Evaluation and

Management of
Acute Cervical
Spine Trauma
LauraPimentel, MDa,b,*,LauraDiegelmann, MDa,c

KEYWORDS

Cervicalspine Trauma Fracture Injury Vertebrae

Theevaluationandmanagementofcervicalspineinjuriesisacorecomponentofthe
practiceofemergencymedicine.Theincidenceofseriouscervicalspineinjuriesislow
butassociatedratesofdeathanddisabilityarehigh;therefore,theemergencyphysi-
cianmusthaveastrongknowledgebasetoidentifytheseinjuriesaswellasclinical
skills that will protect the patient’s spine during assessment. Cervical spine injury
causesanestimated6000deathsand5000newcasesofquadriplegiaintheUnited
Stateseachyear.1Malesareaffected4timesasfrequentlyasfemales.
Twotothreepercentofblunttraumapatientswhoundergocervicalspineimaging
are diagnosed with a fracture. The second vertebra is most commonly injured,
accounting for 24% of fractures; the sixth and seventh vertebrae together account
foranother39%offractures.2Fromaclinicalperspective,itiscrucialfortheemer-
gencyphysiciantodiagnoseafracture.IntheNEXUStrial,56.7%ofcervicalspine
fractures were unstable and another 13.9% were otherwise classified as clinically
significant.2 Older age is an important risk factor for cervical spine injury: patients
65yearsorolderhavearelativerisktwicethatofyoungertraumavictims.3Theasso-
ciatedmortalityrateinthisagegroupis24%.4
Adisproportionatenumberofcervicalspineinjuriesareassociatedwithmoderate
and severe head injuries sustained in motor vehicle crashes. Head-injured patients
are almost 4 times as likely to have a cervical spine injury as those without head
injuries.ThoseathighestriskhaveaninitialGlasgowComaScale(GCS)scoreof8
orlowerandarelikelytosustainunstableinjuriesinthehighcervicalspine.5

a
DepartmentofEmergencyMedicine,UniversityofMarylandSchoolofMedicine,110South
PacaStreet,6thFloor,Suite200,Baltimore,MD21201,USA
b
Department of Emergency Medicine, Maryland Emergency Medicine Network, 110 South
PacaStreet,Baltimore,MD21201,USA
c
DepartmentofEmergencyMedicine,UniversityofMarylandMedicalCenter,110SouthPaca
Street,Baltimore,MD21201,USA
*Correspondingauthor.DepartmentofEmergencyMedicine,UniversityofMarylandSchoolof
Medicine,110SouthPacaStreet,6thFloor,Suite200,Baltimore,MD21201.
E-mailaddress:lpimentel@memn.org

EmergMedClinNAm28(2010)719–738
doi:10.1016/j.emc.2010.07.003 emed.theclinics.com
0733-8627/10/$–seefrontmatterÓ2010ElsevierInc.Allrightsreserved.
720 Pimentel&Diegelmann

Thefocusofthisarticleistheevaluationandmanagementofbluntcervicalspine
trauma by the emergency physician. The authors begin by reviewing the pertinent
anatomy of the cervical spine. Specific cervical spine fractures are discussed, with
anemphasisonunstableinjuriesandassociatedspinalcordpathology.Theassocia-
tion of vertebral artery injury with cervical spine fracture is addressed, followed by
areviewofthemostrecentliteratureonprehospitalcare.Theauthorsthenreviewinitial
considerationsintheemergencydepartment,includingcervicalspinestabilizationand
airwaymanagement.Themostcurrentrecommendationsforcervicalspineimaging
withregardtoindicationsandmodalitiesarecovered.Finally,theemergencydepart-
mentmanagementanddispositionofpatientswithspinalcordinjuriesarereviewed.

ANATOMY

Thecervicalspineconsistsof7cervicalvertebrae,thespinalcord,intervertebraldiscs
beginningattheC2-C3interspace,acomplexnetworkofsupportingligaments,and
neurovascular structures. General vertebral anatomy consists of an annular body
andthevertebralarch,includingthesymmetricpedicles,laminae,superiorandinferior
articular surfaces, transverse processes, and a single posterior spinous process
(Fig.1A).Thecervicalvertebraearesmallerthantheirthoracicorlumbarcounterparts,
andeachtransverseprocesscontainsaforamen(foramentransversarium)(Fig.1B).
Thefirst2andtheseventhboneshaveexceptionalanatomicfeatures.

Fig.1. (A)Cervicalspineanatomy.(FromEuroSpine,PatientLine,www.eurospine.org;with
permission.) (B) Cervical vertebra. (From Agur AMR, Lee MJ, Anderson JE. Distinguishing
featuresandmovements.In:Grant’satlasofanatomy.9thedition.Philadelphia:Lippincott
Williams&Wilkins;1991.p.206;withpermission.)
 AcuteCervicalSpineTrauma 721

Thefirstcervicalvertebraiscalledtheatlasbecauseitsupportsthehead.Distinct
fromallothervertebrae,theatlashasnobodyandnospinousprocess(Fig.2);itis
a ring-like structure with anterior and posterior arches separated by lateral masses
oneachside.6Thesuperiorsurfacesofthelateralmassesarticulatewiththeoccipital
condylesoftheskull,formingtheatlanto-occipitaljoint.Functionally,thisjointallows
50%ofneckflexionandextension.
Thesecondcervicalvertebra,theaxis,formsthesurfaceonwhichtheatlaspivotsto
allowlateralrotationofthehead.Thedens,alsocalledtheodontoidprocess,isthe
cranialextensionofthebodyoftheaxisintotheringoftheatlas;itisthemostchar-
acteristicfeatureofC2(seeFig.2).Thedensarticulateswiththeposterioraspectof

