Evaluation and Management of Cervical Spine Injuries

Primary survey and resuscitation

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  Airway

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  Protect the C-spine

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  Breathing

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  Circulation

Rule out life-threatening injuries.

Clinical

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  Neck pain

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  C-spine tenderness

Imaging

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  Plain film

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    Anteroposterior (AP) view, lateral view (must include C7–T1), and open-mouth odontoid views are required for the evaluation.

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    Information from lateral view

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      Vertebral alignment for the diagnosis of subluxation

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        Pseudo-subluxation: physiological misalignment, normally seen in children

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        Displacement of >3 mm is considered pathological.

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    Diagnosis of cervical fractures based on soft-tissue swelling

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      Normal nasopharyngeal space in an adult at C1 level: 10 mm

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      Normal retropharyngeal space in an adult at C2–4 level: 5–7 mm

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      Normal retrotracheal space at C5–6 level: 22 mm (adults), 14 mm (children)

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    20% of injuries can be missed in plain x-ray.

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    Flexion/Extension view is indicated to evaluate the stability of the injury.

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    Open-mouth view is good for the evaluation of odontoid fracture.

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  CT scan

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    Imaging of choice for the evaluation of details of the bony structures, fracture displacement, and disc herniation

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    Indications

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      Spine injury with neurological deficit

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      Fracture of the posterior element of the cervical canal

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      Subtle fractures for detailed information

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      Bony details in fractures

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  Magnetic resonance imaging (MRI)

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    Imaging of choice for the evaluation of soft tissue structures, disc herniation, and neural structures

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    Indications

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      Fracture with spinal canal involvement

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      Fracture with neurological deficits

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      Suspected ligamentous injuries and soft tissue injuries

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      Evaluation of intervertebral disc

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      Evaluation of epidural hematoma

Respiratory failure

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  Phrenic nerve injury causing diaphragmatic palsy in C3–C5 spinal cord injury

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  Atlantooccipital dislocation causing brainstem injury and acute respiratory failure

Neurogenic shock

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  Cervical and upper thoracic spinal cord injury due to loss of sympathetic tone

Neurological deficit

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  Spinal shock

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  Spinal cord injury at C1–C8 results in complete or incomplete quadriplegia.

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  Nerve injury at neural foramina

Blunt cerebral vascular injury (BCVI)

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  Injury to carotid and vertebral arteries

Flexion

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  Most common mechanism

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  Usually after MVC or diving injury

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  Injuries

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    Anterior atlantoaxial subluxation

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    Anterior subluxation (hyperflexion sprain)

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    Anterior wedge fracture

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    Clay shoveler’s fracture

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    Flexion teardrop fracture

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    Bilateral facet dislocation

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    Hyperflexion fracture–dislocation

Lateral flexion

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  C1 (atlas) lateral mass fracture

Flexion/rotation

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  Unilateral facet dislocation

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  Rotatory atlantoaxial dislocation

Extension

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  Hangman’s fracture: symmetric fracture of bilateral pedicles (pars interarticularis) of C2 (axis) vertebra

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  Extension teardrop fracture

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  Posterior arch C1 fracture

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  Posterior atlantoaxial subluxation

Extension/rotation

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  Articular pillar fracture

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  Floating pillar

Axial loading/compression

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  Burst fracture

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  Jefferson fracture: burst fracture of the atlas (C1) with involvement of anterior and posterior arches

Complex mechanism

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  Odontoid process fracture: hyperflexion or hyperextension with or without compression

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  Atlantooccipital dislocations due to shearing mechanism

Direct injury: Penetrating injury