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Cervical spinal column injuries in adults: Evaluation and initial management

Cervical spinal column injuries in adults: Evaluation and initial management
Author:
Amy Kaji, MD, PhD
Section Editor:
Ani Aydin, MD, FACEP
Deputy Editor:
Michael Ganetsky, MD
Literature review current through: Jan 2024.
This topic last updated: Jan 22, 2024.

INTRODUCTION — Cervical column injuries include fractures, subluxation, dislocation, and ligamentous injuries. Early recognition and appropriate management can reduce the risk of spinal cord injury.

This topic discusses the evaluation of an adult patient with posterior neck pain following trauma, including selection of patients for imaging, and the initial management of those with injuries to the cervical spinal column.

Other aspects of spine injury are reviewed separately:

Choice of imaging modality, image-acquisition procedures, and diagnostic performance (see "Suspected cervical spine injury in adults: Choice of imaging")

Epidemiology, clinically important anatomy, mechanisms of injury, and classification of cervical spinal column injury (see "Spinal column injuries in adults: Types, classification, and mechanisms")

Anatomy, clinical presentation, classification, evaluation, and management of traumatic spinal cord injuries (see "Acute traumatic spinal cord injury" and "Anatomy and localization of spinal cord disorders")

Evaluation and management of patients with neck pain without fracture or unstable soft tissue injury (see "Evaluation of the adult patient with neck pain" and "Management of nonradicular neck pain in adults")

Evaluation and management of pathologic spine fractures from metastatic bone disease (see "Clinical presentation and evaluation of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma" and "Management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma")

Pediatric spine injuries (see "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete")

INITIAL EVALUATION AND MANAGEMENT

Spinal immobilization (prehospital and emergency department)

Blunt trauma — First responders should maintain a high clinical suspicion for spinal column injury in blunt trauma patients, especially in the setting of a motor vehicle collision, assault, fall from a height, older adults, high-risk medical/skeletal conditions (eg, advanced arthritis, cancer, Down syndrome, rheumatoid arthritis), overt signs of head/facial trauma, or sports-related injury. For any patient with a possible cervical spine injury, some form of cervical spinal immobilization or protection should be initiated at the scene and maintained until an unstable spinal injury is excluded using a validated assessment instrument or appropriate diagnostic imaging. A patient who is "found down" with no information about preceding events should be presumed to have a cervical spinal column injury.

Immobilization techniques – Prehospital personnel should attempt to place a cervical collar as per their local protocols. When not possible to place a collar, or to further stabilize the cervical spine and minimize head motion, towel rolls, foam head blocks, and tape may be used.

Traditionally, spinal immobilization has included a backboard, rigid cervical collar, and lateral head supports; however, some states and emergency medical services have revised their protocols to omit the backboard for cervical spine injuries and use only a rigid cervical collar and the padded stretcher with the patient in a supine or Semi-Fowlers position (head of bed inclined 30 degrees). For long transports (as per local prehospital protocols), we recommend removing the patient from the backboard and placing them on a stretcher to prevent potential complications [1].There is no high-quality evidence demonstrating that use of a backboard prevents spinal injury or improves outcome, although it is helpful for extricating trauma patients from vehicles.

Prehospital cervical spine clearance – In some locations, emergency medical services directors have instituted protocols that allow for the use of clinical decision rules, such as National Emergency X-Radiography Utilization Study (NEXUS), to eliminate unnecessary cervical spine immobilization. (See 'Clinical decision rules' below.)

Immobilization while in the emergency department – In the absence of a history or clinical signs suggesting head, neck, or upper torso injury, the clinician must use their clinical judgment to determine whether spinal immobilization is warranted.

Patient arriving on a backboard – In all trauma patients, we recommend removing the backboard as quickly as possible [2]. We agree with a joint policy statement from the American College of Emergency Physicians (ACEP), National Association of EMS Physicians (NAEMSP), and the American College of Surgeons Committee on Trauma (ACS-COT) advocating judicious use of long backboards and early removal [3].

