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Degenerative changes of the C-spine may be confused with acute traumatic change, and osteopenia may limit fracture visualization on x-ray-CT more accurately makes this differentiation.
Degenerative disease and osteopenia increases the risk of upper cervical spine injuries despite low-velocity trauma (3)[B].
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Pediatric Considerations
Consider SCI without radiographic abnormality (SCIWORA): high incidence at <9 years and accounts for up to 50% of all pediatric cervical spine injuries. MRI may help detect the injury.
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TREATMENT
GENERAL MEASURES
- Whiplash, WAD
- Limited or no benefit to cervical collar; if needed, use for <72 hours (8)[C]
- No advantage to engaging early multiprofessional intervention (e.g., pain management and psychology) (9)[C]
- No evidence of different outcomes with physical therapy versus passive (immobilization, rest) treatment. Advance activity levels as tolerated.
- Lack of clear effective treatments in current medical literature in absence of fracture (4)[B]
- Fractures
- Stability determined by imaging; decompression, and stabilization are indicated in
- Incomplete SCIs with spinal canal compromise
- Clinical deterioration or failure to improve despite conservative management
- Hangman fracture: traumatic spondylolisthesis of C2 with bilateral fractures through C2 pedicles, often with anterior subluxation of C2 over C3; can be unstable:
- Managed with halo vest immobilization for 12 weeks until flexion/extension films normalize
- Odontoid fractures: treated according to type:
- I: through apex; usually stable; external immobilization with a cervical collar (less often halo vest) for up to 12 weeks
- II: most common, at base of dens, usually unstable; nonunion rates of up to 67% with halo immobilization alone, especially with dens displacement >6 mm or age >50 years
- III: through C2 body, usually stable; immobilization in halo or cervical collar for 12-20 weeks
- Hyperextension teardrop fractures
- If stable, rigid collar or cervicothoracic brace for 8 to 14 weeks
- If unstable, halo brace for up to 3 months
- CCS: neck immobilization with cervical collar, physical therapy/occupational therapy (PT/OT)
- Cervical strain: No difference in outcomes with active (PT) versus passive (immobilization, rest) treatment; may use soft cervical collar for 10 days for symptomatic relief, then mobilize and increase activity as tolerated.
- Lack of clear effective treatments in current medical literature in absence of fracture (4)[B]
MEDICATION
- Fractures: pain control as needed with analgesics
- CCS: Within 8 hours of injury, consider methylprednisolone 30 mg/kg IV over 15 minutes, then continuous infusion 5.4 mg/kg/hr IV for 23 hours. Further improvement in motor function recovery may be seen if infusion is continued for 48 hours, especially if initial bolus administration is delayed by 3 to 8 hours after injury (10)[A].
- BCVI: Anticoagulation with IV heparin, followed by warfarin therapy for 3 to 6 months, then long-term antiplatelet therapy is a common practice. However, an antiplatelet agent is used as the sole initial therapy in patients with contraindications to anticoagulation. To date, no randomized controlled trials compare the efficacy of antiplatelet versus anticoagulant therapy, so evidence-based recommendations are unavailable.
- Cervical strain: muscle relaxants, acetaminophen/NSAIDs ▒ opiate analgesics are commonly used.
ISSUES FOR REFERRAL
- When cervical spine injury is suspected, the patient should be immobilized and sent to the ED.
- Emergent consultation from a spine surgeon for any concern for unstable fracture or SCI
SURGERY/OTHER PROCEDURES
- Fractures
- Hangman fracture: surgical fixation for excessive angulation or subluxation, disruption of intervertebral disc space, or failure to obtain alignment with external orthosis
- Odontoid fractures
- Type II: Early surgical stabilization is recommended in setting of age >50 years, dens displacement >5 mm, and specific fracture patterns.
- Type III: Surgical intervention is often reserved for cases of nonunion/malunion after trial of external immobilization.
- CCS: Surgical decompression/fixation is indicated in setting of unstable injury, herniated disc, or when neurologic function deteriorates.
