the lower extremities. In the upper extremities he had weakness and sensory loss at the level of C6. Rectal tone was decreased and without sensation. Cervical and thoracic spine magnetic resonance imaging showed spondylotic disc disease, with disc herniation at C6-7 causing severe spinal canal stenosis. Despite i.v. methylprednisolone, pressors, and a prolonged intensive care unit course, the patient was discharged 5 weeks later with continued neurological deficits. Anterior spinal cord syndrome results from compression of the anterior spinal artery and often occurs in the absence of traumatic injury. The recognition, management, and prognosis of this condition are discussed.     

Clinical algorithm for preventing missed diagnoses of occult cervical spine instability after acute trauma: A case report

BACKGROUNDMissed or delayed diagnosis of cervical spine instability after acute trauma can have catastrophic consequences for the patient, resulting in severe neurological impairment. Currently, however, there is no consensus on the optimal strategy for diagnosing occult cervical spine instability. Thus, we present a case of occult cervical spine instability and provide a clinical algorithm to aid physicians in diagnosing occult instability of the cervical spine.CASE SUMMARYA 57-year-old man presented with cervical spine pain and inability to stand following a serious fall from a height of 2 m. No obvious vertebral fracture or dislocation was found at the time on standard lateral X-ray, computed tomography, and magnetic resonance imaging (MRI). Subsequently, the initial surgical plan was unilateral open-door laminoplasty (C3-7) with alternative levels of centerpiece mini-plate fixation (C3, 5, and 7). However, the intraoperative C-arm fluoroscopic X-rays revealed significantly increased intervertebral space at C5-6, indicating instability at this level that was previously unrecognized on preoperative imaging. We finally performed lateral mass fixation and fusion at the C5-6 level. Looking back at the preoperative images, we found that the preoperative T2 MRI showed non-obvious high signal intensity at the C5-6 intervertebral disc and posterior interspinous ligament.CONCLUSIONMRI of cervical spine trauma patients should be carefully reviewed to detect disco-ligamentous injury, which will lead to further cervical spine instability. In patients with highly suspected cervical spine instability indicated on MRI, lateral X-ray under traction or after anesthesia and muscle relaxation needs to be performed to avoid missed diagnoses of occult cervical instability.     

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.     

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.     

A radiological review of cervical spine injuries from an accident and emergency department: has the ATLS made a difference?

The importance of visualizing the entire cervical spine on radiological examination in patients with cervical trauma is well known. A review of the cervical films of 98 patients attending an accident and emergency (A&E) department was undertaken in order to assess the adequacy of imaging. It was found that 33.7% of the films were not sufficient to exclude fracture or dislocation of the cervical spine. The number of patients with inadequate views was significantly reduced when an advanced trauma life support trained senior doctor was involved.     

Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients

INTRODUCTION: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. OBJECTIVE: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. DESIGN: Prospective analysis of case series from August 1, 1995 to August 31, 1998. SETTING: A university-based Level I trauma center. PATIENTS: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. RESULTS: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. CONCLUSION: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.     

Review article: Indications for thoracolumbar imaging in blunt trauma patients: A review of current literature

Thoracolumbar spine injury is a common complication of blunt multitrauma and up to one third of fractures are associated with spinal cord dysfunction. Delayed fracture diagnosis increases the risk of neurological complications. While validated screening guidelines exist for traumatic c‐spine injury equivalent guidelines for thoracolumbar screening are lacking. We conducted a literature review evaluating studies of thoracolumbar injury in trauma patients to generate indications for thoracolumbar imaging. We performed MEDLINE and Pubmed searches using MeSH terms “Wounds, Nonpenetrating”, “Spinal Fractures”, “Spinal Injuries” and “Diagnostic Errors”, MeSH/subheading terms “Thoracic Vertebrae/injuries” and “Lumbar Vertebrae/injuries” and keyword search terms “thoracolumbar fractures”, “thoracolumbar injuries”, “thoracolumbar trauma”, “missed diagnoses” and “delayed diagnoses”. Limits and inclusion criteria were defined prior to searching. We evaluated 16 articles; 5 prospective observational studies (1 cohort study) and 11 retrospective observational studies. Predictors of TL injury in prospective studies – high‐risk injury mechanism, distracting injury, impaired cognition, symptoms/signs of vertebral fracture and known cervical fracture – were defined and used to construct a decision algorithm, which in a total of 14189 trauma patients from all eligible studies recommended TL screening in 856(99.1%) of 864 patients with TL fractures and would probably have directed TL imaging in the remaining 8 patients. There is limited low level evidence guiding surveillance TL imaging in adult blunt trauma patients. Despite this, we propose and evaluate an algorithm with a high negative predictive value for TL fractures. This should be incorporated into spinal injury assessment protocols.     

MR imaging in cervical spine trauma

This article emphasizes the technical aspects of MR imaging in acute cervical trauma, and details the specific protocols used at the authors' institution. A systematic approach to the evaluation of MR images in the trauma setting is discussed, and the role of MR imaging in the characterization of spinal cord injury and identification of spinal instability is defined. Correlations between MR imaging findings and patient functionality and outcome are outlined, and various classifications of cervical spine injuries are reviewed.