Fig.2. (A,B) Cervicalvertebrae1and2:the atlasandaxis.(A)Superiorview.(FromAgur

AMR,LeeMJ,AndersonJE.Atlasanditstransverseligamentandtheaxis.In:Grant’satlas
of anatomy. 9th edition. Philadelphia: Lippincott Williams & Wilkins; 1991. p. 211; with
permission.)(B)Anteriorview.(ModifiedfromAgurAMR,LeeMJ,AndersonJE.Articulated
cervical vertebrae. In: Grant’s atlas of anatomy. 9th edition. Philadelphia: Lippincott
Williams&Wilkins;1991.p.208;withpermission.)
722 Pimentel&Diegelmann

theanteriorringofC1andisstabilizedbythetransverseligament.Thisarticulation
providesstabilityastheatlaspivotsduringrotation.Halfofneck rotationoccursat
thisatlantoaxialjoint.Thereisnointervertebraldiscateithertheatlanto-occipitalor
theC1-C2joints,predisposingthemtoinflammatoryarthritis.7
Thedistinctivefeatureoftheseventhvertebraisitsprominentspinousprocess.Its
lengthextendsbeyondtheothercervicalvertebrae,renderingitpalpableonphysical
examination.Theseventhvertebraisthehighestspinousprocessthatisreliablyiden-
tifiable, making it a useful landmark.6 The length and prominence of the spinous
processpredisposethisvertebratofracture.
IntervertebraldiscsareinterposedbetweenthevertebralbodiesfromC2downto
thesacrum;theyaccountforabout25%oftheheightofthespinalcolumn.Structur-
ally, discs are composed of a soft gelatinous center, the nucleus pulposus, sur-
rounded by a cartilaginous ring of tissue (the annulus fibrosus). Functionally, discs
providesupport,elasticity,andcushioningtothespine.Intervertebraldiscsdeterio-
ratewithage;muchofthegelatinouscenterisreplacedwithfibroustissue,resulting
indecreasedelasticityandmobility.8
Thecervicalspineisconnectedandsupportedbyacomplexnetworkofligaments
(Fig. 3). Three of the most important are the anterior longitudinal ligament and the
posterior longitudinal ligament, which extend from the occiput to the sacrum, and
the ligamentum flavum. The anterior longitudinal ligament, connecting the anterior
aspectsofthevertebralbodies,becomestautandresistshyperextension.Theposte-
rior,connectingtheposterioraspectofthevertebralbodies,tightensandlimitshyper-
flexion. The posterior longitudinal ligament forms the anterior surface of the spinal
canal.Theligamentumflavumconnectsthelaminaeofadjacentvertebraeandforms
theposteriorsurfaceofthespinalcanal.Thisligamentissusceptibletothickeningwith
ageandmaycausespinalstenosis,resultingincordandnerverootcompression.7
The interspinous ligaments are thin and membranous, and span the length of the
spinousprocesses.
Thebloodsupplytothespinalcolumnandcordiscomplex.Themainspinalarteries
consist of a single anterior and 2 posterior vessels originating from the vertebral
arteries;theyrunlongitudinallyfromthemedullaalongthelengthofthecord.These
arteries supply only the superior portion of the cord and are supplemented by
segmental medullary arteries originating from the vertebral arteries in the cervical
spine;theyenterthespinalcolumnthroughtheintervertebralforamen.Alonevessel,

Fig.3. Vertebralligaments.(CourtesyofGoimageMediaServicesInc;withpermission.)
 AcuteCervicalSpineTrauma 723

theanteriorcervicalartery,isparticularlyvulnerabletodamageassociatedwithhyper-
extensioninjuries.Theresultisischemiatotheanteriortwo-thirdsofthecord,adevas-
tatingcomplication.8
Whenconsideringcervicalspineanatomyintheclinicalcontext,emergencyphysi-
ciansshouldthinkofthespinalcolumnas2parallelentities.Thevertebralbodiesand
associated intervertebral discs form the anterior column, which is stabilized by the
anterior and posterior longitudinal ligaments. The posterior column containing the
spinalcordandcanalconsistsofthestructuresposteriortotheanteriorcolumn:pedi-
cles, transverse processes, superior and inferior articulating facets, laminae, and
spinousprocess.Theligamentumflavumandtheinterspinousandassociatedliga-
ments stabilize the posterior column. When only one column is injured, the other
providesstability,substantiallyloweringtheriskofspinalcordinjurycomparedwith
whenbotharecompromised.9
ThewidestportionofthespinalcanalisfromC1toC3,wherethemid-sagittaldiam-
eterrangesfrom16to30mm.ThisdiameternarrowsfromC4toC7toarangeoffrom14
to23mm.Atthislevel,thespinalcordnormallyoccupies40%ofthediameterofthe
canalinahealthyadult.Hyperextensiondecreasesthecanaldiameterapproximately
2to3mm,whichbecomesclinicallyimportantinthecontextofhyperextensioninjury. 8
Thecervicalspineisvulnerabletotrauma;injuryoccurswhenforcesappliedtothe
head or neck overwhelms the anatomic stabilizers of the bony and ligamentous
supportstructures.Degenerativechangesresultinginspinalstenosisincreasevulner-
abilitytocorddamage,particularlywithhyperextensionmechanisms.Fatalinjuriesare
mostcommonatthecraniocervicaljunctionoratlantoaxiallevel.