- BCVI: Surgical and/or angiographic intervention may be required if there is evidence of pseudoaneurysm, total occlusion, or transection of the vessel.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Varies by injury; clinical judgment, imaging findings, concomitant injuries, and need for operative intervention
- Advanced Trauma Life Support protocol with backboard and collar
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Patients with known injuries will often be followed with serial imaging under the care of a specialist. á
PATIENT EDUCATION
For patient instruction on prevention: ThinkFirst Foundation: http://www.thinkfirst.org á
PROGNOSIS
- Presenting neurologic status is the most important.
- Fractures
- Hangman fracture: 93-100% fusion rate after 8 to 14 weeks external immobilization
- Odontoid fracture, fusion rate by type: type I ~100% with external immobilization alone; type II nonunion rates of up to 67% with halo immobilization alone, especially with dens displacement >6 mm or age >50 years; type III, 85% with external immobilization, 100% with surgical fixation
- BCVI: With early diagnosis and initiation of antithrombotic therapy, patients may have fewer neurologic sequelae.
- CCS
- Spontaneous recovery of motor function in >50% of cases over several weeks, with younger patients more likely to regain function
- Leg, bowel, and bladder functions return first, followed by upper extremities.
- WAD: Prognostic factors for development of late whiplash syndrome (>6 months of symptoms affecting normal activity) include increased initial pain intensity, pain-related disability, and cold hyperalgesia (8).
COMPLICATIONS
- Fractures: instability or malunion/nonunion necessitating second operation, reactions, and infection related to orthosis
- BCVI: embolic ischemic events and pseudoaneurysm formation
REFERENCES
11 National Spinal Cord Injury Statistical Center. Spinal Cord Injury: Facts and Figures at a Glance. Birmingham, AL: National Spinal Cord Injury Statistical Center; 2015.22 Oliver áM, Inaba áK, Tang áA, et al. The changing epidemiology of spinal trauma: a 13-year review from a Level I trauma centre. Injury. 2012;43(8):1296-1300.33 Quinlan áKP, Annest áJL, Myers áB, et al. Neck strains and sprains among motor vehicle occupants-United States, 2000. Accid Anal Prev. 2004;36(1):21-27.44 Wenzel áHG, Mykletun áA, Nilsen áTI. Symptom profile of persons self-reporting whiplash: a Norwegian population-based study (HUNT 2). Eur Spine J. 2009;18(9):1363-1370.55 Walton áDM, Pretty áJ, MacDermid áJC, et al. Risk factors for persistent problems following whiplash injury: results of a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2009;39(5):334-350.66 Stiell áIG, Clement áCM, McKnight áRD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518.77 Sierink áJC, van Lieshout áWA, Beenen áLF, et al. Systematic review of flexion/extension radiography of the cervical spine in trauma patients. Eur J Radiol. 2013;82(6):974-981.88 Rasker áJJ, Wolfe áF, McLean et al.'s paper, "Incidence and predictors of neck and widespread pain after motor vehicle collision among U.S. litigants and nonlitigants"Ł. Pain. 2014;155(7):1416.99 Jull áG, Kenardy áJ, Hendrikz áJ, et al. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain. 2013;154(9):1798-1806.1010 Bracken áMB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012;(1):CD001046.
ADDITIONAL READING
- Franz áRW, Willette áPA, Wood áMJ, et al. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg. 2012;214(3):313-327.
- Liu áBC, Ivers áR, Norton áR, et al. Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev. 2008;(1):CD004333.
- Shears áE, Armitstead áCP. Surgical versus conservative management for odontoid fractures. Cochrane Database Syst Rev. 2008;(4):CD005078.
- Watanabe áM, Sakai áD, Yamamoto áY, et al. Upper cervical spine injuries: age-specific clinical features. J Orthop Sci. 2010;15(4):485-492.
