Cervical Spine Injury in Adults

Quick Reference

Critical Alerts

Critical Alert: Assume c-spine injury until cleared: In all high-risk trauma patients with altered consciousness, dangerous mechanism, or neurological symptoms

Critical Alert: Neurogenic shock: Bradycardia + hypotension + warm peripheries = spinal cord injury pattern - differentiate from hemorrhagic shock

Critical Alert: Maintain spinal perfusion: Target MAP ≥85-90 mmHg for 5-7 days in acute SCI to prevent secondary ischemic injury

Critical Alert: Respiratory compromise: High cervical injuries (C3-C5 - "C3-4-5 keeps the diaphragm alive") may cause respiratory failure requiring early intubation

Key Diagnostics

Emergency Treatments

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Definition

Overview

Cervical spine injury encompasses fractures, dislocations, and ligamentous injuries affecting the cervical vertebrae (C1-C7) and associated supporting structures, with or without spinal cord involvement. These injuries represent a spectrum from stable fractures requiring collar immobilization to unstable injuries necessitating emergent surgical intervention, with outcomes ranging from complete recovery to permanent quadriplegia or death.

The cervical spine is anatomically divided into the upper cervical spine (occiput-C1-C2 complex, the "craniocervical junction") and the subaxial cervical spine (C3-C7). Each region has distinct biomechanics, injury patterns, and treatment considerations. Understanding these differences is fundamental to appropriate clinical management. [5]

Epidemiology

Cervical spine injuries represent a significant public health burden with substantial morbidity and healthcare costs. Evidence-based epidemiological data guides clinical decision-making and resource allocation.

Leading Causes by Age Group:

• Young adults (16-35): Motor vehicle collisions (40%), violence (15%), sports/diving (13%)
• Elderly (> 65): Falls (60%), often low-energy mechanism
• Overall: MVCs remain the leading cause globally [6]

Classification Systems

By Anatomical Level:

By Mechanism of Injury:

Subaxial Cervical Spine Injury Classification (SLIC): [8]

SLIC Management Guidelines:

• Score 1-3: Non-operative management generally indicated
• Score 4: Either operative or non-operative (surgeon discretion)
• Score ≥5: Operative management generally recommended [8]

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Pathophysiology

Primary Injury

Primary injury occurs at the moment of trauma and represents the immediate mechanical insult to neural and supporting structures. The extent of primary injury is determined by the magnitude and direction of applied forces relative to the spine's tolerance limits.

Mechanisms of Primary Neural Injury:

• Compression: Bone fragments or disc material impinging on cord
• Contusion: Direct bruising of cord parenchyma
• Laceration: Rare; penetrating trauma or severe displacement
• Stretching/distraction: Traction injury to neural elements
• Ischemia: Vascular disruption leading to immediate infarction

Exam Detail: Biomechanical Considerations:

The cervical spine must balance mobility (greatest range of motion in the spine) with protection of neural structures. Key vulnerabilities include:

1. Upper cervical spine: 50% of cervical rotation occurs at C1-C2; the dens is inherently unstable and relies on ligamentous support
2. Subaxial spine: Greatest flexion-extension at C5-C6; smallest canal-to-cord ratio at this level
3. Vertebral arteries: Course through transverse foramina C1-C6; vulnerable in rotational and distraction injuries

Denis Three-Column Concept (adapted for cervical spine):

• Anterior column: Anterior 2/3 of vertebral body, ALL, anterior annulus
• Middle column: Posterior 1/3 of vertebral body, PLL, posterior annulus
• Posterior column: Pedicles, facets, laminae, spinous processes, interspinous ligaments

Disruption of ≥2 columns typically indicates instability requiring surgical stabilization. [5]

Secondary Injury

Secondary injury is the progressive neurological deterioration following the initial insult, occurring over minutes to weeks post-injury. This cascade represents the primary target for neuroprotective interventions and aggressive medical management. [9]

Temporal Phases of Secondary Injury:

Key Secondary Injury Mechanisms:

1. Vascular dysfunction:

   • Loss of autoregulation
   • Vasospasm and microvascular thrombosis
   • Blood-spinal cord barrier disruption
   • Hemorrhagic necrosis extension

2. Ionic imbalance:

   • Calcium influx triggering cascades
   • Sodium/potassium pump failure
   • Intracellular edema