PATHOPHYSIOLOGY

Cervicalspineinjuriescanbeconsideredbydegreeofmechanicalinstability.White
and colleagues10 defined the concept physiologically and radiographically. These
investigators defined “stability” as limitation of displacement of the spine under
appliedphysiologicloads,whichpreventsspinalcordornerverootdamage.Inthe
adult spine, instability may be diagnosed radiographically when there is more than
3.5mmofdisplacementinthesagittalplanerelativetoanadjacentvertebraonresting
radiographs or with flexion/extension views. This work led to a complex scoring
systemthatmaybeappliedtoinjuriesthatarenotclearlystableorunstable.
Whenevaluatingpatientsintheemergencydepartment,itisnotalwaysclearwhich
fracturesarestable.Someofthedifficultyisthelackofaconsistentconventionfor
classifyingcervicalspineinjuries.Someinjuriesarenamed,forexample,theJefferson,
hangman,andclayshovelerfractures.Othersaredescribedbymechanismofinjury,
pathologiclesion,orcombinationsofthetwo.Anothersourceofconfusionislackof
agreementamonginvestigatorsaboutwhichinjuriesarestable.Therealityisthateach
cervicalspineinjuryisuniqueanditsrelativestabilitydependsonindividualfactors
such as the patient’s age, associated injuries, and underlying health. It is useful to
considerWhite’sstrategyofcombiningradiologicfindingswithresponsetophysio-
logicstresswhenunsure.Allbutthemostminorcervicalspinefracturesintheemer-
gencydepartmentshouldbetreatedasunstableinjuriesuntilprovenotherwise.

AxialCompressionInjury
TheJeffersonfractureisanunstableburstfractureoftheatlascausedbysevereaxial
compression(Fig.4).Divingisacommonmechanism.Theinjuryischaracterizedby
unilateralorbilateralfracturesoftheanteriorandposteriorarchesofC1.Asanisolated
injury,theJeffersonfractureisnotusuallyassociatedwithneurologicinjurybecauseof
724 Pimentel&Diegelmann

Fig.4. Jeffersonfracture:burstfractureofC1.(CourtesyofWilliamHerring,MD,Philadel-
phia, PA and learningradiology.com. Available at: http://www.learningradiology.com/
caseofweek/caseoftheweekpix2006/cow188arr.jpg.)

thewidthofthespinalcanalatthatlevel.However,whenitisassociatedwithruptureof
thetransverseligamentthatstabilizestheodontoidtotheanteriorarchofC1,theJef-
fersonfractureisveryunstable.11Associatedinjuriesmayincludedamagetotheverte-
bral artery traversing the foramen transversarium and a second fracture at a lower
level.12 AJeffersonfracturemaybediagnosedonanopen-mouthedodontoidview
bynotingdisplacementofthelateralmassesofC1relativetoC2.OverhangofC1of
6.9mmoverthelateralmassofC2isdiagnosticofafracture.13Ifthisfindingisnot
presentbutclinicalsuspicionremains,acomputedtomography(CT)scanshouldbe
obtained.
MultipleorComplexMechanism
Odontoidfracturesmaybe1of3types.Themechanismsaremixedandoftenunclear.
Flexion, extension, and rotation may contribute to the fractures. When evaluating
odontoid trauma, emergency physicians should consider that the dens occupies
one-thirdofthespinalcanal,thespinalcordoccupiesanotherthird,andtheremaining
thirdisemptyspace.
ATypeIfractureisanavulsionofthetipofthedensabovethetransverseligament,
thoughttobeanavulsionfracture fromthealarligaments. Inisolation,thisinjuryis
usuallynotassociatedwithinstabilityorspinalcordinjury;however,TypeIodontoid
fracturesmaybeseeninassociationwithatlanto-occipitaldislocation.Thisextremely
dangerousinjurymustberuledoutbeforeconservativetreatmentisinitiated.
 AcuteCervicalSpineTrauma 725

ATypeIIodontoidfracture,themostcommonofthe3,islocalizedtothebaseofthe
dens(Fig.5).Tenpercentofthesefracturesareassociatedwithdamagetothetrans-
verseligament. This complication represents a very unstable injury associated with
high mortality. Because of limited blood supply to the fractured dens, nonunion is
high.Patientsmaybetreatedwithhaloimmobilizationoropensurgery.Riskfactors
fornonunionareageolderthan50yearsanddisplacementofthefracture.12,14Hadley
andcolleagues15reportedthatdisplacementof6mmormorecorrelatedwitha67%
rateofnonunioncomparedwith26%whendisplacementwaslessthan6mm.
ATypeIIIfractureextendsintothebodyofC2(Fig.6).Itisamechanicallyunstable
injury because it allows the atlas and occiput to move as a unit. Nonunion is
uncommon.Mostpatientsaresuccessfullymanagedwithhaloimmobilization.
FlexionMechanism
Amongflexioninjuriesofthecervicalspine,the2mostunstablearetheflexiontear-
drop fracture and the bilateral facet dislocation.1 The flexion teardrop (Fig. 7 ) is
adevastatinginjuryinwhichsubstantialforceisrequiredtofracturetheanteriorinfe-
rioraspectofthevertebralbody.Commonmechanismsaremotorvehiclecrashesand
diving.Fortheteardropfracturetooccur,theremustbedisruptionoftheligamentsof
theposteriorcolumn,displacingthevertebralbodyposteriorlyintothespinalcanal.
Neurologicinjuryisverycommon.Theresultisoftentheanteriorcordsyndrome,man-
ifesting as quadriplegia and loss of pain and temperature sensation. The most
commonlevelforateardropfractureisC5.12
Bilateralfacetdislocationisthemostsevereformofanteriorsubluxation(Fig.8 ).At
thesubluxedlevel,theinferiorfacetsdislocatesuperiorlyandanteriorlytothesuperior
articulatingfacetsofthelowervertebra,causingcompleteanteriorandposteriorlongi-
tudinalligamentousdisruption.Subluxationofmorethan50%willbeseenonalateral
radiograph.Neurologicinjuryiscommon.

