Basics
Description
- 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 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
- Flexion/rotation injuries:
- Unilateral facet dislocation "locked " vertebra: Stable injury
- Rotary 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 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
- 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 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 ˘ ĵ20%.
- Sporting accidents account for 15%.
- Minor trauma in patients with severe arthritis may result in cervical injuries.
- Penetrating trauma
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 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
- 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)
History
- Obtain history of head or neck trauma.
- Identify history of ankylosing spondylitis or other brittle bone diseases.
- Specific symptoms:
- Neck pain
- Weakness
- Numbness or tingling
- Stinger
Physical Exam
- 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
Complete physical exam and radiographic imaging if clinically indicated
Diagnosis Tests & Interpretation
Imaging
- 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.
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 alertness
- Are not intoxicated
- Have no tenderness in the posterior midline cervical spine
- Have no distracting painful injury
- Have 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.
Medication
High-dose steroid protocol for patients with neurologic deficits due to fractures or dislocations.
First Line
Methylprednisolone: 30 mg/kg IV bolus then 5.4 mg/kg/h over the next 23 hr; begin within 8 hr of injury
Follow-Up
Disposition
Admission Criteria
- 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.
Discharge Criteria
- Patients with acute cervical strain "whiplash "
- Musculoskeletal injuries that are associated with mild to moderate pain, no neurologic deficit, and normal radiographs
Issues for Referral
- 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
Return to ED for evaluation if pain increases or numbness, weakness, stingers, or other clinical changes develop.
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