Cervical Spine Injuries: Part II
Cervical Spine Injuries: Part II
Authors:
Karma B. Warren, MD, Assistant Clinical Professor of Emergency Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ.
Tiffany Murano, MD, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ.
Janine D. Grayson, MD, MPH, Assistant Professor, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ.
Peer Reviewer:
Jonathan Glauser, MD, FACEP, Associate Professor of Emergency Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH.
This issue is the second of a two-part discussion of cervical spine injuries. As my introduction to this issue, please allow me to start far afield from this subject; I promise I will tie it back to the topic at hand. I just read a very interesting article from the May 29 issue of the British Medical Journal entitled "Preventing Overdiagnosis: How to Stop Harming the Healthy." The title and the article reminded me that while we have increased our knowledge of many potentially life-threatening disorders seen in the ED, our zeal to detect every last one and avoid missing any has led to our increasing use of laboratory and imaging studies. We are now learning there is a cost to pay for this: both monetary and harm to patients from increased radiation exposure or overzealous treatment. Emergency medicine, like the whole of allopathic medicine, has embraced the use of CT scanning to detect disease and injury. Especially with cervical spine fractures, CT scanning is superior to plain radiographs and, in many hospitals, CT has become the primary imaging modality. Despite the increased awareness of the risk of cancer from medical radiation, CT will continue to be extensively used because an acceptable "miss-rate" for cervical spine fractures has not been defined, and the medical liability system is intolerant for missing a "broken neck." I don't have an easy answer to the call to reduce CT use in the ED. Maybe it is questioning if a stable patient involved in a motor vehicle crash who arrives with a hard cervical collar needs a CT right out of the box? Can we trust our clinical judgment more? Should we use clinical decision tools more? What happened to "watchful waiting?"
This two-part series has discussed cervical spine fractures in detail. Emergency physicians need to have knowledge about these injuries because we are often the ones who initially evaluate these patients, order the imaging studies, identify the fracture, and consult the specialist. Prior to CT and teleradiography, the emergency physician also had to be good at interpreting plain radiographs. Now with CT, identifying subtle changes on plain radiographs is not as useful as it once was. The challenge now is deciding who gets imaging and who does not. The indications for cervical spine imaging and the use of clinical decision tools are discussed in the latter portion of this issue. As you read through that section, think about your own practice and consider the imaging studies you order on patients with potential cervical spine injuries. And if you have a different opinion or thoughts, I'd like to hear from you.
J. Stephan Stapczynski, MD, Editor
Flexion Teardrop Fracture
The flexion teardrop fracture is one of the most severe fractures of the cervical spine. The fracture results from a combination of flexion and major compressive forces. (See Figure 1.) Common incidents include motor vehicle crashes and diving accidents. The most common area affected in adults occurs at the C5-C6 level.1 The fracture is unstable, as it involves not only the anterior ligamentous column but also the disruption of the middle ligamentous complex. Teardrop fractures may involve either an anteroinferior or a posteroinferior fragment. Neurological damage can result from failure of the middle ligamentous column, thus allowing posteroinferior bone fragments to enter into the spinal canal with spinal cord injury.2 When the middle ligamentous column is intact in the presence of a teardrop fracture, there are fewer neurologic injuries.2 Complications stem from an associated anterior cord syndrome, including quadriplegia and loss of sensations of pain, temperature, and touch.
Figure 1: Illustration of Flexion Teardrop Fracture
Reproduced with permission from the website http://www.radiologyassistant.nl
Diagnostic Evaluation. Lateral cervical radiographs will show a fracture fragment off the anteroinferior (see Figure 2) or posteroinferior portion of the vertebral body. CT scans are necessary to determine the presence of the sagittal vertebral body fracture and assess the integrity of the posterior neural arch.2 CT scans have the added benefit of examining adjacent levels for combined injuries that may be overlooked on plain films. (See Figure 2.)
Figure 2: Flexion Teardrop Fracture of C4
A) Lateral view plain film of a flexion teardrop fracture of C4. B) CT scan (sagittal view) of this same injury.
Reproduced with permission from Hughey, MEd, "Operational Medicine, Health Care in Military Settings," NAVMEDPUB 5139. Bureau of Medicine and Surgery, Department of the Navy, Washington, DC, 2001
Management. Surgical decompression is necessary, as this is a true emergency. The goal is to obtain a "free cord in a stable spine" by releasing the canal and stabilizing the spine. Complete tetraplegics and hemodynamic and respiratory instabilities may preclude the pure operative management.3
Facet Dislocations
Facet dislocations are caused by flexion injuries either with or without rotation. Three-fourths of these injuries occur in the lower spine at C3-C7, with more than 15% of these occurring at the C7-T1 junction.4,5 These dislocations can be either unilateral or bilateral.
