by Ozge Can
Cervical Spine Injuries
Case Presentation
A 19-year-old male presented to the emergency department with a fall from height. Emergency Medical Services Providers stabilized him on a backboard and cervical collar. On examination, his BP: 100/70 and HR: 60 GCS 13. There is swelling and ecchymosis right side of the neck but no vertebral step-off sign. His upper and lower extremities motor function was 2/5. The cranial and cervical computed tomography showed cervical dislocation and subarachnoid hemorrhage.
Critical Bedside Actions and General Approach
- Check vital signs
- Check immobilization
- Order monitorization and IV line
- Learn mechanism of injury
- Examine the vertebra
- Examine motor and sensory function
- Check exclusion rules
- Examine other injuries
- Order imaging and labs.
Differential Diagnosis
- Spinal cord injuries
- Cervical spine injuries
- Cervical Ligamentous injuries
- Vertebral artery injuries
- Torticollis
- Cervical hematomas, masses
History and Physical Examination Hints
- The examination must start with general trauma care. On physical examination, the emergency physician should palpate the posterior structure of vertebrae behind the neck (Adam) after unfastening the patient’s cervical collar and preventing the reflexive movement of the head with the other hand. Check the posterior neck for midline sensitivity, swelling, ecchymosis, step-off sign. Examine motor and sensory function.
- If the patient is fully conscious and has no posterior midline tenderness, the emergency physician may remove the cervical collar. Then rotate the head left and right, caudal and cephalad slowly and check if the patient is feeling any pain.
- Evaluate the exclusion criteria if the patient is conscious and has no posterior midline tenderness on examination. Nexus and Canadian C-spine rules are the main rule-out criteria of a cervical spine injury.
- For nexus criteria, watch this video.
- For Canadian C-spine rules, watch this video
- Examine the motor and sensory function. Motor function is assessed from 0 to 5.
- 0 – is total paralyzed,
- 1 – is palpable contraction,
- 2 – motion with gravidity,
- 3 – motion against gravidity,
- 4 – motion is present but less power,
- 5 – normal power.
- To assess sensory function, examine deltoid muscle for C5, the thumb for C6, the middle finger for C7, and the little finger for C8.
- Check deep tendon reflexes (biceps, triceps).
- Spinal cord injuries may lead to neurogenic or spinal shock (See the shock and spinal cord injuries). Hypotension and bradycardia are the main symptoms of shock.
- Motorcycle accidents, falls from height and sports injuries are common causes of cervical spine injuries.
- Victims may be under effects from drug, alcohol, and unconsciousness associated with head trauma.
- Inspect for any other injuries such as maxillofacial and head injuries. Unconscious and vitally unstable patients with a head, abdominal and thoracic injuries should be considered to have a cervical injury.
- Learn the mechanism of injury. Cervical spine injuries are categorized according to mechanism into flexion, extension, and vertical compression.
- Flexion
- C1-2 atlantooccipital or atlantoaxial dislocation is caused by displacement of the head anteriorly and posteriorly. It is diagnosable by plain radiography. Atlantooccipital dislocation is a life-threatening injury and more frequent in children.Flexion
- Simple wedge fracture generally occurs anteriorly when longitudinal ligament pulls vertebrae body and ruptures due to flexion forces.
- Flexion teardrop is an unstable fracture caused by flexion forces. It is associated with severe ligamentous injury, anterior cervical cord syndrome and quadriplegia.
- Clay Shoveler’s fracture is the stable fracture of the C7 spinous process.
- Spinal subluxation is characterized by a bone fracture with enlargement of interspinous and intervertebral space.
- Bilateral facet dislocation is associated with soft tissue, annulus fibrosis and anterior ligament injury.
- Simultaneous flexion and rotation forces may produce unilateral facet dislocation. C2 dens fracture.
- C2 dens fracture has three types:
- Type 1: avulsion fracture
- Type 2: base of dens fracture
- Type 3: dens and vertebra fracture
- Extension
- C1 posterior arch fracture an unstable fracture of the atlas
- Hangman’s fracture is the fracture of bilateral C2 pedicles
- Vertical compression fracture
- Jefferson Jefferson fracture is C1 burst fracture. It is characterized by widened predental space on open mouth odontoid X-ray.
- A burst fracture is mostly seen in lower vertebrae. Lateral views show the fracture best.
Emergency Diagnostic Test and Interpretation
- Decide the need for imaging using exclusion criteria.
- Choose the best test for the patient according to your examination, findings and mechanism of injury.
- Imaging is indicated if pain and midline tenderness, neurologic deficit or intoxication/altered mental status is present.
- Computed Tomography (CT): Cervical CT is indicated if the patient is unconscious, the physical examination is unclear, the neurologic deficit is present or CT is planned for another injury (especially head maxillofacial trauma). However, current AJR guideline recommends CT scan in the presence of any violation of NEXUS or Canadian-C-spine rules.