Uncooperative patient – Trauma victims may not think clearly due to head injury, shock, hypoxia, or drug or alcohol intoxication, making cooperation difficult and spinal movement likely. In some cases, chemical sedation and, rarely, even airway management may be needed to prevent self-injury.

Penetrating trauma

Patient with normal neurologic examination – Spinal injury is uncommon in patients with penetrating trauma and rare in younger patients without evidence of neurologic injury [4,5]. Given this lower risk and the possibility of harm from immobilization, some experts have questioned the need for spinal immobilization in patients with penetrating trauma who do not manifest neurologic deficits or altered mental status. However, first responders and emergency clinicians must remain cautious when they consider removing or not applying spinal immobilization in this setting because victims of penetrating trauma may simultaneously sustain blunt head or neck trauma, such as during an assault. This issue is discussed in greater detail separately. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Cervical spine immobilization'.)

Patient with neurologic deficit – Patients with penetrating neck trauma and neurologic deficits should be immobilized and undergo a workup, including a search for bony injury. In a retrospective study of cervical gunshot wounds sustained by 144 patients over 12 years, 30 percent of patients with a neurologic injury required surgery for instability of the cervical spine [6]. A retrospective study of 2267 patients following explosive injuries found that cervical spine injuries were uncommon; unstable fractures were from penetrating trauma and almost always had irreversible neurological deficits at presentation [7].

Hanging — Cervical spine injuries are less common in cases of self-hanging. Morbidity is primarily due to asphyxiation with cerebral anoxia or soft tissue injury [8,9]. Spinal column injury from judicial hanging occurs secondary to a drop from a height against a knotted rope.

Helmeted patients

Motorcycle, ski, snowboard, or other athletic helmet removal – Safe removal of these helmets requires that manual cervical spine immobilization be maintained continuously, and this can only be done with two people.

The technique is performed as follows [10]:

Open any face shield to assess and, if necessary, assist the patient's airway and breathing.

The first rescuer, positioned above the head, places one palm along each side of the helmet with fingers on the mandible to prevent head movement. The hands are placed on the outside of the helmet.

The second rescuer, positioned beside the patient, then loosens the strap and places one hand at the angle of the mandible and the other hand at the cephalad portion of the posterior neck, just below the rim of the helmet. Maintaining in-line immobilization now becomes the responsibility of the second rescuer.

As the first rescuer gradually slides the helmet halfway off, the second rescuer slides his hands from the posterior neck, just below the helmet rim, to the occiput to prevent the head from falling back.

The helmet is then completely removed, and the cervical spine immobilized.

The cervical spine can move during ski or snowboard helmet removal thus warranting precautions similar to motorcycle helmet removal. For example, a study of 28 volunteers participating in a ski patrol exercise reported increased movement of the cervical spine when their helmets were removed [11].

Football helmet removal – Issues related to whether football and other sports helmets and shoulder padding should be removed and, if so, how to remove them are discussed separately. (See "Field care and evaluation of the child or adolescent athlete with acute neck injury", section on 'When to remove helmet and/or shoulder pads'.)

Airway management — Clinicians should continue to use in-line stabilization whenever they perform tracheal intubation in a patient with a possible spinal column injury until compelling scientific data from randomized trials demonstrate its ineffectiveness, despite the dearth of supporting evidence. When necessary, the priority is expeditious and safe tracheal intubation to prevent hypoxia and further injury.

Using a video laryngoscope or other sophisticated airway management tool improves the clinician's view of the larynx while reducing cervical spine motion compared with in-line stabilization during direct laryngoscopy [12,13]. If time is not an issue, an awake intubation over a flexible intubating endoscope may be a safer, effective option. (See "Devices for difficult airway management in adults for emergency medicine and critical care", section on 'Advanced laryngoscopes' and "Awake tracheal intubation".)