3. Excitotoxicity:

   • Glutamate accumulation
   • NMDA and AMPA receptor overactivation
   • Calcium-mediated cell death

4. Inflammatory cascade:

   • Microglial activation
   • Neutrophil infiltration (peaks 24-48 hours)
   • Cytokine release (IL-1β, TNF-α, IL-6)
   • Secondary tissue damage

5. Oxidative stress:

   • Free radical generation
   • Lipid peroxidation
   • Mitochondrial dysfunction

Clinical Pearl: Rationale for MAP ≥85 mmHg Target: The injured spinal cord loses autoregulation. Maintaining adequate perfusion pressure prevents ischemic extension of the injury penumbra. This is the primary modifiable factor in the acute phase. [9,10]

Spinal Cord Syndromes

Understanding the classical spinal cord syndromes is essential for localization, prognostication, and examination purposes. Each syndrome has characteristic clinical features based on the specific cord tracts affected.

Exam Detail: Central Cord Syndrome - Detailed Pathophysiology:

Most common incomplete SCI syndrome, accounting for approximately 9% of all traumatic SCI. [11]

The characteristic "upper extremity worse than lower extremity" pattern is explained by the somatotopic organization of the corticospinal tract - cervical fibers are located medially, lumbar fibers laterally. Central cord damage preferentially affects medial (cervical/arm) fibers.

Classical Features:

• Disproportionate upper limb weakness (especially hands)
• Lower limb strength relatively preserved
• Variable sensory deficits (sacral sparing common)
• Bladder dysfunction (typically retention)

Typical patient: Elderly person with cervical spondylosis after minor hyperextension injury (e.g., fall striking forehead)

Recovery Pattern:

1. Lower extremities first
2. Bladder function
3. Upper extremities
4. Hand intrinsic muscles (often permanent impairment)

Neurogenic Shock vs Spinal Shock

These two distinct entities are frequently confused. Clear differentiation is essential for appropriate management.

• cord stunning | | Injury level | Typically T6 and above | Any level | | Hemodynamics | Hypotension + bradycardia | Not primarily hemodynamic | | Peripheral signs | Warm, flushed, dry skin | Flaccid paralysis, areflexia | | Duration | Days to weeks | Hours to weeks (average 24-72 hours) | | Resolution marker | Gradual return of vascular tone | Return of bulbocavernosus reflex | | Management | Vasopressors (alpha-agonists), cautious fluids | Supportive; reassess neuro status after resolution |

Clinical Pearl: Bulbocavernosus Reflex: Squeeze glans penis or tug on urethral catheter → anal sphincter contraction. First reflex to return after spinal shock. Absence after 48 hours with complete motor/sensory loss below the level indicates complete injury (ASIA A) with poor prognosis for recovery.

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Clinical Presentation

History

Obtain focused trauma history while maintaining spinal precautions. Pre-hospital information is crucial.

Essential Historical Elements:

AMPLE History Integration:

• Allergies: Contrast allergy for CT/MRI
• Medications: Anticoagulants, steroids (osteoporosis)
• Past medical history: Previous spine surgery, rheumatological conditions
• Last meal: Aspiration risk if intubation required
• Events: Mechanism, extrication difficulty, associated injuries

Physical Examination

Systematic Approach:

1. Primary Survey (ATLS): C-spine maintained throughout

2. Spinal Examination (log-roll with in-line stabilization):

   • Midline palpation for tenderness (most sensitive clinical sign)
   • Step-off deformity
   • Swelling or hematoma
   • Crepitus (rare, indicates instability)
   • Muscle spasm

3. Complete Neurological Examination:

ASIA/ISNCSCI Assessment: [13]

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) provides standardized, reproducible neurological assessment.

Motor Examination (key muscle groups):

Each muscle graded 0-5:

• 0: Total paralysis
• 1: Palpable or visible contraction
• 2: Active movement, gravity eliminated
• 3: Active movement against gravity
• 4: Active movement against some resistance
• 5: Normal power

Sensory Examination:

• Light touch and pinprick tested at key dermatomes bilaterally
• C4: Top of AC joint
• C5: Lateral antecubital fossa
• C6: Thumb
• C7: Middle finger
• C8: Little finger
• T1: Medial antecubital fossa
• T4: Nipple line
• T10: Umbilicus
• S4-S5: Perianal (must test for "sacral sparing")

ASIA Impairment Scale (AIS): [13]

Critical Alert: Sacral Sparing Assessment is Mandatory: Perianal sensation, voluntary anal contraction, and deep anal pressure sensation determine complete vs incomplete injury. Even minimal sacral sparing significantly improves prognosis.