- Because you may not have CT scan availability in some institutions, knowing how to interpret c-spine x-rays is important. Please see this chapter. You will also see many c-spine injury samples in that chapter.
- Magnetic Resonance Imaging (MRI): Spinal Cord Injury without Radiographic Abnormality (SCIWORA) defines the presence of neurological deficit with no radiographic or computed tomographic features of spinal fracture or instability. Therefore, the presence of neurologic deficit necessitates MRI for the diagnosis of traumatic myelopathy.
Emergency Management
- Trauma surveys should be applied any c-spine injury patients. See this chapter. Following recommendations are specific to c-spine, not general trauma management.
- Immobilize the patient at the first contact. Watch this video
- Immobilization is the first step of management. If not done at the prehospital setting, immobilize the patient’s neck, place the collar posteriorly with an assistant and fasten. Unfasten the collar as soon as possible to prevent complications after the spinal injury is excluded by clinical or radiologic means.
- Consider full monitoring. Monitorize the patient for spinal and neurogenic shock or phrenic nerve paralysis.
- Apply sedation to prevent self-injury or other complications in agitated patients secondary to additional injuries or substance effects. (See sedation chapter)
- Provide cervical immobilization with in-line stabilization during intubation. (See intubation indications in a trauma patient).
- In-line stabilization: Have the assistant stand at the head of the patient and stabilize the patient’s neck using both hands and prevent hyperextension.
- Intubation with video laryngoscope is recommended, if available.
- Continue immobilization until the imaging if the patient needs an emergent operation.
- Medications
- Corticosteroid treatment for spinal cord injuries secondary to spine injuries has been shown that having many flaws, therefore is not recommended anymore.
- Analgesics should be applied to awake patient.
Pediatric, Geriatric, Pregnant Patıents and Other Considerations
- Some diseases may predispose a person to cervical injury. Rheumatoid arthritis may cause C2 transverse ligament rupture. Atlantooccipital dislocation is seen with Down syndrome
- Patients with long-term corticosteroid use or osteoporosis are predisposed to fractures.
Disposition Decision
Admission
- The patients with neurologic or spinal shock should be admitted to the ICU.
- The patients with unstable fractures should be admitted and/or operated immediately by neurosurgery.
Discharge
- Patients with stable fractures and no neurologic deficits may be discharged.
- Recommend Philadelphia or Miami collar to the patients with suspected ligament injury.
- Refer the patients to neurosurgery clinic.
Thoracic Spine Injuries
Case Presentation
A 40-year-old male presented to the emergency department after a motorcycle accident. The patient reported chest pain. Blood Pressure: 130/80 mmHg. Heart Rate:120 bpm. His Glasgow Coma Scale was 15. There was no midline tenderness on cervical examination. The respiratory sound was normal. His E-FAST examination showed pleural fluid. The chest x-ray revealed hemothorax. Thorax CT showed thoracic vertebrae spinous process fracture.
Critical Bedside Actions and General Approach
Please refer to cervical spinal injuries section.
Differential Diagnosis
- Spinal cord injuries
- Thoracic Ligamentous injuries
- Vertebral artery injuries
- Kot fracture
- Pneumothorax
- Scapula fracture
History and Physical Examination Hints
- Thoracic injuries mostly occur with high-energy mechanisms, namely, motorcycle accidents, fall from height and gunshot injuries.
- First, immobilize the patient if he is not on a backboard. A vacuum splint or scoop stretchers is useful. Logroll the patient for examination. For logrolling, a leader and three assistants should be available.
- Examine the patient’s vertebrae for midline sensitivity, swelling, ecchymosis, step-off sign. Additionally, check the motor and sensory function and deep tendon reflexes.
- A scapular injury is an indicator of high energy trauma. In case of scapular injury, consider a thoracic spine injury.
- Remember that spinal cord damage may lead to spinal and neurological shock.
- Learn the mechanism: Thoracic vertebra injuries are classified as flexion, extension, rotation, shear, distraction and axial compression injuries according to their mechanisms.
- Flexion injuries: occur with anterior compression. Instability is associated with the posterior ligament injury. Wedge fracture is an example. It is the most common fracture in the thoracic spine.
- Extension injuries: are anterior ligament, facet, laminar, spinous process injuries.
- Axial compression injuries: are burst fractures and occur with high-energy mechanisms.
- Flexion-rotation injuries: occur with a posterior ligament injury.
- Shear injuries: Posterior anterior, lateral listezis occur with ligament injury.
Emergency Diagnostic Test and Interpretation
- Patients who have vertebrae pain, midline sensitivity, bone deformity, neurologic deficit, more than 60 years old and high-energy mechanism requires imaging.
- Anteroposterior (AP) and Lateral X-rays: AP images show lateral pedicles. Lateral images show subluxations, compression fractures (Image 1) and chance fractures.