In a patient with traumatic cardiopulmonary arrest, even with evidence of spinal injury, the preferred approach to definitive airway control is orotracheal intubation. This agrees with the American College of Surgeons' Advanced Trauma Life Support (ATLS) guidelines [14]. (See "Initial management of trauma in adults", section on 'Intubation'.)

In a patient who is breathing but unconscious and in need of airway control or ventilatory support, we recommend orotracheal intubation in conjunction with rapid sequence intubation [15]. (See "Rapid sequence intubation in adults for emergency medicine and critical care".)

The emergency clinician should anticipate airway management problems in patients with cervical spinal column injury [16]. Unstable lesions at or above C3 to C5 may cause immediate respiratory paralysis or cause delayed paralysis from paracervical edema; the risk progressively increases with C5 lesions and higher [17,18]. Lower cervical lesions may cause delayed phrenic nerve paralysis from ascending edema of the spinal cord. In addition, cervical spinal column injury may be associated with airway obstruction from retropharyngeal hemorrhage, edema, or maxillofacial trauma. (See "Anatomy and localization of spinal cord disorders" and "Initial evaluation and management of facial trauma in adults".)

The authors of one review of in-line spinal stabilization question the technique's utility, pointing out that data supporting the technique come from cadaver studies, observations on uninjured volunteers, and case series [19].

Recognizing spinal and neurogenic shock — Transient loss of spinal cord function, sometimes manifested as areflexia, flaccid paralysis, or anesthesia can occur following spinal column injury. It is termed "spinal shock,” but is not a true shock state as it does not result in hemodynamic compromise or organ hypoperfusion. (See "Acute traumatic spinal cord injury", section on 'Transient paralysis and spinal shock'.)

In trauma patients, hemodynamic compromise should always be attributed to hemorrhagic shock until proven otherwise. However, loss of sympathetic tone can result in neurogenic shock, which can cause hypotension and bradycardia. It may occur from injury to the spinal cord, especially the superior portion. The evaluation of spinal cord injury and the management of neurogenic shock are discussed separately. (See "Anatomy and localization of spinal cord disorders", section on 'Clinical localization' and "Acute traumatic spinal cord injury", section on 'Imaging' and "Acute traumatic spinal cord injury", section on 'Cardiovascular complications'.)

Secondary trauma survey — The secondary survey is a standard part of the trauma evaluation and includes taking a history and performing a careful head-to-toe examination. The secondary survey is discussed in detail separately, but important aspects relating to cervical spine injury are discussed below (table 1). (See "Initial management of trauma in adults", section on 'Secondary evaluation and management'.)

History – We ask about details of the trauma, as well as presence of neck pain or neurologic symptoms (eg, weakness, numbness, paresthesias). We obtain a past medical history specifically inquiring about conditions that predispose patients to cervical spinal column injury. As examples, Down syndrome patients are predisposed to atlanto-occipital dislocation, and patients with rheumatoid arthritis are prone to ligamentous injury throughout the whole cervical spine. (See "Down syndrome: Clinical features and diagnosis" and "Cervical subluxation in rheumatoid arthritis".)

Head, neck, face – Signs of injury above the clavicles may be associated with an increased risk of cervical spinal column injury [14]. Based on case series, approximately 5 to 10 percent of patients with significant head and facial trauma sustain associated cervical spine injuries [20,21]. A multicenter study of 250,584 trauma patients (2.3 percent with cervical fracture/dislocation) found that patients with severe facial injury (eg, LeFort fracture; odds ratio [OR] 1.29, 95% CI 1.05-1.59) or with a Glasgow Coma Scale (GCS) <15 (GCS 3 to 8: OR 1.26; GCS 9 to 12: OR 1.22; GCS 13 to 14: OR 1.30) were more likely to have sustained a cervical spine fracture/dislocation [22]. Another retrospective study of 447 consecutive patients with moderate or severe head injury found that patients with a GCS <8 were more likely to have sustained a cervical spine injury (OR 2.77, 95% CI 1.11-7.73) [23]. A retrospective study of 2919 patients with facial fractures (including isolated nasal fractures) found that 3 percent also had cervical spine fractures [24].