Unilateral Facet Dislocation. Unilateral facet dislocation occurs when there is simultaneous flexion and rotation around one of the facet joints. (See Figure 3.) The injury involves forward rotation of one side of the vertebra about the contralateral facet joint. The forward translation of superior vertebral body over that of the inferior body can result in about a 25% displacement of the body diameter as viewed from the side. These forces cause the superior facet to move forward and tip over the inferior facet and lock into the intervertebral foramen anterior to the inferior facet of the joint. Although the posterior ligaments are disrupted, this is considered a stable injury because of the mechanical stability of the locked structure. Pain is at the level of the injury and is often associated with mono-radiculopathy. Patients may have associated torticollis with axial rotation to the contralateral side and lateral bending to the injured side.
Figure 3: Illustration of Unilateral Facet Dislocation
Reproduced with permission from the website http://www.radiologyassistant.nl
Diagnostic Evaluation. Unilateral facet dislocation can be an easily missed injury on plain radiographs because displacement of the vertebral bodies may be subtle.
Figure 4: Unilateral Locked Facets
A) Lateral view plain film demonstrates a unilateral facet dislocation of C6 on C7. B) The same film magnified; the outline shows the overlap of the lateral masses producing the "bow tie" sign.
Reproduced with permission from Hughey, MEd, "Operational Medicine, Health Care in Military Settings," NAVMEDPUB 5139. Bureau of Medicine and Surgery, Department of the Navy, Washington, DC, 2001
Lateral views reveal mild anterior subluxation of the vertebral body above with associated soft-tissue swelling anteriorly: (see Figure 4A)
Vertebral body displaced anteriorly (< 50% AP diameter);
Decreased overlap of articular processes relative to facet joint above;
Two lateral masses of dislocated vertebra will overlap, producing the "bow tie" sign (see Figure 4B).
AP views may reveal rotation at the level of the unilateral facet dislocation, with the spinous process of the inferior vertebra pointing toward the locked side. Oblique views reveal anteriorly dislocated inferior articular process that is forced down into the lower half of neuroforamen, thus causing nerve root compression.
CT scans are very useful to determine the presence of fractures and the amount of displacement. MRI can identify associated disc herniation, which can result in catastrophic neurologic deficit.
Management. Although most injuries are stable, anterior discectomy and intervertebral body fusion may be necessary if significant disc extrusion is also present. Non-surgical management is the treatment when minimal subluxation is present. Patients are placed in Philadelphia-type collars for six weeks with orthopedic or neurosurgery follow-up. If there is less than 3.5 mm dislocation, closed reduction and halo immobilization for three months is typically used.6 Surgical management is indicated when closed reduction has failed. In addition, if middle ligamentous column injury is present with greater than 25% subluxation, greater than 1.7 mm disc widening, greater than 3.5 mm displacement, or angulation greater than 11 degrees, then surgery is immediately indicated.7 Open reduction and internal fixation of unilateral facet injuries have given better results.12 Complications include re-dislocation, inadequate healing, and scapular decubiti.
Bilateral Facet Dislocation. Bilateral facet dislocation occurs when both inferior facets of the superior vertebra are translated forward over the lower vertebra's superior facets, locking into place in the intervertebral foramens. This degree of movement allows for about 50% of the superior vertebral body to be displaced anteriorly over that of the inferior body when viewed from the side. The mechanism is thought to be due to hyperflexion-rotation. (See Figure 5.) Integrity of all ligaments of the cervical canal is also lost, including middle/posterior ligaments, anterior/posterior longitudinal ligaments, discs, and articular facet joints. The result is severe spinal cord injury and a severely unstable fracture. When there is complete dislocation of the facets with 50% or more anterior subluxation, this is called bilateral locked facets. Bilateral facet dislocation often has associated injuries such as soft-tissue trauma, disc herniation, and epidural hematomas. Ten percent of patients with this injury will have disc herniation on presentation.8,9
Figure 5: Illustration of Bilateral Facet Dislocation
Reproduced with permission from Adam Flanders, MD Department of Radiology and Regional Spinal Cord Injury Center of the Delaware Valley, Thomas Jefferson University Hospital, Philadelphia from the website http://www.radiologyassistant.nl
Radiographic Findings. In addition to the traditional three views, plain radiographic imaging includes pillar views. Pillar views are obtained when the patient is lying supine with the neck hyperextended. The central X-ray beam is directed to the center of the neck at the thyroid cartilage with caudal angulation of 30-35 degrees. This allows direct visualization of any associated articular mass fractures. Widening of interspinous distance is seen on AP views. Lateral views reveal the greater than 50% subluxation and dislocation or fracture of the superior or inferior facets. Oblique views reveal an articular mass lying within the intervertebral foramen.
