Overview
Cervical Spine Injury
Quick Reference
Critical Alerts
- Assume c-spine injury until cleared: In all high-risk trauma patients
- Neurogenic shock: Bradycardia + hypotension = spinal cord injury pattern
- Avoid secondary injury: Maintain MAP >85 mmHg for spinal perfusion
- Clinical clearance possible: Use NEXUS or Canadian C-Spine Rules
- CT is gold standard: For imaging in adults
- Complete vs incomplete: Incomplete injuries have better prognosis
Key Diagnostics
| Test | Finding | Significance |
|---|---|---|
| NEXUS/CCR | Low-risk criteria met | Clinical clearance without imaging |
| CT C-spine | Fracture, subluxation, prevertebral swelling | Gold standard imaging |
| MRI C-spine | Ligamentous injury, spinal cord damage, SCIWORA | If neurological deficit or CT concerning |
| Motor/Sensory exam | Level of injury, complete vs incomplete | Determines prognosis and management |
Emergency Treatments
| Condition | Treatment | Details |
|---|---|---|
| Immobilization | Rigid collar + spine board | Until clinically cleared |
| Neurogenic shock | IV Fluids + Vasopressors | Target MAP >5 mmHg |
| Spinal cord injury | High-dose methylprednisolone | Controversial; if used, within 8 hours |
| Respiratory failure | Intubation | Manual in-line stabilization |
| Unstable fracture | Surgical stabilization | Neurosurgery consultation |
Definition
Overview
Cervical spine injury encompasses fractures, dislocations, and/or ligamentous injuries to the cervical vertebrae (C1-C7) and associated soft tissues. Spinal cord injury (SCI) may or may not accompany bony injury. These injuries range from stable fractures requiring collar immobilization to unstable injuries requiring surgical fixation, with outcomes varying from full recovery to complete quadriplegia or death.
Classification
By Stability:
| Classification | Features | Examples |
|---|---|---|
| Stable | Intact posterior ligamentous complex | Wedge compression, spinous process fracture |
| Unstable | Disruption of 2 or more columns | Bilateral facet dislocation, burst fracture |
By Level:
- Upper cervical (C1-C2): Atlas (C1) and axis (C2) fractures; high mortality if complete SCI
- Subaxial (C3-C7): Most common location for injury; C5-C6 most frequently involved
By Neurological Status:
| Type | Definition | Prognosis |
|---|---|---|
| Complete SCI | No motor or sensory function below injury | <5% recover ambulation |
| Incomplete SCI | Some function preserved below level | Better prognosis varies by syndrome |
| No SCI | Bony/ligamentous injury without cord damage | Best prognosis |
Epidemiology
- Incidence: 15,000-20,000 new SCI per year in US
- Cervical involvement: 55% of all spinal injuries
- Age distribution: Bimodal - young adults (trauma) and elderly (falls)
- Gender: Male 80% of SCI
- Mortality: 10-15% pre-hospital mortality; C1-C2 injuries higher
- Leading causes: MVCs (40%), falls (30%), violence (14%), sports (8%)
Etiology and Mechanisms
High-Risk Mechanisms:
| Mechanism | Associated Injuries |
|---|---|
| High-speed MVC | Multiple level injuries, associated injuries |
| Motorcycle crash | Severe injuries, road rash |
| Diving into shallow water | Upper c-spine, athletic injuries |
| Fall from height | Compression fractures, elderly |
| Assault/GSW | Direct trauma, unstable |
| Contact sports | Flexion/extension injuries |
Mechanism-Injury Correlation:
| Mechanism | Typical Injury |