Back – The entire spine and paraspinal musculature should be exposed and palpated for areas of tenderness or deformity; a step-off in the spine may indicate vertebral subluxation or fracture. Widening of an interspinous space indicates a tear in the posterior ligament complex and a potentially unstable spinal injury, although this finding is difficult to appreciate.

Neurologic examination – A focused but systematic evaluation should be performed in all patients with a possible spine injury. Clinicians should assess the presence, strength, and symmetry of both voluntary and involuntary movements, changes in sensation, reflexes, proprioception, and hemodynamic status. Priapism may occur with severe spinal cord injury from loss of sympathetic tone. An abnormal breathing pattern may indicate a cervical injury, as the diaphragm is innervated by the phrenic nerve [25]. Any sensory deficits, including the dermatome where they occur, should be noted. Bowel or bladder incontinence or retention is an important finding. The spinal cord syndromes and manifestations based on level of injury are summarized in the following tables (table 2 and table 3). Comprehensive summaries of the neurologic examination are found separately. (See "The detailed neurologic examination in adults" and "Anatomy and localization of spinal cord disorders", section on 'Clinical localization'.)

When assessing for cervical spine injury, it is preferable to conduct the neurologic examination when the patient is alert and sober; however, this is not always practical or feasible. At minimum, gross motor function should be assessed in every patient. In an intoxicated patient with intact gross motor function, a normal cervical spine computed tomography (CT) scan obtained with a multidetector scanner with multiplanar reformations is sufficient to provide cervical spine clearance. (See 'Cervical spine clearance (removal of cervical collar)' below.)

Rectal examination – We do not routinely perform a digital rectal examination for the sole purpose of evaluating a spinal cord injury. This agrees with current ATLS guidelines. Previous iterations of ATLS advocated performing a rectal examination on all trauma patients during the secondary survey, but evidence does not exist that this examination is an accurate means for detecting spinal cord injury [26-29]. In specific circumstances, such as pelvic trauma, the rectal examination may provide useful clinical information. (See "Pelvic trauma: Initial evaluation and management", section on 'Physical examination'.)

DETERMINING THE NEED FOR IMAGING

Approach to patient selection — Our approach to determining if a patient with blunt trauma needs cervical spine imaging is presented in the algorithm (algorithm 1).

Hemodynamically unstable trauma patient – This patient should proceed rapidly to the operating room and is presumed to have an unstable cervical spine injury. Spinal immobilization is maintained until radiographic evaluation can be performed postoperatively. If it does not delay transfer to the operating room or procedural stabilization, a cross-table lateral cervical spine radiograph can be obtained (either in the emergency department or operating room) to evaluate for injuries that may contribute to hemodynamic instability (eg, atlantoaxial dislocation, hangman's fracture).

Hemodynamically stable trauma patient with high risk for injury – We obtain a computed tomography (CT) scan of the cervical spine without contrast (in addition to any other appropriate imaging studies) if any of the following are present:

The presence of any of the following, which suggests high risk of cervical spine injury [30]:

-High-speed (≥56 kph [35 mph] combined impact) motor vehicle crash

-Death at scene of motor vehicle crash

-Fall from height (≥3 m [10 feet])

-Significant closed head injury or intracranial hemorrhage seen on CT

-Neurologic symptoms or signs (eg, weakness, numbness, paresthesias) referred to the cervical spine (table 1 and table 2 and table 3)

-Pelvic or multiple extremity fractures

Disproportionate midline neck or back pain, focal spine tenderness, upper extremity paresthesias, or other suggestive symptoms

History of severe osteoporosis, advanced arthritis, cancer, degenerative bone disease, Down syndrome, rheumatoid arthritis, or advanced age

Patients who have sustained major trauma and are undergoing CT imaging to assess for head, chest, or abdomen injury