The use of helical CT scan with spine reconstruction enables the physician to more reliably distinguish bilateral from unilateral cervical facet dislocations.10 (See Figure 6.) If narrowing of the disc space is seen, an MRI should be performed to evaluate for extrusion of disc fragments.
Figure 6: Bilateral Facet Dislocation of C5-C6
a) Plain film, b) CT scan, and c) MRI.
Reproduced with permission from the website http://www.radiologyassistant.nl
Management. Nonsurgical management involves the progressive application of increasing weights under direct fluoroscopy to lengthen the spine until reduction is achieved. An MRI should always precede any attempts at reduction.11 Surgical management involves open reduction when attempts at closed reduction have failed and when the pre-operative MRI reveals no associated disc herniation. Bilateral facet dislocations have a higher incidence of re-dislocation following closed reduction. Catastrophic compression of the spinal cord has been seen after an uncontrolled facet reduction in patients with associated disc herniation. Other potential problems include re-dislocation, inadequate healing, and scapula decubiti.13
Anterior Subluxation
Anterior subluxation occurs after hyperflexion that causes partial or complete disruption of the posterior column ligaments without facet dislocation. It can also occur with injuries to the anterior column with compression fractures. It is an unstable injury when there is associated compression fracture, greater than 25% loss of height, and fractures through the vertebrae. It is most often seen at the C5-C6 level on patients with existing facet disease.14 It is sometimes referred to as "hyperflexion sprain." Anterior subluxation may be stable initially, but it is associated with 25-50% delayed instability.15,16 As such, the recognition of these radiographic findings is crucial for early diagnosis. A high suspicion should be maintained if patients continue to have pain and neurological complaints.
Figure 7: C4-C5 Anterior Subluxation
Diagnostic Evaluation. Radiographs reveal loss of normal cervical lordosis, anterior displacement of the anterior vertebrae body, and fanning of the interspinous distance. (See Figure 7.) Radiograph findings found with unstable anterior subluxations are greater than 4 mm anterior displacement, an associated compression fracture of more than 25% of the affected vertebrae body, and an increase or decrease in normal disc space. CT scan may show associated fractures that extend through the vertebrae body centrum seen in the coronal planes, representing anterior ligamentous column failure.
If the patient has severe focal pain (especially with movement), or symptoms or signs of radiculopathy or cervical cord injury and no abnormality is present on radiograph, a major ligamentous injury must be confirmed or denied by further radiographs taken of the joint under strain with flexion and extension views as well as MRI.
Management. Anterior subluxations are often unstable and usually undergo posterior stabilization and then fusion.
Spinous Process Fracture
A spinous process fracture occurs as a result of abrupt hyperflexion resulting in sudden pulling of the muscular attachments, producing an avulsion injury. The radiograph appearance is an oblique fracture of the spinous process base. (See Figure 8.) This fracture is known as the "clay-shoveler's" fracture, so named for Australian miners in the 1930s who developed this injury as a result of sudden flexion of the neck against the supraspinatous ligament when lifting heavy shovels.17 In modern times, this injury is most commonly a result of direct trauma to the region or MVC with abrupt deceleration. It is most often seen in decreasing order at the levels C7, C6, then T1. It is considered a very stable fracture unless the fracture extends into the lamina, where there is potential for spinal cord injury.18
Figure 8: Spinous Process or "Clay-shoveler's" Fracture
Diagnostic Evaluation. Lateral and flexion-extension views on plain radiographs easily reveal the spinous process fracture. An AP view revealing a double spinous process resulting from the displaced spinous process fracture is often called the "ghost sign." CT scans are indicated if the spinous process fracture extends into the lamina, as there is greater potential for spinal cord involvement.
Management. Spinous process fractures are treated with nonsurgical management. Hard cervical collars are worn until callus is formed. Spinous process fractures rarely have any long-term sequelae. However, patients may continue to complain of intermittent pain at the level of the injury.