Distracting Injuries

Injuries that may mask cervical spine symptoms:

Clinical Pearl: Definition Challenge: "Distracting injury" is not precisely defined in NEXUS. Clinical judgment required. Generally: any injury producing pain sufficient to distract from cervical symptoms, or any injury requiring immediate intervention.

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Red Flags

Immediate Life Threats

High-Risk Features Mandating Imaging

Based on Canadian C-Spine Rule high-risk criteria: [1]

• Age ≥65 years
• Dangerous mechanism:
  • Fall from ≥1 meter/5 stairs
  • Axial load to head (diving)
  • MVC high-speed (> 100 km/h), rollover, ejection
  • Motorized recreational vehicle accident
  • Bicycle collision with immovable object
• Paresthesias in extremities

Conditions Increasing Injury Severity

• extreme rigidity | Unstable fractures from minor trauma; MRI essential | | DISH | Ossified ligaments | Similar to AS; maintain in position found | | Rheumatoid arthritis | C1-C2 instability | Atlantoaxial subluxation risk | | Down syndrome | Ligamentous laxity | Atlantoaxial instability | | Osteoporosis | Brittle bone | Increased fracture risk from falls | | Previous cervical fusion | Stress concentration at adjacent levels | Higher risk of adjacent segment fracture |

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Differential Diagnosis

Primary Considerations

Must Not Miss

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Diagnostic Approach

Clinical Clearance Algorithms

NEXUS Low-Risk Criteria (National Emergency X-Radiography Utilization Study): [14]

The NEXUS criteria were validated in 34,069 patients across 21 US centers. All five criteria must be met to clear without imaging.

NEXUS Performance: [14]

• Sensitivity for any injury: 99.0% (95% CI: 98.0-99.6%)
• Sensitivity for clinically significant injury: 99.6%
• Specificity: 12.9%
• Negative predictive value: 99.8%

Canadian C-Spine Rule (CCR): [1]

The CCR was developed and validated in 8,283 patients. It is a stepwise algorithm that is more specific than NEXUS while maintaining high sensitivity.

Step 1: Any high-risk factor mandating radiography?

• Age ≥65 years
• Dangerous mechanism
• Paresthesias in extremities → YES to any = Imaging required

Step 2: Any low-risk factor allowing safe range-of-motion assessment?

• Simple rear-end MVC
• Sitting position in ED
• Ambulatory at any time since injury
• Delayed onset of neck pain
• Absence of midline cervical tenderness → NO to all = Imaging required

Step 3: Able to actively rotate neck 45° left AND right? → NO = Imaging required → YES = No imaging required

CCR Performance: [1]

• Sensitivity: 99.4% (missed 1 of 169 injuries in validation)
• Specificity: 45.1%
• Would reduce imaging rates by ~44%

CCR vs NEXUS Head-to-Head Comparison: [1] In direct comparison, CCR was more sensitive (99.4% vs 90.7%, pless than 0.001) and more specific (45.1% vs 36.8%, pless than 0.001) than NEXUS. CCR would have missed 1 patient; NEXUS would have missed 16 patients with clinically important injuries.

Clinical Pearl: Which Rule to Use?

• CCR is more accurate and reduces imaging more than NEXUS
• However, CCR cannot be used if patient cannot participate in range-of-motion testing
• NEXUS may be applied more broadly (includes pediatrics, not validated less than 16 for CCR)
• Know both for examinations; CCR preferred when applicable

Imaging Modalities

CT Cervical Spine (Gold Standard for Bony Injury): [2]

Indications for CT:

• Fails NEXUS or CCR criteria
• High-risk mechanism in any patient
• Obtunded/intubated patient
• Known or suspected SCI
• Positive plain radiographs (if obtained)

MRI Cervical Spine: [2,15]

Indications for MRI:

• Neurological deficit (even with normal CT)
• SCIWORA suspected (symptoms, normal CT)
• Awake patient with persistent pain/tenderness and normal CT
• Obtunded patient with negative CT (controversial - options include MRI vs continued immobilization)
• Pre-operative planning for surgical cases
• Assessment of cord compression for timing of surgery