SEE ALSO
Spine Injury: Cervical á
CODES
ICD10
- S13.4XXA Sprain of ligaments of cervical spine, initial encounter
- S13.101A Dislocation of unspecified cervical vertebrae, init encntr
- S14.109A Unsp injury at unsp level of cervical spinal cord, init
- S13.4XXA Sprain of ligaments of cervical spine, initial encounter
- S13.101A Dislocation of unspecified cervical vertebrae, init encntr
- S14.109A Unsp injury at unsp level of cervical spinal cord, init
- S13.20XA Dislocation of unspecified parts of neck, initial encounter
- S12.100A Unsp disp fx of second cervical vertebra, init for clos fx
- S12.401A Unsp nondisp fx of fifth cervical vertebra, init for clos fx
- S12.091A Oth nondisp fx of first cervical vertebra, init for clos fx
- S12.390A Oth disp fx of fourth cervical vertebra, init for clos fx
- S12.691A Oth nondisp fx of seventh cervical vertebra, init
- S14.139A Ant cord syndrome at unsp level of cerv spinal cord, init
- S12.500A Unsp disp fx of sixth cervical vertebra, init for clos fx
- S12.000A Unsp disp fx of first cervical vertebra, init for clos fx
- S12.600A Unsp disp fx of seventh cervical vertebra, init for clos fx
- S13.8XXA Sprain of joints and ligaments of oth prt neck, init encntr
- S12.090A Oth disp fx of first cervical vertebra, init for clos fx
- S12.300A Unsp disp fx of fourth cervical vertebra, init for clos fx
- S12.391A Oth nondisp fx of fourth cervical vertebra, init for clos fx
- S12.301A Unsp nondisp fx of fourth cervical vertebra, init
- S14.2XXA Injury of nerve root of cervical spine, initial encounter
- S14.9XXA Injury of unspecified nerves of neck, initial encounter
- S14.4XXA Injury of peripheral nerves of neck, initial encounter
- S14.8XXA Injury of other specified nerves of neck, initial encounter
- S12.101A Unsp nondisp fx of second cervical vertebra, init
- S12.601A Unsp nondisp fx of seventh cervical vertebra, init
- S14.129A Central cord synd at unsp level of cerv spinal cord, init
- S12.590A Oth disp fx of sixth cervical vertebra, init for clos fx
- S12.291A Oth nondisp fx of third cervical vertebra, init for clos fx
- S12.201A Unsp nondisp fx of third cervical vertebra, init for clos fx
- S12.400A Unsp disp fx of fifth cervical vertebra, init for clos fx
- S14.119A Complete lesion at unsp level of cervical spinal cord, init
- S12.591A Oth nondisp fx of sixth cervical vertebra, init for clos fx
- S12.501A Unsp nondisp fx of sixth cervical vertebra, init for clos fx
- S14.0XXA Concussion and edema of cervical spinal cord, init encntr
- S14.5XXA Injury of cervical sympathetic nerves, initial encounter
- S12.690A Oth disp fx of seventh cervical vertebra, init for clos fx
- S12.490A Oth disp fx of fifth cervical vertebra, init for clos fx
- S12.001A Unsp nondisp fx of first cervical vertebra, init for clos fx
- S12.491A Oth nondisp fx of fifth cervical vertebra, init for clos fx
- S13.29XA Dislocation of other parts of neck, initial encounter
- S12.191A Oth nondisp fx of second cervical vertebra, init for clos fx
- S12.200A Unsp disp fx of third cervical vertebra, init for clos fx
- S12.290A Oth disp fx of third cervical vertebra, init for clos fx
- S14.159A Oth incmpl lesion at unsp level of cerv spinal cord, init
- S13.9XXA Sprain of joints and ligaments of unsp parts of neck, init
ICD9
- 847.0 Sprain of neck
- 805.00 Closed fracture of cervical vertebra, unspecified level
- 952.00 C1-C4 level with unspecified spinal cord injury
- 839.00 Closed dislocation, cervical vertebra, unspecified
- 952.08 C5-C7 level with central cord syndrome
- 952.03 C1-C4 level with central cord syndrome
SNOMED
- 262522002 Injury of cervical spine
- 39848009 Whiplash injury to neck
- 269062008 Closed fracture of cervical spine
- 111648001 Closed dislocation of cervical vertebra
- 282787000 central cord syndrome (disorder)
- 405758006 Central cervical cord injury, without spinal bony injury, C5-7
- 405766002 Unspecified cervical spinal cord injury, without spinal bone injury, C1-4
CLINICAL PEARLS
- Follow NEXUS or Canadian Cervical Spine rules on every patient with potential neck injury to determine imaging needs, but they do not supercede clinical judgment!
- Inquire about preexisting cervical spine conditions, especially in the elderly, as they may increase risk of injury or change radiographic interpretation.
- Suspect SCI until exam and imaging suggest otherwise.
- Consider BCVI when neurologic deficits are inconsistent with level of known injury or significant mechanism exists.