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Spine Injury: Cervical, Adult, Emergency Medicine

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Spine Injury: Cervical, Adult, Emergency Medicine

Basics

Description

Complete physical exam and radiographic imaging if clinically indicated

High-dose steroid protocol for patients with neurologic deficits due to fractures or dislocations.

Methylprednisolone: 30 mg/kg IV bolus then 5.4 mg/kg/h over the next 23 hr; begin within 8 hr of injury

Return to ED for evaluation if pain increases or numbness, weakness, stingers, or other clinical changes develop.

  • Injury to the neck that results in injury to the spinal cord, cervical spine, or ligaments supporting the cervical spine
  • May have more than 1 mechanism concurrently
  • Flexion injuries:Simple wedge fracture: Usually a stable fractureAnterior subluxation: Disruption of the posterior ligament complex without bony injury; potentially unstable injuryClay shovelers fracture: Avulsion fracture of the spinous process of C7, C6, or T1; stable fractureFlexion teardrop fracture: Extremely unstable fracture; may be associated with acute anterior cervical cord syndromeAtlanto-occipital dislocation: Unstable injuryBilateral facet dislocation: Can occur from C2 " “C7; unstable injury
  • Flexion/rotation injuries:Unilateral facet dislocation "locked "  vertebra: Stable injuryRotary atlantoaxial dislocation: Unstable injury
  • Extension injuries:Extension teardrop fracture: An avulsion fracture of the anteroinferior corner of the involved vertebral body; unstable in extension and stable in flexionPosterior arch of C1 fracture: Arch is compressed between the occiput and the spinous process of the axis during hyperextension; unstable fractureAvulsion fracture of the anterior arch of the atlas: Horizontal fracture of C1 and prevertebral soft tissue swelling on the lateral C-spineHangman fracture: Traumatic spondylolisthesis of the axis involving the pedicles of C2; unstable fractureHyperextension dislocation: Described as the syndrome of the paralyzed patient with a radiographically normal-appearing C-spine
  • Extension " “rotation injury:Pillar fracture: Generally stable fracture
  • Vertical compression (axial loading) injuries:Jefferson fracture: Burst fracture of both the anterior and posterior arches of C1; extremely unstable fractureBurst fracture: A comminuted fracture of the vertebral body with variable retropulsion of the posterior body fragments into the spinal canal
  • Simple wedge fracture: Usually a stable fracture
  • Anterior subluxation: Disruption of the posterior ligament complex without bony injury; potentially unstable injury
  • Clay shovelers fracture: Avulsion fracture of the spinous process of C7, C6, or T1; stable fracture
  • Flexion teardrop fracture: Extremely unstable fracture; may be associated with acute anterior cervical cord syndrome
  • Atlanto-occipital dislocation: Unstable injury
  • Bilateral facet dislocation: Can occur from C2 " “C7; unstable injury
  • Unilateral facet dislocation "locked "  vertebra: Stable injury
  • Rotary atlantoaxial dislocation: Unstable injury
  • Extension teardrop fracture: An avulsion fracture of the anteroinferior corner of the involved vertebral body; unstable in extension and stable in flexion
  • Posterior arch of C1 fracture: Arch is compressed between the occiput and the spinous process of the axis during hyperextension; unstable fracture
  • Avulsion fracture of the anterior arch of the atlas: Horizontal fracture of C1 and prevertebral soft tissue swelling on the lateral C-spine
  • Hangman fracture: Traumatic spondylolisthesis of the axis involving the pedicles of C2; unstable fracture
  • Hyperextension dislocation: Described as the syndrome of the paralyzed patient with a radiographically normal-appearing C-spine
  • Pillar fracture: Generally stable fracture
  • Jefferson fracture: Burst fracture of both the anterior and posterior arches of C1; extremely unstable fracture
  • Burst fracture: A comminuted fracture of the vertebral body with variable retropulsion of the posterior body fragments into the spinal canal

Etiology

  • Blunt trauma is the major cause of neck injuries:Automobile accidents account for >50%.Falls account for ˘ ˆ ĵ20%.Sporting accidents account for 15%.Minor trauma in patients with severe arthritis may result in cervical injuries.
  • Penetrating trauma
  • Automobile accidents account for >50%.
  • Falls account for ˘ ˆ ĵ20%.
  • Sporting accidents account for 15%.
  • Minor trauma in patients with severe arthritis may result in cervical injuries.