Fig.5. TypeIIodontoidfracture.(CourtesyofAdamFlanders,MD,DepartmentofRadiology,
ThomasJeffersonUniversityHospital,Philadelphia,PA.Availableat:www.radiologyassistant.
nl/images/4911d5fd8c73bdens1.jpg.)
726 Pimentel&Diegelmann

Fig.6. TypeIIIodontoidfracture.(CourtesyofWilliamHerring,MD,Philadelphia,PA.Avail-
ableat:www.mypacs.net/repos/mpv3_repo/viz/full/108,110/5,405,541.jpg.)

Fig. 7. Flexion teardrop flexion. (Courtesy of Amilcare Gentili, MD, La Jolla, CA at www.
gentili.net. Available at: www.gentili.net/image.asp?ID540&imgid5flexteardrop.jpg&Fx5
Flexion+Tear+Drop+Fracture.)
 AcuteCervicalSpineTrauma 727

Fig.8. Bilateralfacetdislocation.

Lessdevastatingflexioninjuriesofthecervicalspineincludewedgefractures,ante-
rior subluxations, and clay shoveler fractures (an avulsion fracture of the spinous
process of C7) (Fig. 9). These injuries are usually stable, without neurologic deficit.
An anterior subluxation must be evaluated very carefully to rule out disruption of
posteriorligaments.

ExtensionMechanism
Hangman’sfractureisafractureofthepediclesoftheaxisorsecondcervicalvertebra
(Fig. 10). The usual mechanism of injury is extreme hyperextension during a diving
accidentormotorvehiclecollision.Thisfractureisconsideredunstablebecauseof
itslocation,butspinalcordinjuryisnotcommonbecausethespinalcanaliswidest
atC2.Thepediclefractureallowsdecompressionofthecanal,preventingpressure
onthespinalcord.11
The extension teardrop fracture is a potentially unstable injury caused by neck
extension.ThemostcommonlocationisC2(Fig.11).Thisfractureisradiographically
similartotheflexionteardropfracture;however,thepathophysiologyandmechanism
of injury are different. In forced hyperextension, tension on the anterior longitudinal
ligamentcausesavulsionoftheanteriorinferioraspectofthevertebralbody.Neuro-
logicinjuryisusuallynotsevere,butitisextremelyimportanttopreventneckexten-
sion and thus avoid injury to the anterior ligament.12 When the extensor teardrop
728 Pimentel&Diegelmann

Fig.9. Clayshoveler’sfracture.(CourtesyofDrKaiMingLiau,PulauPinang,Malaysia.Available
at: http://static.squidoo.com/resize/squidoo_images/-1/draft_lens2184941module11827967photo_
1,222,874,817c7spinousfracture_clay_shovelers.jpg.)

occursatlowerlevels,typicallyC5toC7,centralcordsyndromemaybecausedby
bucklingoftheligamentumflavumintothecord.16

VertebralArteryInjury
Vertebralarteryocclusioncomplicates17%ofcervicalspinefractures.17Thecauseof
occlusion is usually vasospasm or dissection. Most unilateral injuries are not

Fig. 10. Hangman’sfracture.(CourtesyofDrKaiMingLiau,PulauPinang,Malaysia.Available

at: http://static.squidoo.com/resize/squidoo_images/-1/draft_lens2184941module11827962photo_
1,222,874,681c2c3subluxation.jpg.)
 AcuteCervicalSpineTrauma 729

Fig.11. Extensionteardropfracture.(ReprintedfromJarolimekAM,CoffeyEC,SandlerCM,
et al. Imaging of upper cervical spine injuries—part III: C2 below the dens. Appl Radiol
2004;33(7):9–21;withpermissionfromAndersonPublishingLtd.)

symptomaticbecausecollateralbloodissuppliedthroughtheCircleofWillis.When
present, typical clinical findings are vertigo, unilateral facial paresthesia, cerebellar
signs, lateral medullary signs, and visual field defects.18 The clinical significance of
dissectionisthepredispositiontothrombusformation,leadingtobasilarstroke.Coth-
renandcolleagues19noteaconsistent20%strokerateinuntreatedpatients.Cervical
spine injuries at high risk for vertebral artery injury are fractures associated with
subluxation,transverseprocessfracturesextendingintotheforamentransversarium,
andfracturesofC1toC3.Patientswiththeseinjuriesshouldbescreenedforvertebral
artery injury.20 The gold standard test has been 4-vessel cerebrovascular angiog-
raphy.TheincreasingavailabilityofmultisliceCTscanshasimprovedtheaccuracy
ofCTangiographyforidentificationofvertebralarteryinjury.21

SPINALCORDINJURYWITHOUTRADIOGRAPHICABNORMALITY

Mostoftenaspinalcordinjuryisassociatedwithradiographicfindingssuchasfrac-
tures,ligamentousinjuries,orsubluxations.However,aspinalcordinjurycanoccur
when bony abnormalities are not present. Spinal cord injury without radiographic
abnormality(SCIWORA)isdefinedasthepresenceofaspinalcordinjuryonmagnetic
resonanceimaging(MRI)intheabsenceofafractureorsubluxationonCTorplain
radiography. Most studies limit SCIWORA to injuries of the spinal cord, not just
a neurologic deficit that can also represent a peripheral nerve injury or a brachial
plexusinjury.Oncethoughttobeafindingprimarilyinchildren,SCIWORAhasnow
beenfoundtooccurmoreofteninadults.AretrospectivereviewoftheNEXUSdata
found that 3.3% of adult patients had SCIWORA,22 similar to the 4.2% prevalence
documentedinanothermorerecentretrospectivestudy.23