Lower, but not negligible, risk of cervical spine injury – These are patients who have sustained less severe trauma (eg, minor fall or motor vehicle collision), do not meet any of the above criteria, and have posterior neck pain. It is possible for patients with a clinically significant cervical spine fracture to be ambulatory with an intact neurologic examination [31]. We use a clinical decision rule, if applicable, to determine whether imaging is necessary. We use either the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria or the Canadian C-spine Rule (CCR); both are well validated and sensitive clinical decision rules. These rules are NOT applicable to the following patients (see 'NEXUS low-risk criteria' below and 'Canadian C-spine Rule' below):

Direct blow to the neck

Penetrating trauma (see "Penetrating neck injuries: Initial evaluation and management")

Older age: NEXUS and CCR are not applicable to adults >65 years

Children: Both are not applicable to children <10 years (see "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging')

Clinical decision rule not applicable – If neither the NEXUS nor CCR are applicable, we use clinical judgment to determine the need for imaging. For example, in a frail, older patient with even a minor fall, we will often obtain CT imaging given increased risk of fracture but may choose not to image an older patient with lateral neck pain and no midline tenderness after a low-speed rear-ended motor vehicle collision.

However, a very low threshold should be used to determine the need for imaging studies in older adult trauma patients given the higher risk of cervical spine injury due to osteoporosis, comorbidities, and other factors [32,33]. For example, in a frail, older patient with even a minor fall, we will often obtain CT imaging but may choose not to image an older patient with lateral neck pain and no midline tenderness after a low-speed rear-ended motor vehicle collision. Test characteristics of clinical decision rules in older adults are discussed below, and issues specific to cervical spine trauma are discussed separately. (See 'Clinical decision rules' below and "Geriatric trauma: Initial evaluation and management", section on 'Cervical spine injury'.)

Our approach to determining if a patient needs cervical spine imaging is based on available studies and our clinical experience. No standard approach has been explicitly defined and some debate continues regarding the most efficient and effective method of cervical spine clearance. Various studies support the use of one or more of the criteria for high risk of cervical spine injury listed above, and we believe they provide reasonable guidance regarding which patients warrant imaging [34,35]. However, no subsequent trials have validated the use of all six high-risk criteria.

In all cases of suspected spinal column injury, immobilization of the spine must be maintained until an unstable injury is ruled out. Unstable injuries are listed in the table and discussed in greater detail separately (table 4). (See "Spinal column injuries in adults: Types, classification, and mechanisms" and "Suspected cervical spine injury in adults: Choice of imaging".)

Clinical decision rules

NEXUS low-risk criteria — The NEXUS decision instrument stipulates that imaging is not necessary in a patient younger than 65 years who satisfies all five of the following low-risk criteria:

Absence of posterior midline cervical tenderness

Normal level of alertness

No evidence of intoxication

No abnormal neurologic findings

No painful distracting injuries

The definitions of painful distracting injury and altered level of alertness are sometimes questioned:

Painful distracting injury – According to the NEXUS authors, examples of a "painful distracting injury" include long bone fractures, visceral injury requiring surgical consultation, large lacerations, crush injuries, large burns, and any injury the clinician thinks "to have the potential to impair the patient's ability to appreciate other injuries" [36]. Some experts believe that the presence of a painful distracting injury does not limit the accuracy of a clinical assessment of the cervical spine performed in an alert trauma patient [37], but we feel such a conclusion is premature. A study that assessed each component of the NEXUS low-risk criteria found that the overall sensitivity decreased to 93.5 percent when the painful distracting injury criteria was removed [38].

Altered level of consciousness – This is defined in NEXUS as any of the following [36]:

Glasgow Coma Scale (GCS) score <15

Disorientation to person, place, time, or events

Inability to remember three objects at five minutes

Delayed or inappropriate response to external stimuli

A brief, transient loss of consciousness at the time of a motor vehicle collision does not preclude the use of NEXUS, assuming the patient meets all other criteria.