|---|---|
| Axial loading | Burst fracture, Jefferson fracture (C1) |
| Hyperflexion | Wedge compression, bilateral facet dislocation |
| Hyperextension | Hangman's fracture (C2), central cord syndrome |
| Rotation | Unilateral facet dislocation |
| Combined | Complex fracture-dislocations |
Pathophysiology
Primary vs Secondary Injury
Primary Injury:
- Immediate mechanical damage at time of trauma
- Cord compression, laceration, contusion
- Cannot be reversed; prevention is key
Secondary Injury:
- Occurs minutes to weeks after primary injury
- Mechanisms: ischemia, inflammation, edema, excitotoxicity
- Potentially preventable with aggressive management
- Reason for MAP goal >85 mmHg
Spinal Cord Syndromes
| Syndrome | Mechanism | Features | Prognosis |
|---|---|---|---|
| Central Cord | Hyperextension (elderly) | UE > LE weakness; bladder dysfunction | Fair; LE recovery first |
| Anterior Cord | Flexion injury; anterior spinal artery | Motor and pain/temp loss; preserved proprioception | Poor |
| Brown-Séquard | Penetrating injury; hemisection | Ipsilateral motor/proprioception loss; contralateral pain/temp loss | Best prognosis |
| Posterior Cord | Rare; extension injury | Loss of proprioception; motor preserved | Good |
| Complete Transection | Severe injury | Complete loss below level | Poor |
| Cauda Equina | Lower injury (not true SCI) | LMN; bowel/bladder; saddle anesthesia | Variable |
Neurogenic Shock vs Spinal Shock
| Feature | Neurogenic Shock | Spinal Shock |
|---|---|---|
| Definition | Loss of sympathetic tone | Transient loss of all cord function below injury |
| Mechanism | Disruption of sympathetic pathways | Cord "stunning" |
| Presentation | Hypotension + bradycardia + warm extremities | Flaccid paralysis, areflexia |
| Duration | Days to weeks | Hours to weeks |
| Management | Vasopressors, fluids | Supportive; monitor for return of reflexes |
Clinical Presentation
History
AMPLE History:
Key Questions:
Physical Examination
Spinal Examination (Log-roll with in-line stabilization):
| Assessment | Findings |
|---|---|
| Midline tenderness | Highly sensitive for fracture |
| Step-off | Suggests dislocation |
| Swelling/hematoma | Local injury |
| Crepitus | Unstable fracture |
| Muscle spasm | Protective response |
Neurological Examination (ASIA Assessment):
| Component | Assessment |
|---|---|
| Motor | Key muscle groups C5-T1, L2-S1 (0-5 grading) |
| Sensory | Light touch and pin prick at each dermatome |
| Deep tendon reflexes | Biceps (C5-6), triceps (C7), patellar (L3-4), Achilles (S1) |
| Rectal exam | Tone, voluntary contraction, perianal sensation |
| Bulbocavernosus reflex | First reflex to return after spinal shock |
ASIA Impairment Scale:
| Grade | Description |
|---|---|
| A | Complete - no motor or sensory function in S4-S5 |
| B | Sensory incomplete - sensory but no motor below level, including S4-S5 |
| C | Motor incomplete - motor function preserved below, <50% key muscles grade 3 |
| D | Motor incomplete - motor function preserved, ≥50% key muscles grade 3 |
| E | Normal |
Distracting Injuries: May mask c-spine symptoms
Allergies
Common presentation.
Medications (especially anticoagulants)
Common presentation.
Past medical history (prior spine disease, rheumatoid arthritis, ankylosing spondylitis)
Common presentation.
Last meal
Common presentation.
Events/mechanism of injury
Common presentation.