SPINALANDNEUROGENICSHOCK

Spinalshockisthephenomenonoflossofreflexesandsensorimotorfunctionbelow
thelevelofaspinalcordinjury.Itmanifestsasflaccidparalysis,includingthelossof
bowel and bladder reflexes and tone. Spinal shock is a temporary physiologic
responsetotraumathatlastsfromhourstodays.Thedegreeofrecoverydepends
730 Pimentel&Diegelmann

ontheextentoftheinitialinsult.Evenwithsevereinjury,patientswillrecoverspinal
cordreflexarcssuchasthebulbocavernosusandanalwink.24
Neurogenicshockreferstohemodynamicinstabilitythatoccursinhighspinalcord
injury,includingcervicalcordandT1-T4.The3majormanifestationsarehypotension,
bradycardia,andhypothermia.Hypotensionistheresultofsympatheticdenervation
thatcauseslossofarteriolartoneandresultsinvenouspooling.Bradycardiaoccurs
with interruption of cardiac sympathetics, allowing unopposed vagal stimulation. A
neurogenic source of shock is suggested by the combination of hypotension and
bradycardiaorvariableheartrateresponse.25,26Lossofautonomicregulationoccurs
inhighspinalinjuries,contributingtohemodynamicinstabilityandalteredthermoreg-
ulation,typicallymanifestingashypothermia.27

PREHOSPITALMANAGEMENT

Emergencymedicalservicessystems(EMS)haveonebasicprinciple:deliverfastand
efficientpatientcareforprompttransfertoahospital.Whenmanagingcervicalspine
injuries,on-sceneEMSpersonnelmustrapidlytriagepatientsandattendtothemost
criticalinjuries.Whenperformingtheinitialevaluation,theABCDEs(airway,breathing,
circulation, disability, and exposure) should be monitored first. The airway must be
securedbeforeproceedingwiththeinitialevaluation.Iftheairwayneedsimmediate
attention, manual in-line stabilization should be maintained at all times. The first
respondermustalwaysassumethataninjured patienthasaspinalcoldinjuryuntil
proven otherwise. The initial insult causes the most damage to the cervical spine,
andcautionmustbetakentopreventfurtherinjury.Goodimmobilizationtechniques
preventsecondaryinjuryandpreventtheinitialinsultfromprogressing.
EMS personnel follow protocols when approaching a patient with a potential
cervical spine injury. The first step is to survey the scene and ensure that itis safe
toapproachthepatient.AftersecuringtheABCs,theEMSprovidercanmoveonto
thesecondarysurvey,assessingtheextentofinjuries.Foranytraumapatient,EMS
providers follow standard immobilization procedures. The physician who receives
the patient in an emergency department will see various types of immobilization.
The most common are the backboard, the rigid cervical collar, spider straps, and
headblocks.Themostimportantpointistosecurethepatienttothebackboardto
minimizemovementincasethepatientvomitsandneedstoberolledontotheside
topreventaspiration.AnotherimmobilizationdeviceistheKendrickExtricationDevice
(KED),28whichisoftenusedtoimmobilizeandextricatepatientsfromvehicles.
Theprotocolforspinalimmobilizationisasfollows:

1. Maintaintheheadinneutralin-linepositionwithacervicalcollarinplace
2. Logrollthepatientontothebackboard
3. Securethetorsowithspiderstrapsorbucklestraps
4. Securetheheadtothebackboardwithfoamblocksortowelrolls
5. Securethelegstothebackboard.

Thebackboardhasclaimeditselfasthegoldstandardforspineimmobilizationin
theprehospitalsetting.Thebackboard helpsmaintainneutralposition ofthespinal
column en route and helps facilitate easy transfer once at the hospital. Occipital
paddingachievesthemostneutralposition;withoutit98%ofthepatientswouldbe
in relative extension.29 Studies are unclear regarding how long the patient should
remain on the backboard before he or she is at risk for developing complications,
suchasincreaseddiscomfortorpressureulcers.Currentrecommendationssuggest
 AcuteCervicalSpineTrauma 731

timelyremovalfromthebackboardassoonastheprimarysurveyiscompleteandthe
patientisstable,toavoidsuchcomplications.30

EMERGENCYDEPARTMENTEVALUATION
ClinicalAssessment
Amissedcervicalspineinjurycanhavedevastatingconsequences.Whenapproach-
ingthetraumapatienttoevaluatethecervicalspine,theemergencyphysicianshould
firstconsiderwhetherthespinecanbeclearedwithouttheuseofimaging.Itisbestto
approach the cervical spine evaluation in a structured manner. An unstructured
approachtoexaminingthecervicalspinehaslowsensitivitycomparedwithamore
systematicapproach.31Onecanapplystructuredclinicaldecisionrulesinalertstable
patientswithoutneurologicdeficitstodeterminehowtoproceedwiththeworkupto
evaluateforaclinicallysignificantcervicalspineinjury.Aclinicallyimportantcervical
spineinjuryisdefinedasanyfracture,dislocation,orligamentousinstabilitydemon-
stratedondiagnosticimaging.Aclinicallyunimportantinjuryisdefinedasanisolated
avulsion fracture ofanosteophyte, anisolated fracture of atransverseprocess not
involving a facet joint, an isolated fracture of a spinous process not involving the
lamina, or a simple compression fracture involving less than 25% of the vertebral
bodyheight.