Cerebrovascular Injuries
The overall prevalence of blunt cerebrovascular injuries (BCVI) in the United States is 1.4-1.6% of blunt trauma admissions to Level I trauma centers.19 The anatomic proximity of the carotid artery and the vertebral artery to the cervical spine makes them particularly susceptible to injury. The vertebral artery runs through the transverse foramen of C6 to C1, while the internal carotid artery runs perpendicularly in front of the transverse processes of C1 to C3 from the bifurcation of the common carotid artery to the carotid canal in the temporal bone.20 The mechanical forces (namely cervical hyperextension and rotation, hyperflexion, or direct blow) result in an intimal tear in the vessel, leading to platelet aggregation and subsequent thrombus formation.21,22 The thrombus may potentially embolize or occlude the vessel. Alternatively, the tear may propagate into a dissection or lead to pseudoaneurysm formation at a future time.
The first reported association between BCVI and cervical spine fractures was documented in 1955 by Suechting et al, who described a patient who developed Wallenberg's syndrome four days after sustaining a C5-C6 fracture-dislocation.23 Cervical spine fractures are actually an independent predictor for blunt vertebral artery injury. Individuals with evidence of a high-risk cervical spine injury pattern, such as subluxation, fracture extension into the transverse foramen, or fractures within the upper cervical spine (C1-C3), should routinely be evaluated for BCVI.20,24 The most frequent cause of injury is MVC, followed by falls, then pedestrians struck by a vehicle.20,22
Table 1: Indications for Cervical CT Angiography
Cervical spine fractures, especially with:
- C1-C3 fractures
- Subluxation of vertebral bodies
- Fracture extension into transverse foramen
Neurologic abnormality not explained by a identified injury
Epistaxis from suspected arterial source
Asymptomatic patients with significant blunt heart trauma and:
- GCS ≤ 8
- Petrous bone fracture
- Diffuse axonal injury
- Le Fort II or III facial fractures
Angiography is the gold standard for evaluation of BCVI; however, CT angiography has been used more frequently as a screening modality.24 (See Table 1.) The majority of cases of BCVI are generally asymptomatic and, on presentation, this injury can easily be overlooked. Jang et al found that those patients who were asymptomatic with a CVI had a mortality of 7%, whereas those with a neurologic event and CVI had an 18% mortality.24 The treatment recommendations tend to be controversial; however, many studies recommend the use of anticoagulation either via heparin or antiplatelet therapy.25
Clinical Evaluation and Radiographic Imaging
Removal of Cervical Collars. Rigid cervical collars prevent movement of the C-spine. Movement of the neck in a patient who has an undiagnosed C-spine injury has the potential to increase neurologic damage if an unstable injury is present. Therefore, the cervical collar should remain in place until it is deemed safe for removal by a clinician. However, it is in the patient's best interest to have the cervical collar removed expeditiously. Patients who have the cervical collars removed earlier have lower rates of associated complications such as collar-related decubitus ulceration, delirium, and pneumonia, as well as decreased hospital and intensive care unit length of stay.26 Patients should wear cervical collars and be on log-roll precautions until radiographic studies are completed.
Table 2: NEXUS Low-risk Criteria
Any finding indicates radiographic imaging is warranted:
- Tenderness at the posterior midline of the cervical spine
- Focal neurologic deficit
- Decreased level of alertness
- Evidence of intoxication
- Clinically apparent pain that might distract the patient from the pain of a cervical spine injury
To assist emergency physicians in determining which patients should have imaging of the cervical spine in the setting of blunt trauma, clinical decision rules were developed. The two most notable ones are the National Emergency X-Radiography Utilization Study (NEXUS) Low Risk Criteria (NLC) and the Canadian C-spine Rule (CCR).27-29 (See Tables 2 and 3.)
The NEXUS study concluded that in those patients who had absence of posterior midline tenderness, focal neurologic deficits, intoxication, altered mental status, and distracting painful injuries, cervical spine injury is highly unlikely, with a sensitivity of 99% and a negative predictive value of 99.8%.27 Thus, the cervical spine may be clinically cleared (without the use of radiographic studies) in that subset of patients.
Using the CCR, if there are no high-risk features present, there is a presence of low-risk features, and if the patient is able to rotate his or her neck 45 degrees to the left and the right, then cervical spine injury may be ruled out clinically with a sensitivity of 100%. (See Table 3.)29