MRI Findings and Significance:

Plain Radiographs: [16]

Largely replaced by CT in adult trauma. May still be used in:

• Low-resource settings
• Minor mechanism with low pretest probability
• Follow-up of known stable injuries

Three-view series (if used): Lateral, AP, open-mouth odontoid

• Sensitivity: 52-85% (inadequate as primary modality)
• Must visualize C7-T1 junction (often obscured)

CT Angiography:

Consider for vertebral artery injury screening if:

• Transverse foramen fracture
• Facet fracture-dislocation
• High-energy mechanism with upper cervical injury
• Unexplained neurological findings (posterior circulation stroke)

Approach to the Obtunded Patient

This remains a challenging clinical scenario. Current evidence-based approach: [17]

Recommended Protocol:

1. Maintain immobilization
2. CT cervical spine (skull base to T4 if possible)
3. If CT negative for bony injury:

Option A (preferred if MRI available within 72 hours):

• MRI cervical spine
• If MRI negative → clear collar
• If MRI positive → appropriate management

Option B (if MRI not available or contraindicated):

• Continue collar immobilization
• Serial neurological examinations
• Clear collar when patient can participate in clinical examination
• Consider delayed MRI

4. If CT positive: Neurosurgical consultation; MRI as indicated for surgical planning

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Treatment

Principles of Management

Goals of Care:

1. Prevent secondary neurological injury
2. Restore spinal stability
3. Optimize conditions for neurological recovery
4. Prevent systemic complications
5. Early rehabilitation

The Golden Hour for SCI: While less defined than stroke, early intervention matters:

• Aggressive hemodynamic support within first hours
• Early decompression surgery (less than 24 hours) improves outcomes in incomplete SCI [3]

Pre-Hospital Management

Current Recommendations (2023 PHTLS/ACS): [18]

• "Spinal motion restriction" replaces "immobilization"
• Backboards for extrication only; remove as soon as possible (pressure ulcer risk)
• Collar application if concern for injury
• Clinical assessment guides need for precautions

Emergency Department Management

Initial Stabilization (ATLS approach):

1. Airway:

   • High cervical injuries may compromise airway
   • Rapid sequence intubation with manual in-line stabilization (MILS)
   • Video laryngoscopy preferred (better glottic view with less movement) [4]
   • Front of collar removed; manual stabilization by assistant
   • Consider awake fiberoptic if time permits and patient cooperative

2. Breathing:

   • Assess for paradoxical breathing (diaphragmatic only = high cervical)
   • Measure FVC in cooperative patients (if less than 15 mL/kg, anticipate deterioration)
   • Early intubation if declining respiratory function

3. Circulation:

Neurogenic Shock Management Protocol: [9,10]

Duration: Maintain MAP goals for 5-7 days [9]

4. Disability: Complete neurological assessment as above

5. Exposure: Log-roll examination; temperature management

Pharmacological Management

Methylprednisolone (Controversial): [19]

The NASCIS trials (I, II, III) previously suggested benefit from high-dose methylprednisolone. Current evidence and guidelines:

Historical Protocol (if used after informed discussion):

• Within 8 hours of injury only
• Bolus: 30 mg/kg over 15 minutes
• Maintenance: 5.4 mg/kg/hour for 23 hours (if started less than 3 hours) or 48 hours (if started 3-8 hours)

Risks: Infection, GI bleeding, hyperglycemia, delayed wound healing, pneumonia

Current Consensus: Risks outweigh benefits; neuroprotective effect not convincingly demonstrated. [19]

Other Pharmacological Considerations:

Specific Injury Management

Upper Cervical Injuries (C1-C2):

Subaxial Injuries (C3-C7):

Surgical Management

Indications for Surgery: [3]

1. Unstable injury pattern (SLIC ≥5)
2. Progressive neurological deficit
3. Incomplete SCI with cord compression
4. Irreducible dislocation
5. Unstable ligamentous injury
6. Failure of non-operative management

Timing of Surgery: [3]

Surgical Approaches:

Closed Reduction of Facet Dislocations:

Prerequisites:

• Awake, cooperative patient able to report neurological change
• MRI before reduction (ideal) to assess disc herniation - controversial
• Neurosurgical availability for emergent surgery if deterioration