Red Flags
Life-Threatening Conditions
| Finding | Concern | Action |
|---|---|---|
| Hypotension + bradycardia | Neurogenic shock | Vasopressors, fluids, maintain MAP >5 |
| Respiratory failure | High cervical injury (C3-5) | Early intubation with in-line stabilization |
| Rapidly ascending paralysis | Expanding hematoma, edema | Emergent imaging and surgery |
| Complete quadriplegia | High cord injury | ICU, multidisciplinary care |
| Associated severe TBI | Concurrent injuries | Manage both simultaneously |
High-Risk Features for C-Spine Injury
- Age >65 years
- Ankylosing spondylitis, rheumatoid arthritis, Down syndrome
- Dangerous mechanism (fall >3 ft, axial load, MVC >100 km/h, rollover, ejection)
- Paresthesias in extremities
- Midline cervical tenderness
- Focal neurological deficit
- Inability to actively rotate neck 45° bilaterally
Differential Diagnosis
Must-Consider Alternatives
| Condition | Distinguishing Features |
|---|---|
| Cervical strain/sprain | No fracture on imaging, normal neurological exam |
| Pre-existing cervical spondylosis | Chronic changes on imaging, no acute trauma |
| Disc herniation | Radicular symptoms, MRI findings |
| Central cord syndrome without fracture | SCIWORA - MRI positive |
| Vertebral artery dissection | Neck pain, posterior circulation symptoms |
| Myocardial infarction | Chest pain, troponin elevation (for anterior neck pain) |
| Cardiac arrhythmia | ECG changes (for bradycardia without trauma history) |
Diagnostic Approach
Clinical Clearance Algorithms
NEXUS Criteria (Low-Risk Criteria - All Must Be Met):
| Criterion | Assessment |
|---|---|
| No midline cervical tenderness | Palpation of spinous processes |
| No focal neurological deficit | Motor/sensory exam |
| Normal level of alertness | GCS 15 |
| No intoxication | Clinical assessment, BAL |
| No painful distracting injury | Clinical assessment |
If ALL criteria met: C-spine can be cleared clinically (sensitivity 99.6%)
Canadian C-Spine Rule (CCR):
| Step | Question |
|---|---|
| 1 | Any high-risk factor? (Age ≥65, dangerous mechanism, paresthesias) → YES = image |
| 2 | Any low-risk factor that allows safe assessment? (Simple MVC, sitting in ED, ambulatory, delayed onset pain, no midline tenderness) → NO = image |
| 3 | Can actively rotate neck 45° left and right? → NO = image, YES = clear |
CCR sensitivity: 99.4%; more specific than NEXUS
Imaging Studies
CT C-Spine (Gold Standard):
| Indication | Notes |
|---|---|
| Does not meet NEXUS/CCR for clearance | First-line imaging |
| High-risk mechanism | All trauma patients not clinically cleared |
| Obtunded/altered mental status | Cannot be clinically assessed |
| Known or suspected SCI | Essential for surgical planning |
- Sensitivity: >99% for bony injury
- Reconstructions: Include sagittal and coronal reformats
CT Angiography:
- Consider if high-risk for vertebral artery injury
- Transverse foramen involvement, high-energy mechanism
MRI C-Spine:
| Indication | Findings |
|---|---|
| Neurological deficit with CT findings | Cord compression, hemorrhage, edema |
| Neurological deficit with normal CT (SCIWORA) | Ligamentous injury, cord contusion |
| Awake patient with persistent pain/tenderness and normal CT | Ligamentous injury, disc herniation |
- Best for: Soft tissue, ligaments, spinal cord assessment
Plain Radiographs:
- Largely replaced by CT in adults
- May still be used in low-resource settings or pediatrics
- Three views: AP, lateral, open-mouth odontoid
- Sensitivity ~60-80% (inadequate)
Evaluation of Obtunded Patient
- Maintain immobilization
- CT c-spine (should capture at top of skull to T1 minimum)
- If CT negative:
- Option 1: MRI within 72 hours
- Option 2: Collar removal after 48-72 hours of observation if no clinical concern
- If CT positive: Neurosurgery consultation, MRI as indicated
Treatment
Principles of Management
- Immobilization: Until injury excluded or treated
- Spinal perfusion: Maintain MAP >85 mmHg if SCI
- Prevent secondary injury: Avoid hypoxia, hypotension, hyperthermia
- Definitive treatment: Collar, halo, surgery based on injury