Diagnosis

Signs and Symptoms

  • Neck pain, tenderness on palpation
  • Numbness, weakness, paresthesias of upper or lower extremities
  • Always assume a C-spine injury in any patient with:Altered mental status (unconscious, intoxicated, on drugs, or hypoxic) following trauma or if events are unknown but trauma is likelyInability to communicate (mentally retarded, language barrier, or intubated) following trauma or if events are unknown but trauma is likelyDistracting injuryBlunt trauma involving head or neck
  • Incomplete cervical cord syndromes (see separate chapter):Brown-Sequard syndrome: Hemisection of cord from penetrating injury (ipsilateral motor paralysis/contralateral sensory hypesthesia)Anterior cord syndrome: Cervical flexion injury causing cord contusion (paralysis/hypesthesia with sparing of position/touch/vibratory sensations)Central cord syndrome: Patients with cervical degenerative arthritis with forced hyperflexion (deficits greater in upper extremities relative to lower extremities)
  • Altered mental status (unconscious, intoxicated, on drugs, or hypoxic) following trauma or if events are unknown but trauma is likely
  • Inability to communicate (mentally retarded, language barrier, or intubated) following trauma or if events are unknown but trauma is likely
  • Distracting injury
  • Blunt trauma involving head or neck
  • Brown-Sequard syndrome: Hemisection of cord from penetrating injury (ipsilateral motor paralysis/contralateral sensory hypesthesia)
  • Anterior cord syndrome: Cervical flexion injury causing cord contusion (paralysis/hypesthesia with sparing of position/touch/vibratory sensations)
  • Central cord syndrome: Patients with cervical degenerative arthritis with forced hyperflexion (deficits greater in upper extremities relative to lower extremities)
  • Obtain history of head or neck trauma.
  • Identify history of ankylosing spondylitis or other brittle bone diseases.
  • Specific symptoms:Neck painWeaknessNumbness or tinglingStinger
  • Neck pain
  • Weakness
  • Numbness or tingling
  • Stinger
  • Direct visualization of neck for bruising or deformity
  • Palpation over the spinous processes
  • Motor, sensory, and reflex exam of upper and lower extremities

Essential Workup

Diagnosis Tests & Interpretation

  • Standard radiographs include 3 separate views: Lateral, anteroposterior, and open-mouth views of the odontoid while still immobilized.
  • Lateral radiograph must include C1 " “T1; a swimmers view may be necessary to view lower levels.
  • Supine oblique views may help in identifying subtle rotational injuries.
  • CT should be obtained when C-spine fractures, dislocations, or soft tissue swelling is seen on plain films or for unexplained neck pain/neurologic deficit with normal radiograph.
  • CT (helical) is considered a good alternative to plain films and is favored in certain patients, including intubated victims of blunt trauma.
  • Flexion " “extension views may be needed to evaluate for dynamic ligamentous injuries if static radiographs are negative and the alert, cooperative patient still complains of pain.
  • MRI has become a valuable tool in evaluating patients with neurologic deficits, including spinal cord injury without radiographic abnormality.

Differential Diagnosis

  • Cervical muscle strain injury (whiplash)
  • C-spine dislocation
  • Cervical fracture dislocation
  • Complex or simple cervical fractures

Treatment

Pre-Hospital

  • If C-spine injury suspected, immobilize with a hard collar, neck pads, and backboard.
  • Immobilized patients require constant observation in case of vomiting.
  • Immobilize C-spine in patients with penetrating neck wounds only if a neurologic deficit is present.
  • If the weapon is still embedded, immobilize the neck to avoid further injury and do not remove the impaling object unless it directly impedes breathing.

Initial Stabilization/Therapy

  • Immobilize the spine using a rigid collar and backboard plus tape/towels or lightweight foam pads along the side of the neck.
  • Stabilize the airway, establish IV access, and support circulation:Preferred method is careful orotracheal rapid sequence intubation with inline spinal immobilization.Fiberoptic intubation set should be at the bedside and considered if available.
  • Preferred method is careful orotracheal rapid sequence intubation with inline spinal immobilization.
  • Fiberoptic intubation set should be at the bedside and considered if available.