Table 3: Summary of Canadian C-Spine Rule (Steill)56
|
1. Any high-risk factor that mandates radiography? Age ≥ 65 years Dangerous mechanism:
Paresthesias in extremities |
If yes, then radiography. If no, then proceed to question 2. |
|
2. Any low-risk factor that allows safe assessment of range of motion?
|
If no, then radiography. If yes, then proceed to question 3. |
|
3. Able to actively rotate neck 45 degrees left and right? |
If able, then no radiography. If unable, then radiography. |
When the NLC criteria were compared to the CCR, Steill et al found that the CCR had an increased sensitivity and specificity, and concluded that appropriate use of the CCR guidelines would result in a decrease in radiographic utilization.30 However, a more recent study by Duane et al prospectively compared clinical examination with CT scan for identification of cervical spine fractures in blunt trauma patients. This study found that sensitivity and negative predictive value of clinical examination was 76.9% and 95.7%, respectively, suggesting that clinical examination alone is unreliable for diagnosis or exclusion of a cervical spine fracture.31
The Eastern Association for the Surgery of Trauma (EAST) practice management guidelines maintain that radiographic imaging is not necessary in trauma patients who are awake and alert and have no neurologic deficit, distracting injury, neck pain or tenderness with full range of motion of the C-spine.26
Trauma patients who are suspected to have C-spine injury and are unable to be clinically cleared must have radiographic imaging performed. The three modalities used for imaging of the cervical spine are plain radiographs, CT, and MRI. Plain radiographs are useful as an initial modality in most patients with a traumatic mechanism. Plain films of the cervical spine should consist of at least three views: anterior-posterior, lateral, and an open-mouth (odontoid) view. Lateral cervical spine films should demonstrate all seven cervical vertebrae and include the top of the first thoracic vertebra. Overlying bony structures, body habitus, inadequate technique, and inability to visualize the lower cervical spine (C6 and C7) may limit the usefulness of plain films. In these patients, a swimmer's view in which the patient's arm is raised above his or her head, and the X-ray beam is aimed through the axilla may adequately visualize C6, C7, and the C7-T1 junction. Even with these views, there have been reports of inadequate visualization in 50-80% of initial films and 25% of repeat films, resulting in additional radiographic imaging.28,32,33 (See Figures 9A and 9B.) Some studies have challenged the utility of plain radiographs in blunt trauma patients. One study demonstrated missed injuries in 7-35% of patients, and as high as 57% in high-risk patients with the use of plain radiographs.28
Figure 9A: C7-T1 Subluxation Not Visualized on Plain Radiographs
Figure 9B: MRI of C7-T1 Subluxation Not Visualized on Plain Radiographs
Helical CT scan has a higher sensitivity than both plain radiographs and MRI for detecting cervical spine fractures.34 CT scan detects between 97% and 100% of fractures.34 A meta-analysis comparing trauma patients who had CT scan to plain films of the C-spine found the overall sensitivity for plain films to be 52% and 98% for CT scan.35 One prospective study that compared plain films to CT scan of the C-spine in the identification of injuries found that plain films had a sensitivity and specificity of 45% and 97.4%, respectively, while CT scan had 100% and 99.5%, respectively.36 In patients who are at an increased risk for cervical spine fractures, CT scan is considered to be the preferred screening modality. The EAST practice management guidelines recommend that CT scan of the cervical spine be the primary imaging modality for those patients whose C-spines cannot be clinically cleared.26
MRI has demonstrated relatively low sensitivity for detecting anterior and posterior element fractures. MRI is the modality of choice when assessing patients for spinal cord, cervical ligament, and soft-tissue injury.37 Limitations of MRI include lack of availability, claustrophobia, and technical difficulty in the severely injured patient.
For patients who have negative radiographic imaging, clinical clearance using physical examination is appropriate. In the awake and alert patient who has no neurologic deficits and/or distracting or painful injuries, occult injury is highly unlikely and the cervical collar may be removed. There is some question as to whether the cervical spine can truly be cleared in the intubated or obtunded blunt trauma patient (OBTP) who has negative CT scans of the cervical spine. Obviously, physical examination is not reliable in intubated and obtunded patients and there exists the potential for missing ligamentous injury in these patients. A recent meta-analysis addressing this question found that CT scan was highly sensitive for detecting unstable injuries, missing only 7 out 14,327 patients who were found to have clinically significant cervical spine injuries after a negative CT scan.38 Como et al prospectively studied OBTPs who were grossly moving all extremities, who had their cervical collars removed after CT scans of the cervical spine were read as negative.39 They found that the majority of patients (62%) were found to have no clinical signs or symptoms upon re-examination when not obtunded; 2.5% of patients continued to have pain and had a follow-up MRI that was negative for injury; and only one patient out of the 13% who died before re-examination was found to have a stable ligamentous injury on autopsy report.39
There has also been some question as to whether a negative CT scan of the cervical spine is sufficient for detecting injuries in patients who have persistent neck pain or posterior midline tenderness. Schuster et al found that neurologically intact blunt trauma patients who had CT scans that were negative for traumatic injury but had persistent cervical spine pain all had subsequent MRI scans that were negative for clinically significant injuries.40 However, a recent study by Ackland et al found that 44% of blunt trauma patients who had neurologically intact physical examination, negative CT scans, and persistent midline tenderness had positive findings on subsequent MRI (2.8% underwent operative management).41 Further investigation needs to be conducted to reconcile these different findings.