AirwayManagement
Patients presenting to the emergency department may require emergency airway
management before a full assessment for cervical spine injuries can be performed.
When approaching the trauma patient, the physician should assume that an injury
to the cervical spine is present. If the patient has an associated head injury, with
a GCS score of less than 9, the risk of cervical spine injury increases significantly.
Thispatientisalsotheonewhomostlikelyneedsanemergentairway.Lesionsabove
C3causeimmediateneedforairwaymanagementbecauseofrespiratoryparalysis.
Lower lesions may cause phrenic nerve paralysis or increasing respiratory distress
fromascendingedema.Injuriestothecervicalspinemaycauselocalswelling,edema,
orhematomaformationthatmayobstructtheairway,necessitatingintubation.
Recommendationsformanagingtheairwayofatraumapatientare32:

1. Rapid-sequenceintubation (RSI):When managinganunconsciouspatient,stan-

darddrugsshouldbeusedforparalysisandinduction
2. Manual in-line stabilization: An assistant firmly holds both sides of the patient’s
head,withtheneckinthemidlineandtheheadonafirmsurfacethroughoutthe
procedure, to reduce cervical spine movement and minimize potential injury to
thespinalcord
3. Orotrachealintubationispreferredintraumapatientsrequiringintubation
4. UseatrachealtubeintroducersuchasaBougieorstylet
5. Haveaselectionofbladesready:evidencesupportstheuseofaMacintoshblade
6. Alaryngealmaskairway(LMA)canbeusedasatemporarydevice.
Manualin-lineimmobilization(MILI),asdescribedbyCrosby,33isdesignedtohold
sufficientforcesoneithersideoftheheadtopreventmovementduringinterventions
suchasairwaymanagement.Thereare2approachestoMILI:(1)anassistantstanding
attheheadofthebedgraspsthepatient’smastoidprocesswiththefingertipsand
then cradles the occiput in the palms of the hands; or (2) an assistant standing at
the side of the bed cradles the mastoids and grasps the occiput with the fingers.
Once the head and neck are stabilized by one of these methods, the front of the
732 Pimentel&Diegelmann

cervicalcollarcanberemovedtoincreasemouthopeningandvisualizationbydirect
laryngoscopy. The neck should be maintained in neutral position throughout the
procedure,andtheanterioraspectofthecollarshouldbereplacedpromptlywhen
ithasbeencompleted.
Ideally,MILIshouldpreventallmovementthatmayworsenaspinalcordinjury.In
practice, this goal is not necessarily achieved. Crosby33 found that MILI minimizes
distraction and angulation at the level of injury but has no effect on subluxation at
theinjurysite.MILImayimprovelaryngoscopicviewscomparedwithimmobilization
withacollar,sandbags,ortape.InCrosby’sseries,onlypoorviews(grade3or4),
caused by limited mouth opening, were obtained in 64% of patients immobilized
with techniques other than MILI and in 22% of the MILI group.33 In a retrospective
study,Patterson34evaluatedneurologicoutcomeinpatientswithcervicalspineinjury
whorequiredemergentintubationintheemergencydepartment.Nopatientsinwhom
cervical spine injury was subsequently identified had a worsening of neurologic
outcomerelatedtoimmobilization.Thisstudydidnotconsiderthespecifictechnique
usedtoimmobilizethecervicalspine,butdidassumethatacervicalspineinjurywas
presentinallpatientspresentingwithtrauma.

Cord-LevelFindings
Neurologicdeficitscorrelatewiththeleveloftheinjury,resultinginweaknessorparal-
ysis below the lesion. There are 8 pairs of spinal nerves in the cervical spine. The
dermatomaldistributionforthecordateachvertebraislistedinFig.12.FromC1to
C7,thenerverootexitsabovethelevelofthevertebra;fromC8andbelow,thenerve
rootexitsbelowthelevelofthevertebra.

Fig.12. Dermatomemap.(FromAgurAMR,LeeMJ,AndersonJE.Dermatomes.In:Grant’s
atlasofanatomy.9thedition.Philadelphia:LippincottWilliams&Wilkins;1991.p.252.)
 AcuteCervicalSpineTrauma 733

The presentation of incomplete cord injuries depends on the level and location
of the lesion. The anterior column conveys motor function, pain, and temperature,
and the posterior column conveys impulses related to fine touch, vibration, and
proprioception.Syndromesresultingfrompartialinjuriesaredescribedhere.

PartialCordSyndromes
Anteriorcordsyndromeresultsfromcompressionoftheanteriorspinalartery,direct
compressionoftheanteriorcord,orcompressioninducedbyfragmentsfromburst
fractures.Anteriorcordsyndromemanifestsascompletemotorparalysis,withloss
ofpainandtemperature perceptiondistal tothelesion.Posteriorcordsyndromeis
veryrare;involvementoftheposteriorcolumnismostoftenseeninBrown-Se´quard
syndrome.
Brown-Se´quardsyndromeischaracterizedbyparalysis,lossofvibrationsensation,
andproprioceptionipsilaterally,withcontralaterallossofpainandtemperaturesensa-
tion.Thesesignsandsymptomsresultfromhemisectionofthespinalcord,mostoften
frompenetratingtraumaorcompressionfromalateralfracture.
Centralcordsyndrome,inducedbydamagetothecorticospinaltract,ischaracter-
izedbyweaknessintheupperextremities,moresothaninthelowerextremities.The
weakness is more pronounced in the distal portion of the extremities. This injury is
usuallycausedbyhyperextensioninapersonwithanunderlyingconditionsuchas
stenosisorspondylosis.