Ed Treatment/Procedures

  • Assess patient for other injuries; remember that the abdominal exam in a C-spine " “injured patient is unreliable and further objective testing is indicated.
  • Patients with ankylosing spondylitis or other brittle bone diseases are at risk for fracture and cord injury with even trivial mechanisms.
  • Patients may be clinically cleared and do not require C-spine radiograph (based on NEXUS) if they:Have no altered level of alertnessAre not intoxicatedHave no tenderness in the posterior midline cervical spineHave no distracting painful injuryHave no focal neurologic deficit
  • If a neurologic deficit is present, consult neurosurgery.
  • If the radiographs or CT is abnormal, consult neurosurgery or the orthopedic spine service.
  • If the radiographs are normal but the alert and cooperative patient is having severe neck pain, consider flexion " “extension films, CT, or MRI; if abnormal, consult neurosurgery.
  • Have no altered level of alertness
  • Are not intoxicated
  • Have no tenderness in the posterior midline cervical spine
  • Have no distracting painful injury
  • Have no focal neurologic deficit

Medication

Follow-Up

Disposition

  • C-spine fractures or dislocations associated with a neurologic deficit or any unstable fracture or dislocation should be admitted to the ICU or a monitored setting.
  • Stable C-spine fractures or dislocations should be admitted.
  • Isolated spinous process fractures that are not associated with any neurologic deficit or instability on plain films.
  • Simple cervical wedge fractures with no neurologic deficit.
  • Patients with acute cervical strain "whiplash " 
  • Musculoskeletal injuries that are associated with mild to moderate pain, no neurologic deficit, and normal radiographs
  • The patient with a radiographically normal C-spine but continuous pain may be discharged with a hard collar and appropriate orthopedic follow-up.
  • Patients with persistent symptoms from stinger should be followed up in 3 " “4 wk for EMG.

Followup Recommendations

Pearls and Pitfalls

  • Trivial neck injuries in patient with ankylosing spondylitis or other brittle bone diseases may result in significant injuries.
  • All the NEXUS criteria need to be applied to safely rule out a clinically significant spinal fracture without imaging.

Additional Reading

  • Committee on Trauma. Cervical Spine: Advanced Trauma Life Support. 8th ed. Chicago: American College of Surgeons; 2008.
  • Hoffman ‚ JR, Mower ‚ WR, Wolfson ‚ AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94 " “99.
  • Richards ‚ PJ. Cervical spine clearance: A review. Injury. 2005;36:248 " “269.
  • Sama ‚ AA, Keenan ‚ MAE. Cervical spine injuries in sports: Emedicine. Available at http://emedicine.medscape.com/article/1264627-overview.
  • Van Goethem ‚ JW, Maes ‚ M, Ozsarlak ‚ O, et al. Imaging in spinal trauma. Eur Radiol. 2005;15:582 " “590.

See Also (Topic, Algorithm, Electronic Media Element)

  • Ankylosing Spondylitis
  • Head Trauma, Blunt
  • Spinal Cord Syndromes

Codes

ICD9

  • 805.00 Closed fracture of cervical vertebra, unspecified level
  • 839.00 Closed dislocation, cervical vertebra, unspecified
  • 959.09 Injury of face and neck
  • 952.00 C1-C4 level with unspecified spinal cord injury
  • 839.01 Closed dislocation, first cervical vertebra
  • 847.0 Sprain of neck

ICD10

  • S12.9XXA Fracture of neck, unspecified, initial encounter
  • S13.101A Dislocation of unspecified cervical vertebrae, init encntr
  • S19.9XXA Unspecified injury of neck, initial encounter
  • S14.109A Unsp injury at unsp level of cervical spinal cord, init
  • S13.121A Dislocation of C1/C2 cervical vertebrae, initial encounter
  • S13.4XXA Sprain of ligaments of cervical spine, initial encounter

SNOMED

  • 262522002 Injury of cervical spine
  • 269062008 Closed fracture of cervical spine
  • 263040004 Subluxation of joint of cervical spine (disorder)
  • 405754008 cervical spinal cord injury (disorder)
  • 207904007 Closed fracture cervical vertebra, wedge (disorder)
  • 209557005 neck sprain (disorder)
  • 263014005 Dislocation of atlanto-occipital joint (disorder)
  • 39848009 Whiplash injury to neck