ED Management and Disposition
As with evaluation of all trauma patients, it is crucial to assess airway, breathing, and circulation as a part of the primary survey. If the patient has not been immobilized in a rigid cervical collar in the prehospital setting and a cervical spine injury is suspected based on the mechanism of injury, history, or physical examination, then the patient should have one placed by the ED staff. During the primary and secondary surveys, cervical spine in-line stabilization should be maintained.
If the patient requires intubation, rapid sequence intubation via the orotracheal route is the preferred method. There has been controversy regarding the effectiveness of manual in-line stabilization during the intubation of trauma patients who have suspected cervical spine injury. Current guidelines set forth by the American College of Surgeons' Advanced Trauma Life Support (ATLS) maintain that manual in-line stabilization of the cervical spine should be maintained by having a member of the treatment team hold the head in an effort to prevent hyperextension of the neck. The evidence supporting this principle is based on expert opinion and empiric treatment of patients with spine injuries. However, in recent years this practice has come into question. Some authors point out that limiting optimal positioning of the head during endotracheal intubation not only limits visualization of the laryngeal structures but also may ultimately cause hypoxia by lengthening the time of intubation.42,43 One study found that manual in-line stabilization increased the failed intubation rate at 30 seconds in patients with normal airways.43 Additionally, there are data that support the fact that intubation using direct laryngoscopy is unlikely to result in a significant amount of movement, and that manual in-line stabilization may not actually be effective in immobilizing injured portions of the cervical spine.42
Video-assisted laryngoscopes may be used to facilitate intubation in the setting of cervical spine trauma. However, one recent study that compared experienced anesthesiologists performing endotracheal intubation using video laryngoscopes with Macintosh laryngoscope use in manikins wearing rigid cervical collars found that video laryngoscopes did not facilitate endotracheal intubation.44 In fact, endotracheal intubation with the Macintosh laryngoscope was actually faster.
Consults
Patients who have multisystem traumatic injuries should have emergent consultation by a trauma specialist or be transferred to a facility with the capability of caring for a multisystem trauma patient. A spine specialist (either orthopedics or neurosurgery) should be consulted emergently to evaluate the patient and to guide the management of the injuries.
Steroid Use
The use of steroids has become controversial over the years since it became touted as the standard of care after the results of the second National Acute Spinal Cord Injury Study (NASCIS II) were published in 1992. The controversy stems from the fact that the effectiveness of steroids in reducing post-injury neurological damage has not been replicated.45 Since the NASCIS II, several large follow-up studies (both prospective and retrospective) have shown no significant effect of steroids on any neurologic outcome variable.46,47
In addition, serious side effects from the use of high doses of steroids have been a concern. Several authors have cited the many significant complications of high-dose steroid use, most notably the increased incidence of pneumonia, sepsis, gastrointestinal bleeding, and length of intensive care unit stay.48-50
"The resultant publicity, strong recommendations by professional societies and federal agencies, coupled with the fear of litigation, made high-dose steroids the 'standard of care' for patients with suspected spinal cord injury.51 Despite the lack of controlled studies in children, the use of high-dose steroids is also used in older children.52 But, as noted, the benefits of high-dose steroids in patients with suspected spinal cord injury have not been replicated since the initial NASCIS II study."