The NEXUS low-risk criteria was the first decision rule to be developed and was prospectively validated in a large, multicenter, observational study [39]. The NEXUS study evaluated 34,069 blunt trauma patients who underwent imaging of the cervical spine (either three-view cervical spine radiograph, cervical spine CT, or magnetic resonance imaging [MRI]) at 21 participating emergency departments. Of these patients, 818 (2.4 percent) had sustained a cervical spinal column injury. Sensitivity, specificity, and negative predictive value of the NEXUS low-risk criteria for a clinically significant injury were 99.6 percent (95% CI 98.6-100), 12.9 percent (95% CI 12.8-13.0), and 99.9 percent (95% CI 99.8-100), respectively. Insignificant injuries were defined as those that would not lead to any consequences if left undiagnosed.

Even though post-hoc subgroup analysis of older patients in the original study population reported very high sensitivity for the NEXUS criteria [40], subsequent studies have found lower sensitivity in patients >65 years old. In the original study population, this age group only accounted for 8.6 percent of patients and had a higher rate of cervical spine injury (4.6 versus 2.2 percent). A retrospective registry study of 4035 trauma patients (age ≥65 years) found the sensitivity of the NEXUS criteria for identifying cervical spine fracture was 94.8 percent (95% CI 92.1–96.7); the NEXUS criteria would have missed 21 fractures (4.5 percent) [41]. Another study of 320 blunt trauma patients (age >65 years, median = 75 years) found the sensitivity of the NEXUS criteria for cervical spine fracture was 66 percent compared with 84 percent in 2465 younger patients (median = 36 years) [32]. Issues specific to trauma in older patients are discussed separately. (See "Geriatric trauma: Initial evaluation and management".)

Canadian C-spine Rule — The CCR was developed to address the low specificity of the NEXUS low-risk criteria and based upon three clinical questions derived from 25 clinical variables associated with spine injury [42]. The authors of the CCR expressed concern that relying on NEXUS might increase the use of cervical spine imaging in some regions of the United States and in most other countries.

Applying the CCR involves the following steps:

Condition one: Perform imaging in patients with any of the following:

Age 65 years or older

Dangerous mechanism of injury:

-Fall from 1 m (3 feet) or five stairs

-Axial load to the head (such as diving accident)

-Motor vehicle crash at high speed (>100 km/hour [>62 mph])

-Motorized recreational vehicle accident

-Ejection from a vehicle

-Bicycle collision with an immovable object, such as tree or parked car

Paresthesias in the extremities

Condition two: In patients with none of the criteria in condition one, assess for any low-risk factor that allows for safe assessment of neck motion. The low-risk factors are the following:

Simple rear-end motor vehicle accident; excludes: pushed into oncoming traffic, hit by bus or large truck, rollover, hit by high-speed (>100 km/hour [>62 mph]) vehicle

Sitting position in emergency department

Ambulatory at any time

Delayed onset of neck pain

Absence of midline cervical spine tenderness

If none of the low-risk conditions are met, the patient must be imaged. Such patients are not suitable for neck motion testing.

If any low-risk condition is met, perform range-of-motion testing as described in condition three.

Condition three: Test active range of motion. Perform imaging in patients who are not able to rotate their neck actively 45 degrees both left and right. Patients able to rotate their neck, regardless of pain, do not require imaging. Passive (examiner facilitated) range of motion testing should not be done.

In the derivation study, the CCR demonstrated a sensitivity of 100 percent and a specificity of 42.5 percent for identifying clinically important cervical spine injuries [42]. The CCR was prospectively studied in 8283 patients in nine Canadian tertiary care emergency departments and 162 patients (two percent) had a clinically significant cervical spine injury [34]. The sensitivity, specificity, and negative predictive values of the CCR for clinically significant injuries were 99.4 (95% CI 96-100), 45.1 (95% CI 44-46), and 100 percent, respectively. The CCR has also been validated in larger hospital-based studies and in an out-of-hospital study of paramedics [43,44].

NEXUS versus Canadian C-spine Rule — Both the NEXUS low-risk criteria and the CCR are sensitive, and either can be used to determine the need for cervical spine imaging. Controversy persists about which of the two rules is more specific.