Technique:

• Gardner-Wells tongs application
• Sequential weight addition (start 10 lbs; add 5-10 lbs every 10-15 minutes)
• Continuous neurological monitoring
• Serial radiographs
• Maximum: ~10 lbs per spinal level

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Complications

Early Complications (less than 7 days)

Late Complications (> 7 days)

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Disposition

Admission Criteria

ICU Admission:

• Any spinal cord injury with neurological deficit
• Neurogenic shock requiring vasopressor support
• High cervical injury (C1-C4) or respiratory compromise
• Unstable fracture requiring close monitoring
• Polytrauma with c-spine injury

Floor Admission:

• Stable fractures for observation and pain management
• Post-operative monitoring (if ICU not indicated)
• Awaiting MRI or definitive management planning

Transfer to Spinal Injury Center:

• All patients with SCI should be transferred to a specialized center when stable
• Improved outcomes in high-volume SCI centers [20]

Discharge Criteria (Stable Non-Operative Injuries)

• Spine surgery clearance for outpatient management
• Pain controlled with oral medications
• Proper collar fitted with understanding of wear instructions
• ADL capability (or home support arranged)
• Follow-up appointment confirmed
• Red flag education provided
• Driving restrictions understood

Follow-Up Schedule

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Special Populations

Elderly (> 65 years)

Ankylosing Spondylitis and DISH

Critical Alert: High-Risk Population: Fused/rigid spines are extremely vulnerable to fracture from minor mechanisms. Fractures are often unstable and associated with high rates of SCI and mortality.

Penetrating Trauma

Pregnancy

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Exam-Focused Sections

Common Viva Questions

Q1: "Describe your approach to a patient brought in after an MVC with neck pain."

Model Answer: "This patient requires full spinal precautions until the cervical spine is cleared clinically or radiographically. I would approach systematically using ATLS principles.

In the primary survey, I would ensure adequate airway management while maintaining cervical spine immobilization - using jaw thrust and in-line stabilization if airway intervention needed.

For clinical clearance, I would apply the Canadian C-Spine Rule as it has superior sensitivity and specificity compared to NEXUS. If there are any high-risk features - age over 65, dangerous mechanism, or paresthesias - imaging is mandatory. If low-risk features are present, I would assess active range of motion.

If clinical clearance is not possible, CT cervical spine is the gold standard imaging modality with over 99% sensitivity for bony injury. If CT is normal but there is neurological deficit, MRI is indicated to assess for ligamentous injury or SCIWORA."

Q2: "What is your management of neurogenic shock?"

Model Answer: "Neurogenic shock results from loss of sympathetic tone following spinal cord injury at T6 or above, causing vasodilation, hypotension, and bradycardia with warm, well-perfused peripheries - distinguishing it from hemorrhagic shock.

Management aims to maintain spinal cord perfusion to prevent secondary injury. I would target a MAP of 85-90 mmHg for 5-7 days.

Initial fluid resuscitation with 1-2 liters of crystalloid is appropriate, but I would avoid excessive fluids due to risk of pulmonary edema without vasoconstriction.

The mainstay is vasopressor therapy - norepinephrine is my first choice due to its alpha-adrenergic effect providing vasoconstriction. If there is significant bradycardia, I would consider dopamine for its chronotropic effect, or atropine. Temporary pacing may be needed for refractory bradycardia.

Concurrent with hemodynamic management, I would ensure the patient is in an ICU setting with continuous monitoring, catheterization for strict urine output measurement, and early involvement of the spinal injuries team."

Q3: "Describe the ASIA classification and its prognostic significance."

Model Answer: "ASIA is the American Spinal Injury Association classification, now incorporated into the International Standards for Neurological Classification of Spinal Cord Injury or ISNCSCI.

The scale grades injury from A to E:

• ASIA A is a complete injury with no motor or sensory function preserved in the sacral segments S4-S5.
• ASIA B is sensory incomplete with sensory but no motor function below the level, including S4-S5.
• ASIA C is motor incomplete with motor function preserved below the level but less than half of key muscles have grade 3 or greater strength.
• ASIA D is motor incomplete with at least half of key muscles having grade 3 or greater.
• ASIA E is neurologically normal.