CERVICALSPINEIMAGING

Twodecisionrulesguidetheuseofcervicalspineradiographyinpatientswithtrauma:
theNEXUSLowRiskCriteria(NLC)andtheCanadianC-SpineRule(CCR).TheNLC
werederivedfromtheNationalEmergencyX-radiographyUseStudy(NEXUS),which
was designed to identify patients who do not need diagnostic imaging to exclude
aclinically significantcervicalspineinjury.Cervicalspineradiographsareindicated
fortraumapatientsunlesstheyhaveallofthefollowing5characteristics:theyarealert,
arenotintoxicated,havenoposteriormidlinetenderness,havenoneurologicindica-
tionsoftheinjury,andhavenodistractinginjuries(eg,alongbonefracture,alarge
laceration,acrushinjury,alargeburn,oranotherinjurythatproducesacutefunctional
impairment).Thedefinitionsof“intoxicated”and“distractinginjury”areopentointer-
pretation,requiringphysicianjudgmentindecidingwhethertoobtainimagingstudies.
TheCCRwasdevelopedoutofconcernforthepotentiallylowspecificityandsensi-
tivityoftheNLCfordetectingclinicallysignificantcervicalspineinjuries.35TheCCR
poses3questions:

1. Doesthepatienthaveanyhigh-riskfactors?Patientsareathigherriskiftheyare
olderthan65years,iftheirmechanismofinjurywas“dangerous,”oriftheyexpe-
rienced paresthesia in the extremities after the injury. Examples of dangerous
mechanismsofinjuryincludefallfromaheightgreaterthan3ft,axialloadtothe
head,high-speedmotorvehiclecrash,rollover,ejection,andbicyclecrash.
2. Areanylow-riskfactorspresentthatwouldallowasafeassessmentofrangeof
motion?Low-riskcriteriaincludesimplerear-endmotorvehiclecrash,theability
tosituprightintheemergencydepartment,ambulationatanypointaftertheinci-
dent, delayed onset of neck pain, and the absence of midline cervical spine
tenderness.
3. Isthepatientabletoactivelyrotatetheneck45totheleftandright?Ifthepatient
has active rotation of the neck as well as low-risk factors and the absence of
734 Pimentel&Diegelmann

high-riskfactors,thenthephysiciancansafelyclearthespinewithoutradiographic
imaging.35

A prospective cohort study done in Canada found the CCR to be more sensitive
(99.4%vs90.7%)andspecific(45.1%vs36.8%)thantheNLCfordetectinginjury.
Inaddition,theCCRresultedindecreasedradiographyrates(55.9%vs66.6%).36

ImagingModalities
Threemethodsexistforimagingthecervicalspineintheemergencydepartment:plain
radiographs,CT,andMRI.Eachhasadvantagesanddisadvantages,andtheclinical
situationmustbeconsideredwhendecidingwhichmethodtouse.
Plainradiographytypicallyincludes3views:anteroposterior,lateral,andodontoid.
Thisimagingmodalityisfallingoutoffavorbecauseitsfalse-negativerateishigher
thanthatassociatedwithCT.EmergencydepartmentscommonlyrelyonCTimaging
toevaluatepatientsforinjury.CTallowseasyimagingofthecervicalspinewhenclin-
icallyindicated.ACTscanisbestfordetectingbonyabnormalities;itcandetect97%
ofosseousfractures.Whenligamentousinjuryorspinalcordinjuryissuspected,MRI
is indicated. Holmes and colleagues37 reported that CT detected no spinal cord
injuriesandonly25%ofligamentousinjuriesintraumapatients.Inthesameseries,
MRIalloweddiscoveryofallspinalcordandligamentousinjuries.

EMERGENCYDEPARTMENTMANAGEMENT

Thetreatmentofcervicalspineinjuriesbeginsaftertheinitialclinicalevaluation.After
management of the airway, attention to hemodynamic support and blood pressure
managementisessential.Hypotensionshouldnotbeattributedtoneurogenicshock
until blood loss or other trauma-related causes have been managed or ruled out.
Regardlessofetiology,itiscriticallyimportanttoaggressivelymanagehypotension
inpatientswithcervicalcordinjuries.Hypotensionisassociatedwithworseoutcomes
and is thought to contribute to secondary injury because of reduced spinal cord
perfusion.38
Thegoalforoptimalspinalcordperfusionismaintenanceofameanarterialpres-
sureof85to90mmHg.Unstablepatientsrequirearteriallinesandcentralvenous
orSwanGanzmonitoring.Initialtreatmentiswithcrystalloid.Ifindicated,bloodtrans-
fusionshouldbestartedtocorrectbloodloss.Aftervolumecorrection,ifthemean
arterialpressureremainslow,pressorsshouldbeinitiated.Avasopressorshouldbe
chosen with the goal of treating both hypotension and bradycardia. Agents with
a-andb-agonistproperties,suchasdopamine,norepinephrine,orepinephrine,are
preferred to provide both inotropic and chronotropic support. Caution is warranted
whenconsideringtheuseofphenylephrineitspurestimulationofa-receptorsisasso-
ciatedwithreflexbradycardia.Bradycardiamayrequireatropineorapacemaker.27,38
In patients with a cervical spine injury and abnormal neurologic examination, the
questionoftheefficacyandsafetyofmethylprednisolonearises.Threemulticenter,
randomized, double-blind clinical trials have studied this question. Results of the
NationalAcuteSpinalCordInjuryStudiesI,II,andIII(NASCII,II,andIII)werepub-
lishedin1984,1990,and1997.39–41 Thefirststudycomparedoutcomesinpatients
treated with a 100-mg bolus of methylprednisolone and then 100 mg daily for 10
days with those of patients treated with a 1000-mg bolus and then 1000 mg per
day for 10 days in 330 patients with acute spinal injury. The investigators reported
nodifferenceinneurologicrecoveryat6weeksand6monthsafterinjury.Acontrol
groupwasnotused.
 AcuteCervicalSpineTrauma 735