- Complication prevention: DVT prophylaxis, respiratory care, skin care
Pre-Hospital and Initial Stabilization
Spinal Motion Restriction:
| Equipment | Indication | Duration |
|---|---|---|
| Rigid cervical collar | All suspected c-spine injury | Until cleared |
| Head blocks/tape | Added if on spine board | Until imaging |
| Spine board | Only for extrication | Remove ASAP (pressure ulcer risk) |
| Log-roll technique | Any patient repositioning | Until cleared |
Airway Management in C-Spine Injury:
- Preferred technique: Video laryngoscopy with manual in-line stabilization (MILS)
- Front of collar removed, manual stabilization maintained
- Avoid excessive neck movement
- Consider awake intubation if time permits and patient cooperative
Hemodynamic Management
Neurogenic Shock (SCI injury above T6):
| Intervention | Target |
|---|---|
| IV fluid resuscitation | Cautious boluses (1-2L) - may worsen pulmonary edema |
| Vasopressors | Norepinephrine or phenylephrine |
| MAP target | >5 mmHg for 5-7 days |
| Heart rate | Monitor; bradycardia may require atropine or temporary pacing |
Differentiate from Hemorrhagic Shock:
| Feature | Neurogenic | Hemorrhagic |
|---|---|---|
| Heart rate | Bradycardia | Tachycardia |
| Skin | Warm, dry, flushed | Cool, clammy |
| Response to fluids | Minimal | Improvement |
Pharmacological Treatment
Methylprednisolone (Controversial):
- Not currently recommended by most guidelines (AANS, CNS)
- If used: Started within 8 hours, 30mg/kg bolus then 5.4mg/kg/hr × 23-48 hours
- Associated risks: Infection, GI bleeding, hyperglycemia
- Discuss with neurosurgery
Other Considerations:
- H2 blocker or PPI for stress ulcer prophylaxis
- DVT prophylaxis: Mechanical initially; chemical when safe
- Bowel regimen
- Pain management (avoid hypotension from opioids)
Specific Injury Management
Upper Cervical (C1-C2):
| Injury | Management |
|---|---|
| Jefferson fracture (C1 burst) | Collar vs halo vs surgery depending on stability |
| Hangman's fracture (C2 pars) | Often stable; collar vs halo |
| Odontoid fracture Type I | Collar |
| Odontoid fracture Type II | High non-union rate; often surgery |
| Odontoid fracture Type III | Halo or collar |
| Atlantoaxial subluxation | Urgent surgical stabilization |
Subaxial (C3-C7):
| Injury | Management |
|---|---|
| Compression fracture (<25%) | Collar if stable |
| Burst fracture | Collar vs surgery based on canal compromise |
| Unilateral facet dislocation | Closed reduction then surgery |
| Bilateral facet dislocation | Urgent closed/open reduction; posterior fusion |
| Flexion-distraction | Surgical stabilization |
Surgical Considerations
- Indications: Unstable injuries, neurological deficit with cord compression, failed closed reduction
- Timing: Early surgery (<24 hours) may improve neurological outcomes in incomplete SCI
- Approach: Anterior, posterior, or combined based on injury pattern
Disposition
Admission Criteria
ICU Admission:
- Spinal cord injury with neurological deficit
- Neurogenic shock requiring vasopressors
- Respiratory compromise (especially high cervical)
- Unstable fracture requiring monitoring
- Polytrauma with c-spine injury
Floor Admission:
- Stable fractures requiring observation
- Post-operative monitoring
- Pain control
Discharge Criteria (for Stable Injuries Managed Non-Operatively)
- Fracture stable for outpatient management (per neurosurgery)
- Adequate pain control with oral medications
- Proper collar fitting and instructions
- Able to perform ADLs with assistance arranged
- Follow-up arranged (spine surgery)
- Driving restrictions discussed
Follow-Up
| Timeframe | Purpose |
|---|---|
| 1-2 weeks | Spine surgery follow-up |
| 6 weeks | Repeat imaging (flexion/extension views) |
| 3 months | Assessment of healing |
| Ongoing | Rehabilitation for SCI patients |
Patient Education
Collar Wear Instructions
- Wear collar at all times until cleared by surgeon
- Do not remove collar except as instructed for skin care
- Keep skin under collar clean and dry
- Check for skin breakdown
