Cervical Spine Injury

Aka: Cervical Spine Injury, C-Spine Injury, Spinal Trauma

1. Also See
   1. Pediatric Cervical Spine Injury
2. Epidemiology
   1. Significant spinal cord injuries per year: 11,500
      1. Patients who die of their injuries: 6500
      2. New quadriplegic and paraplegic patients: 500
   2. Prevalence of morbidity in United States
      1. Paralysis or paresis in United States: 170,000
   3. Mechanisms of spinal injury in United States
      1. Motor Vehicle Accident: 37%
      2. Violent crime: 26%
      3. Fall-related injury: 24%
      4. Sports injury: 7%
         1. Football
         2. Ice Hockey
   4. Underdiagnosed c-spine injuries are common in sports
      1. Feldick (2003) Clin Sports Med 22:445-65
3. Associated Conditions: Spinal Injuries
   1. Vertebral Dislocation
   2. Vertebral Fracture
      1. Cervical Vertebral Fracture: 50%
      2. Thoracic Vertebral Fracture: 16%
      3. Lumbosacral Vertebral Fracture: 33%
   3. Complete transection of the spinal cord
   4. Rare Injuries
      1. Spinal cord hemisection (Brown-Sequard Syndrome)
      2. Epidural Hematoma
   5. Associated injuries in sports (e.g. Football)
      1. Neuropraxia (Stinger, Burner)
      2. Cervical Ligamentous Instability
4. Evaluation: General
   1. Do not lose sight of primary ABCs in focus on spine
      1. See Acute stabilization below
      2. Hypoxia (start Oxygen)
      3. Hypotension
   2. Avoid unnecessary motion
      1. Assign one person responsible for immobilization
      2. See immobilization below
5. Evaluation: Acute Stabilization (Primary Survey)
   1. Airway
   2. Breathing
      1. High lesion: Ventilator dependent
      2. Lower lesion: Diaphragmatic breathing
   3. Circulation
      1. Spinal Shock
         1. Temporary flaccid paralysis
         2. Loss of segmental reflexes
      2. Spinal Neurogenic Shock
         1. Hypotension (Systolic Blood Pressure <90 mmHg)
         2. Paradoxical Bradycardia
            1. Heart Rate 60-80 despite low Blood Pressure
         3. Skin warm, dry, and with normal color
            1. Despite Hypotension
      3. Occult Hemorrhage
   4. Disability
   5. Exposure
   6. Perform secondary survey
      1. See Trauma Secondary Survey
6. Evaluation: Acute Stabilization: Additional Interventions
   1. Oxygen
   2. Two large bore IVs
   3. Nasogastric Tube
   4. Foley Catheter
7. Evaluation: Immobilization
   1. Indications
      1. Loss of consciousness with trauma
      2. Significant multi-system trauma or high energy injury
      3. Severe head or facial trauma
      4. Neurologic deficit
         1. Extremity Paresthesias or numbness
         2. Extremity weakness
      5. Neck Pain or Neck tenderness
      6. Multiple painful injuries (distracting injuries)
      7. Altered Level of Consciousness: Alcohol or drugs
      8. No history available
      9. Setting suggests traumatic injury
      10. References
          1. Stroh (2001) Ann Emerg Med 37:609-15
   2. Technique
      1. Immobilize spine completely
         1. Requires cervical collar and backboard
         2. Do not place on spine board until adequate support
            1. Proper log-roll requires 3-4 trained persons
            2. One person is assigned to stabilize the neck
      2. Do not move patient until complete immobilization
         1. Exception: Imminent environmental danger
      3. Special circumstances: Football injury
         1. Immobilize with helmet and pads in place
            1. Sideline removal excessively moves cervical spine
         2. Leave both helmet and Shoulder pads in place
            1. C-spine is malaligned if one of the 2 is removed
            2. Face mask may be removed if face access is needed
         3. References
            1. Gastel (1998) Ann Emerg Med 32:411-7
            2. Palumbo (1996) Am J Sports Med 24:446-53
8. Evaluation: Cervical Spine
   1. General
      1. Immobilize the spine and image if any concerns
      2. Requires stepwise approach
         1. If one step is abnormal, halt exam until imaging
         2. Primary, secondary trauma survey takes precedence
   2. Start without moving head or neck
      1. Assess peripheral strength and sensation
      2. Palpate the neck
         1. Focal Vertebral tenderness
         2. Asymmetric spasm
      3. Evaluate isometric neck strength
   3. Provocative mameuvers
      1. Evaluate c-spine active range of motion
      2. Spurling Test (axial compression)
   4. Interpretation
      1. All Steps Negative: Patient may be moved
      2. Any Step Positive: Complete spine immobilization
         1. Transport to emergency department for imaging
         2. Re-evaluate primary and secondary survey above
9. Imaging
   1. General Rules
      1. When in doubt leave cervical collar on
      2. XRay entire spine when Vertebral Fracture found
         1. Incidence of more than one spinal Fracture: 10-15%
   2. Pre-XRay
      1. Assistant stabilizes neck with collar removed
      2. Palpate for tenderness, swelling, or instability
   3. Cases where a C-Spine XRay is not needed
      1. Patient is awake, alert, and sober and
      2. Patient is neurologically intact and
      3. Patient has no Neck Pain
   4. C-Spine CT Indications
      1. C-Spine XRay poorly shows Vertebrae (esp. C7-T1)
      2. C-Spine XRay abnormal
      3. C-Spine XRay negative but symptoms suggest injury
   5. Post-XRay (if negative or not indicated)
      1. Remove cervical collar
      2. Patient demonstrates Active range of motion only!
         1. Nod yes and no
         2. Touch ears to Shoulder
         3. Rotation to sides
      3. If no discomfort, then can leave off cervical collar
   6. Imaging Modalities
      1. Cervical Spine XRay (see above)
      2. Consider C-Spine CT (see above)
      3. Other imaging in trauma
         1. Chest XRay
         2. Abdominal XRay
         3. Pelvic XRay
10. Management
    1. Consult Neurosurgery or Orthopedics
    2. Methylprednisolone (Very high dose)
       1. Controversial - initial studies showing efficacy
          1. Local expert consultation is recommended
       2. Bolus: 30 mg/kg over 15 minutes and wait 45 minutes
       3. Maintenance: 5.4 mg/kg/h for 23 hours IV
       4. Significantly improves motor and sensory outcomes
          1. Without significant complication
          2. Sensory improvement only if given in first 8 hours
11. Resources
    1. C-Spine Clearance (Regions Trauma)
       1. http://www.youtube.com/watch?v=NhjF9kDOcjE
12. References
    1. Cantu (2000) Semin Neurol 20(2):173-8
    2. Ghiselli (2003) Clin Sports Med 22:445-65
    3. Haight (2001) Physician SportsMed 29:45-62
    4. Whiteside (2006) Am Fam Physician 74(8):1357-62