NASCI II used a much higher dose of methylprednisolone (a 30-mg/kg bolus fol-

lowedbya5.4-mg/kg/hinfusionfor23hours).Thisgroupwascomparedwithpatients
withcomparableinjuriestreatedwithanaloxoneregimenorplacebo.Atotalof487
patientswereenrolledanddividedinto3treatmentarms.Patientsinthemethylpred-
nisolonearmtreatedwithin8hoursofinjuryhadastatisticallysignificantimprovement
inmotorandsensoryfunctionat6monthscomparedwiththoseintheother2groups.
TheGuidelinesfortheManagementofAcuteCervicalSpineandSpinalCordInjuries,
publishedbytheAmericanAssociationofNeurologicalSurgeons(AANS),document
methodological,scientific,andstatisticalflawsinthetrial,citingnumerouscriticisms
infollow-uppublications.38
TheNASCISIIItrialcomparedtheefficacyofmethylprednisolonefor24hourswith
thatofa48-hourregimen.Thesalientfindingswerethatpatientsinallgroupstreated
within3hoursafterinjurydidequallywell.Amongpatientstreatedbetween3and8
hoursafterinjury,thosereceivingthe48-hourregimenwerestatisticallysignificantly
better at 6 weeks and 6 months than those treated for 24 hours. Unfortunately,
patientstreatedfor48hoursalsohadhigherratesofseveresepsisandseverepneu-
monia.Nevertheless,theinvestigatorsrecommended24hoursoftreatmentforthose
receivingmethylprednisolonewithin3hoursofinjuryand48hoursoftherapyforthose
forwhomtreatmentstarted3to8hoursafterinjury.41 Intheirpublishedguidelines,
however, the AANS concludes that the available evidence does not demonstrate
significant clinicalbenefit of treatment of patients with acute spinal cord injury with
methylprednisoloneforeither24or48hours.Thereportstates,“Inlightofthefailure
ofclinicaltrialstoconvincinglydemonstrateasignificantclinicalbenefitofadministra-
tionofmethylprednisolone,inconjunctionwiththeincreasedrisksofmedicalcompli-
cationsassociatedwithitsuse,methylprednisoloneinthetreatmentofacutehumans
spinalcordinjuryisrecommendedasanoptionthatshouldonlybeundertakenwith
theknowledgethattheevidencesuggestingharmfulsideeffectsismoreconsistent
thanthesuggestionofclinicalbenefit.”38 Theinvestigatorssuggestthatemergency
physiciansconsidertheindividualfactorsuniquetoeachclinicalcasewhenmaking
thedecisionofwhethertoinitiatetreatment.Consultationwiththeacceptingtrauma
serviceorneurosurgeonisappropriateandencouraged.
Surprisingly little evidence exists to guide emergency physicians when treating
patients with cervical strain without associated fracture or neurologic deficit.
Commonlyusedmodalitiesincluderest,ice,analgesics,andmusclerelaxants.Acet-
aminophenandnonsteroidalanti-inflammatory medicationsarethecornerstonesof
analgesictherapyintheUnitedStates.Turturroandcolleagues42studiedtheefficacy
of 800 mg ibuprofen with and without cyclobenzaprine administered to adults with
acutemyofascialstrain.Theseinvestigatorsfoundsignificantpainreliefat48hours
but no incremental benefit to the use of cyclobenzaprine. Central nervous system
sideeffectsweremoreprevalentinthegroupreceivingcyclobenzaprine.Cyclobenza-
prinealone,however,hasdemonstratedefficacyinacutemusclespasmoftheneck
andback.43Onestudyshowednodifferenceinpainreliefbetweenpatientsreceiving
5mg3timesperdayand10mg3timesperday.Sedationwaslowerintheformer
group.ACochraneReviewfoundthatadministrationofintravenousmethylpredniso-
lone within 8 hours of injury significantly reduced pain at 1 week and decreased
days lost from work at 6 months.44 Other evidence suggests that gentle exercise
andphysicaltherapyaremoreefficaciousthanrest,softcollar,andgradualadvance-
mentofneckmobility.45 Basedonthelimitedevidencetodate,theauthorsrecom-
mend gentle range of motion exercises and treatment with an analgesic such as
ibuprofen.Inpatientswithcontraindicationstononsteroidalanti-inflammatorymedi-
cationsorpalpablespasm,amusclerelaxantsuchascyclobenzaprineat5mg3times
736 Pimentel&Diegelmann

perdaymaybesubstituted.Allpatientsshouldfollowupwithaprimarycarephysician
whocanarrangeforphysicaltherapyifnecessary.

DISPOSITION

Earlyconsultationwithaspineorneurosurgeoniscriticaltooptimalmanagementof
cervicalspineinjuries.Earlyinterventionaccomplishingclosedreduction,halotrac-
tion, open reduction, or decompression of serious injuries with cord compromise
providesthebestpatientoutcomes.Criticalcareconsultationandadmissiontothe
intensive care unit are indicated for unstable cervical spinefractures or spinal cord
injury.Numerousstudiesdocumentthebenefitsandimprovedneurologicoutcomes
of optimal hemodynamic and respiratory management. Severely injured patients
frequently suffer from hypotension, cardiac instability, hypoxemia, and pulmonary
dysfunctionfor7to14days.38Placementofahardcervicalcollarprovidesprotection
fromasecondaryinjury.Thosewithminormuscularandligamentousstrainmaybe
treated symptomatically with analgesics or muscle relaxants and gentle range of
motionexercises.

SUMMARY

Cervicalspinetraumaishighriskandanxietyprovokingforpatientsandemergency
physicians.Adetailedunderstandingoftheclinicalapproachtothepatientinthefield
andtheemergencydepartmentisessentialtolimitmorbidity.Thisarticlehasreviewed
the clinical and radiographic evaluation, relevant anatomy, common fractures, and
management principles. Careful study and implementation of these concepts
provides the emergency physician with the necessary knowledge to safely and
expertlycareforthisimportantgroupofinjuredpatients.

ACKNOWLEDGMENTS

TheauthorsthankLindaKesselring,ELSfortechnicalassistanceinthepreparation
ofthemanuscript.

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