- Sleep with collar on; may use thin pillow
Activity Restrictions
- No driving until medically cleared
- No heavy lifting, strenuous activity
- Avoid bending or twisting neck
- Gradual return to activity as directed
Warning Signs Requiring Return
- New or worsening weakness or numbness
- Difficulty breathing
- Loss of bladder or bowel control
- Increasing pain
- Fever
Special Populations
Elderly (>65 years)
- Higher incidence from falls
- Pre-existing spondylosis makes imaging interpretation difficult
- Higher mortality from SCI
- More likely to have central cord syndrome
- Lower threshold for imaging (included in CCR high-risk)
Ankylosing Spondylitis/DISH
- "Bamboo spine" - extremely brittle
- Low-energy mechanisms can cause unstable injuries
- Fractures may not be apparent on initial imaging
- MRI often needed
- Higher rate of neurological injury
- Maintain in position found (may be kyphotic)
Pediatric Patients
- SCIWORA more common (ligamentous laxity)
- Pseudosubluxation of C2 on C3 is normal finding
- Plain films may be appropriate first-line
- Lower threshold for MRI
- Higher cervical injuries (C1-C3) more common
Pregnant Patients
- Shield fetus during imaging, but CT if clinically indicated
- MRI safe (no gadolinium in 1st trimester if possible)
- Consider left lateral displacement of uterus
- Involve obstetrics
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Immobilization maintained until clearing | 100% | Prevent secondary injury |
| Clinical clearance rule applied | >0% | Reduce unnecessary imaging |
| CT within 1 hour (high-risk) | 100% | Rapid diagnosis |
| MAP maintained >5 (if SCI) | 100% | Spinal perfusion |
| DVT prophylaxis initiated | 100% | High VTE risk in SCI |
| Neurosurgery consulted for SCI | 100% | Specialty care |
Documentation Requirements
- Mechanism of injury
- Neurological examination (motor level, sensory level, ASIA grade)
- Immobilization status
- Clinical clearance criteria if applied
- Imaging results
- MAP goals and vasopressor use if SCI
- Surgical consultation
- Disposition plan
Key Clinical Pearls
Diagnostic Pearls
- NEXUS and CCR are validated: Can safely clear c-spine without imaging
- CCR is more specific than NEXUS: Fewer unnecessary CTs
- CT is gold standard: Plain films are inadequate in adults
- MRI for persistent symptoms with normal CT: Ligamentous injury
- SCIWORA exists: Normal CT with cord injury - get MRI
- Check for vertebral artery injury: With transverse foramen fractures
Treatment Pearls
- Maintain MAP >85 for SCI: Improves outcomes, especially early
- Neurogenic shock = bradycardia + hypotension: Different from hemorrhage
- Early intubation if high cervical injury: Before respiratory failure
- Steroids are controversial: Most guidelines do not recommend
- Early surgery may improve outcomes: In incomplete SCI with compression
- Remove spine board ASAP: Pressure ulcers develop within hours
Disposition Pearls
- All SCI to trauma/spine center: Specialized care essential
- Collar instructions at discharge: Patients often remove incorrectly
- Driving restrictions: Important safety counseling
- VTE prophylaxis critical: High risk in SCI patients
- Rehabilitation planning starts early: Even in ICU
References
- Hoffman JR, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99.
- Stiell IG, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518.
- Ryken TC, et al. The acute cardiopulmonary management of patients with cervical spinal cord injuries. Neurosurgery. 2013;72 Suppl 2:84-92.
- Fehlings MG, et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury. Global Spine J. 2017;7(3_suppl):84S-94S.
- Como JJ, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma. J Trauma. 2009;67(3):651-659.
- Schroeder GD, et al. Cervical Spine Injuries in the Elderly. J Am Acad Orthop Surg. 2018;26(17):e361-e369.
- American Spinal Injury Association. International Standards for Neurological Classification of SCI (ISNCSCI). 2019.
- Patel MB, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient. J Trauma Acute Care Surg. 2015;78(2):430-441.