Many hospitals with trauma level designates have existing protocols with respect to the administration of steroids, and it is best to be familiar with the standard of care at the practicing hospital. Utilizing the results of the NASCIS II, the current recommended dose of methylprednisolone is a 30 mg/kg load, followed by 5.4 milligrams per kilogram per hour for 23 hours.53
Disposition
Patients who have minor muscular pain and have no radiographic injury or neurologic deficits are safe to be discharged home. Nonsteroidal anti-inflammatory agents may be helpful for analgesia and for reducing soft-tissue inflammation. Many patients will continue to have pain up to six weeks following the inciting event, and approximately one-quarter of patients will continue to experience neck pain one year later.17,54 Although some patients may request a soft cervical collar, its utility has been unsupported.54,55 One study that compared the pain, recovery, improvement, and deterioration in patients with neck pain following MVCs with and without the use of soft cervical collars found there were no differences between the two groups.54
Summary
Cervical spine injury should be ruled out in all blunt trauma patients who have a significant mechanism of injury. Cervical spine immobilization must be maintained until injury is ruled out either clinically or by radiographic imaging. When applied appropriately, the NLC and CCR decision criteria are helpful in determining which patients do not require cervical spine imaging. CT scan is highly sensitive for detecting clinically significant cervical spine injuries and has been accepted as the initial screening modality for cervical spine injury in patients with a significant traumatic mechanism. Clinical signs suggestive of an injury in the setting of a negative CT scan warrant further evaluation with MRI. Traumatic mechanisms causing hyperextension of the neck generally result in unstable injuries. Multi-system trauma patients should be evaluated by a trauma surgeon or be transferred to a trauma center for management. Spine surgeons should be consulted emergently in all patients who have injury to the cervical spine.
References
1. Pimentel L, Diegelmann L. Evaluation and management of acute cervical spine trauma. Emerg Med Clin North Am 2010;28:719-738.
2. Torg JS, Pavlov H, O'Neill MJ, et al. The axial load teardrop fracture. A biomechanical, clinical and roentgenographic analysis. Am J Sports Med 1991;19: 355-364.
3. Favero KJ, Van Peteghem PK. The quadrangular fragment fracture. Roentgenographic features and treatment protocol. Clin Orthopaedics Related Research 1989:40-46.
4. Cooper C, Atkinson EJ, O'Fallon WM, et al. Incidence of clinically diagnosed vertebral fractures: A population-based study in Rochester, Minnesota, 1985-1989. J Bone Min Research 1992;7:221-227.
5. Ndoumbe A, Motah M, Mballa Amougou JC, et al. [A case of unilateral dislocation of C3 right facet joint treated with lateral mass plating]. Neuro-Chirurgie 2011;57:100-104.
6. Rorabeck CH, Rock MG, Hawkins RJ, et al. Unilateral facet dislocation of the cervical spine. An analysis of the results of treatment in 26 patients. Spine 1987;12:23-27.
7. Vollmer DG, Gegg C. Classification and acute management of thoracolumbar fractures. Neurosurg Clin North Am 1997;8:499-507.
8. Doran SE, Papadopoulos SM, Ducker TB, et al. Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation. J Neurosurgery 1993;79: 341-345.
9. Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. Case report. J Bone Joint Surg (American volume) 1991;73:1555-1560.
10. Dailey AT, Shaffrey CI, Rampersaud R, et al. Utility of helical computed tomography in differentiating unilateral and bilateral facet dislocations. J Spinal Cord Med 2009;32:43-48.
11. Cotler HB, Miller LS, DeLucia FA, et al. Closed reduction of cervical spine dislocations. Clin Orthopaedics Related Research 1987:185-199.
12. Beyer CA, Cabanela ME, Berquist TH. Unilateral facet dislocations and fracture-dislocations of the cervical spine. J Bone Joint Surg (British volume) 1991;73: 977-981.
13. Mahale YJ, Silver JR. Progressive paralysis after bilateral facet dislocation of the cervical spine. J Bone Joint Surg (British volume) 1992;74:219-223.
14. Fehring TK, Brooks AL. Upper cervical instability in rheumatoid arthritis. Clin Orthopaedics Related Resarch 1987: 137-148.
15. Lingawi SS. The naked facet sign. Radiology 2001;219:366-367.
16. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg (American volume) 1979;61: 1119-1142.
17. Hockberger RS, Kaji AH, Newton E. Spinal Injuries. In: Rosen's Emergency Medicine Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2009:337-375.
18. Cancelmo JJ, Jr. Clay shoveler's fracture. A helpful diagnostic sign. Am J Roentgenology 1972;115:540-543.
19. Biffl WL, Ray CE, Jr, Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: Importance of routine follow-up arteriography. Ann Surgery 2002;235:699-706; discussion -7.
20. Kopelman TR, Leeds S, Berardoni NE, et al. Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures. Am J Surgery 2011;202:684-688; discussion 8-9.
21. Swartz EE, Floyd RT, Cendoma M. Cervical spine functional anatomy and the biomechanics of injury due to compressive loading. J Athletic Training 2005;40:155-161.
22. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surgery 1999;178:517-522.
23. Management of vertebral artery injuries after nonpenetrating cervical trauma. Neurosurgery 2002;50(3):S173-S178.
24. Jang JW, Lee JK, Hur H, et al. Vertebral artery injury after cervical spine trauma: A prospective study using computed tomographic angiography. Surgical Neurology International 2011;2:39.