- Computed Tomography (CT): Patients with a neurologic deficit or altered mental status require CT.
- Magnetic Resonance Imaging (MRI): Patients with the suspected ligament, disk or epidural space injuries require MRI.
Emergency Management
- Check immobilization
- Remove backboard if there are no signs of injury. Prefer a sliding board instead of backboard when prolonged immobilization needed (i.e. the risk of injury continues).
- Provide full monitoring, especially in patients with spinal or neurogenic shock or phrenic nerve paralysis.
- Flexion restriction braces (Jewett or Knight-Taylor) is recommended if there is no stable angle fracture.
- Medications
- Please refer to cervical spinal injuries section.
Pediatric, Geriatric, Pregnant Patıents and Other Considerations
- Long-term corticosteroid use, malignancies or osteoporosis is predisposing factors for fractures.
Disposition Decision
Admission
Patients with spinal and neurogenic shock symptoms should be admitted to the intensive care unit.
Discharge
Patients with stable fractures and no neurologic deficits may be discharged after the consultation with neurosurgery or orthopedic department. Referral to these clinics should also be planned.
Lumbar Spinal Injuries
Case Presentation
A 70-year-old woman arrived in the emergency department after a fall from stairs. She had a history of corticosteroid usage. Vital signs are normal. On her examination, she had pain on her back at the level of lumbar 2-3. The lateral X-ray showed an L2 compression fracture.
Critical Bedside Actions and General Approach
Please refer to spinal injuries section.
Differential Diagnosis
- Spinal cord injuries
- Lumbar spine injuries
- Spinal epidural hematoma
- Paraspinal hematoma
- Retroperitoneal hematoma
- Renal injuries
- Soft tissue injuries
- İntraabdominal trauma
- Pelvic injuries
History and Physical Examination Hints
- Examination findings and history are similar to those of thoracic injuries.
- Lumbar vertebrae fracture is the most frequent of all and may happen after relatively minor trauma.
- Examine hip flexion, leg extension, ankle dorsiflexion, and toe extension to assess motor function.
- Evaluate rectal tonus by a rectal exam in patients with suspected lumbar injuries.
- Lumbar fracture types:
- Wedge fracture: Isolated anterior column fracture
- Burst fracture: Fracture of the anterior and middle column
- Flexion-distraction: injuries are most frequently seen in seat belt injuries. Fractures at T12-L1 junction is called chance fracture. Flexion-distraction fractures may be associated with abdominal injuries.
- Transverse process fracture: is the most common lumbar spine fracture. An x-ray may miss most of the transverse process fractures. The abdominal or pelvic injury may accompany.
Emergency Diagnostic Test and Interpretation
Please refer to thoracic spine injury section.
Emergency Management
- Please refer to cervical injuries section.
- Medications
- Please refer to the cervical thoracic injuries section.
Pediatric, Geriatric, Pregnant Patients and Other Considerations
- A lumbar fracture is rare in infants. Consider child abuse, especially in fractures with paralysis.
- Consider epidural hematoma in geriatric patients on anticoagulation
Disposition Decision
Admission
- Admit patients with shock and intraabdominal organ injuries to intensive care unit.
Discharge
- Patients with a simple transverse sacral fracture, isolated spinous fracture or isolated transverse process fracture may be discharged.
- Patients with a simple wedge fracture and no neurologic deficit may be discharged with pain control.
- Discharge decisions should be taken with neurosurgery and/or orthopedic consultations. Referral to these clinics should also be planned.
References and Further Reading
- Robert S Hockberger,Amy h. Kaji, and Edward Newton Chapter 40 Spine Injuries Rosen’s Emergency Medicine 8 th Edition
- Michelle Lin and Swaminatha V.Mahadevan Chapter 75 Spine Trauma and Spinal cord Injury Emergency Medicine Clinical Essential Second Edition
- Amy Kaji,Robert S hockberger Evaluation and acute mangement of cervical spinal column injuries in adults – link
- Amy Kaji,Robert S hockberger Spinal column injuries in adults: Definition, mechanisms, and radiographs- link
- Chapter 7 Spine and Spinal Cord Trauma ATLS 8th Edition
- Gary M. Vilke Spine Injury: Cervical, Adult Rosen and Barkin’s 5-Minute Emergency Medicine Consult 5E
- https://www.youtube.com/watch?v=YnH9rVcN9OA
- https://www.youtube.com/watch?v=4Fa81ur0QxM
- Bonny J Baron, Kevin J McSherry, James L LarsonJr, Thomas M. Scalea Chapter 255 Spine and Spinal Cord Trauma Tintinallis Emergency Medicine A Comprehesive Study Guide 7th E
- https://www.youtube.com/watch?v=fY7SAR5RXbY
- Stephen R. Hayden Spine Injury: Lumbar Rosen and Barkin’s 5-Minute Emergency Medicine Consult 5E