Prognostically, the distinction between complete and incomplete injury is crucial. Patients with ASIA A injuries have less than 5% chance of functional motor recovery. In contrast, patients with ASIA B, C, or D injuries have progressively better prognoses - most patients with ASIA D will regain functional independence.

The presence of sacral sparing - even minimal - significantly improves prognosis, which is why careful perianal examination is mandatory in all suspected spinal cord injuries."

Common Mistakes in Examinations

Key Statistics to Know

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Key Clinical Pearls

Diagnostic Pearls

• CCR is superior to NEXUS: Higher sensitivity AND specificity; should be the primary clinical decision rule when applicable
• CT is gold standard: Plain radiographs have inadequate sensitivity (less than 85%) and should not be used as primary modality in adults
• SCIWORA is real: Spinal cord injury without radiographic abnormality occurs; MRI is essential if symptoms present with normal CT
• Sacral sparing defines prognosis: Even minimal preserved function in S4-S5 indicates incomplete injury with better prognosis
• Elderly + minor fall = image: Age ≥65 is an automatic high-risk feature in CCR; low-energy mechanisms can cause significant injury

Management Pearls

• MAP ≥85 mmHg for 5-7 days: Maintaining spinal cord perfusion is the most important modifiable factor in preventing secondary injury
• Neurogenic shock ≠ hemorrhagic shock: Bradycardia with hypotension suggests neurogenic; tachycardia suggests hemorrhage (or both may coexist)
• Remove the backboard: Pressure ulcers can develop within 30 minutes; backboards are for extrication only
• Early surgery improves outcomes: Decompression within 24 hours associated with better neurological recovery in incomplete SCI
• Steroids are not standard of care: NASCIS protocols are no longer recommended by major guidelines

Disposition Pearls

• SCI patients to specialized centers: Outcomes are better at high-volume spinal cord injury units
• VTE prophylaxis is mandatory: SCI patients have 50-80% DVT risk without prophylaxis
• Rehabilitation starts early: Even in ICU, positioning, range of motion, and goal-setting begin immediately
• Psychological support essential: Depression affects 30-40% of SCI patients

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References

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2. Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78(2):430-441. doi:10.1097/TA.0000000000000503

3. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037. doi:10.1371/journal.pone.0032037

4. Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012;116(3):629-636. doi:10.1097/ALN.0b013e318246ea34

5. Torretti JA, Sengupta DK. Cervical spine trauma. Indian J Orthop. 2007;41(4):255-267. doi:10.4103/0019-5413.36985

6. Ahuja CS, Wilson JR, Nori S, et al. Traumatic spinal cord injury. Nat Rev Dis Primers. 2017;3:17018. doi:10.1038/nrdp.2017.18

7. Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine. 2001;26(24 Suppl):S2-S12. doi:10.1097/00007632-200112151-00002

8. Vaccaro AR, Hulbert RJ, Patel AA, et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. Spine. 2007;32(21):2365-2374. doi:10.1097/BRS.0b013e3181557b92

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10. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60 Suppl 1:82-91. doi:10.1227/01.neu.0000430319.32247.7f

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12. McKinley W, Santos K, Meade M, Brooke K. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007;30(3):215-224. doi:10.1080/10790268.2007.11753929

13. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Revised 2019. Available at: https://asia-spinalinjury.org/isncsci/

14. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-99. doi:10.1056/NEJM200007133430203

15. 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 Surg. 2005;140(8):762-766. doi:10.1001/archsurg.140.8.762

16. 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(3):651-659. doi:10.1097/TA.0b013e3181ae583b

17. Malhotra A, Wu X, Kalra VB, et al. Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT. Eur Radiol. 2018;28(7):2823-2829. doi:10.1007/s00330-017-5285-y

18. Fischer PE, Perina DG, Delbridge TR, et al. Spinal motion restriction in the trauma patient - a joint position statement. Prehosp Emerg Care. 2018;22(6):659-661. doi:10.1080/10903127.2018.1481476

19. Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2015;76 Suppl 1:S71-S83. doi:10.1227/01.neu.0000462080.04196.f7

20. Parent S, Barchi S, LeBreton M, Casha S, Bhargava R. The impact of specialized centers of care for spinal cord injury on length of stay, complications, and mortality: a systematic review of the literature. J Neurotrauma. 2011;28(8):1381-1397. doi:10.1089/neu.2009.1151