25. Parbhoo AH, Govender S, Corr P. Vertebral artery injury in cervical spine trauma. Injury 2001;32:565-568.
26. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: Update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma 2009;67:651-659.
27. Goldberg W, Mueller C, Panacek E, et al. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med 2001;38:17-21.
28. Greenbaum J, Walters N, Levy PD. An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med 2009;36:64-71.
29. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.
30. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349: 2510-2518.
31. Duane TM, Dechert T, Wolfe LG, et al. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma 2007;62:1405-1408; discussion 8-10.
32. Morris CG, McCoy E. Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening. Anaesthesia 2004;59:464-482.
33. West OC, Anbari MM, Pilgram TK, et al. Acute cervical spine trauma: Diagnostic performance of single-view versus three-view radiographic screening. Radiology 1997;204:819-823.
34. Crim JR, Moore K, Brodke D. Clearance of the cervical spine in multitrauma patients: The role of advanced imaging. Semin Ultrasound, CT, MR 2001;22: 283-305.
35. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: A meta-analysis. J Trauma 2005;58:902-905.
36. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007;62:1427-1431.
37. Klein GR, Vaccaro AR, Albert TJ, et al. Efficacy of magnetic resonance imaging in the evaluation of posterior cervical spine fractures. Spine 1999;24:771-774.
38. Kirschner J, Seupaul RA. Does computed tomography rule out clinically significant cervical spine injuries in patients with obtunded or intubated blunt trauma? Ann Emerg Med 2012 [epub ahead of print].
39. Como JJ, Leukhardt WH, Anderson JS, et al. Computed tomography alone may clear the cervical spine in obtunded blunt trauma patients: A prospective evaluation of a revised protocol. J Trauma 2011;70:345-349; discussion 9-51.
40. Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surgery 2005;140:762-766.
41. Ackland HM, Cameron PA, Varma DK, et al. Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med 2011;58:521-530.
42. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: Historical review and current questions. Ann Emerg Med 2007;50:236-245.
43. Thiboutot F, Nicole PC, Trepanier CA, et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: A randomized controlled trial. Can J Anaesthesia 2009;56: 412-418.
44. Wetsch WA, Spelten O, Hellmich M, et al. Comparison of different video laryngoscopes for emergency intubation in a standardized airway manikin with immobilized cervical spine by experienced anaesthetists. A randomized, controlled crossover trial. Resuscitation 2012;83:740-745.
45. Lukas R, Zykova I, Barsa P, et al. [Current role of methylprednisolone in the treatment of acute spinal cord injury]. Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca 2011;78:305-313.
46. Gerhart KA, Johnson RL, Menconi J, et al. Utilization and effectiveness of methylprednisolone in a population-based sample of spinal cord injured persons. Paraplegia 1995;33:316-321.
47. George ER, Scholten DJ, Buechler CM, et al. Failure of methylprednisolone to improve the outcome of spinal cord injuries. Am Surgeon 1995;61:659-663; discussion 63-4.
48. Matsumoto T, Tamaki T, Kawakami M, et al. Early complications of high-dose methylprednisolone sodium succinate treatment in the follow-up of acute cervical spinal cord injury. Spine 2001;26: 426-430.
49. McCutcheon EP, Selassie AW, Gu JK, et al. Acute traumatic spinal cord injury, 1993-2000: A population-based assessment of methylprednisolone administration and hospitalization. J Trauma 2004;56:1076-1083.
50. Mathison DJ, Kadom N, Krug SE. Spinal cord injury in the pediatric patient. Clin Pediatric Emerg Med 2008;9:106-123.
51. Hurlbert RJ, Hamilton MG. Methylprednisolone for acute spinal cord injury: 5-year practice reversal. Can J Neurological Sciences 2008;35:41-45.
52. Arora B, Suresh S. Spinal cord injuries in older children: Is there a role for high-dose methylprednisolone? Pediatric Emerg Care 2011;27:1192-1194.
53. Young W, Bracken MB. The Second National Acute Spinal Cord Injury Study. J Neurotrauma 1992;9 Suppl 1: S397-405.
54. Gennis P, Miller L, Gallagher EJ, et al. The effect of soft cervical collars on persistent neck pain in patients with whiplash injury. Acad Emerg Med 1996;3:568-573.
55. Muzin S, Isaac Z, Walker J, et al. When should a cervical collar be used to treat neck pain? Curr Rev Musculoskeletal Med 2008;1:114-119.
This issue is the second of a two-part discussion of cervical spine injuries.Subscribe Now for Access
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