The prospective Canadian study of the CCR discussed above also evaluated the NEXUS low-risk criteria in the same patients [34]. Compared with the NEXUS low-risk criteria, the CCR was more sensitive (99.4 versus 90.7 percent), more specific (45.1 versus 36.8 percent) for injury, and its use would have resulted in a lower imaging rate (55.9 versus 66.6 percent). The authors reported that the CCR would have missed one patient with an important cervical spine injury compared with 16 that would have been missed by the NEXUS low-risk criteria. However, in this study the NEXUS low-risk criteria had a lower sensitivity and a higher specificity compared with the original NEXUS study, possibly from differences in inclusion criteria: the Canadian group excluded patients under the age of 16 years and subjects with a GCS of less than 15, whereas these subjects were included among the original NEXUS cohort. In addition, the original NEXUS study excluded all patients in whom imaging was deemed unnecessary, while the Canadian investigators included such individuals. Thus, selection bias may account for the lower number of false negatives and true negatives reported in the Canadian study, potentially inflating both the sensitivity and specificity of the CCR. Finally, the prospective validation phase of the CCR study was performed in the same institutions in which the derivation phase was performed, raising concerns about improved performance due to familiarity with the rule [35].

Initial imaging — In a patient who requires imaging for suspected cervical spine injury, cervical spine CT without contrast is the preferred imaging examination. If possible, it should be performed with a multidetector scanner with thin-slice axial images from the skull base through C7-T1 disc space. The selection and performance of the appropriate imaging study are reviewed separately. (See "Suspected cervical spine injury in adults: Choice of imaging", section on 'Choice of initial imaging modality'.)

Cervical spine radiographs have a significantly lower sensitivity compared with CT. Some clinicians perform plain radiographs when CT is unavailable, but a patient with negative radiographs and persistent examination findings concerning for injury (eg, focal midline cervical tenderness, neurologic findings localizing to the upper extremities) should be managed with the presumptive diagnosis of a cervical spine injury pending more advanced imaging. (See "Suspected cervical spine injury in adults: Choice of imaging", section on 'Radiography'.)

If a fracture of the cervical spine is identified in a blunt trauma patient, there is a significant chance that additional fractures of the spinal column are present, and we obtain imaging of the entire spinal column [45,46]. Some experts reevaluate the patient for additional potential injuries requiring further imaging and do not necessarily image the entire spine after a cervical fracture is identified. (See "Thoracic and lumbar spinal column injury in adults: Evaluation", section on 'Decision rules for imaging thoracolumbar injury'.)

Cervical spine injury (eg, vertebral body or transverse foramen fracture, subluxation/dislocation, two-level fracture, fractures of C1 to C3) is a risk factor for blunt cerebrovascular injury (vertebral artery injury) and may warrant a CT angiogram, which is discussed separately. (See "Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation".)

SPINAL CORD INJURY WITHOUT RADIOGRAPHIC ABNORMALITY

Diagnosis — A cervical ligamentous injury or spinal cord injury without radiographic abnormality (SCIWORA) should be suspected in an alert patient with upper extremity paresthesias or focal neurologic findings (eg, upper extremity weakness) (table 1 and table 2 and table 3) despite a normal computed tomography (CT) examination. SCIWORA is commonly defined as the presence of neurologic deficits in the absence of evidence of bony injury on a complete, technically adequate plain radiography examination or CT examination.

In the obtunded patient or a patient with an unreliable examination, this is a difficult clinical issue. Approaches vary to imaging and removal of the cervical collar. (See 'Cervical spine clearance (removal of cervical collar)' below.)

Epidemiology in adults — Several studies published subsequent to the increased use of magnetic resonance imaging (MRI) report higher rates of SCIWORA among adults than previously suspected [47-50], although reported rates vary widely:

A retrospective review of the National Emergency X-Radiography Utilization Study (NEXUS) data found that of 818 patients with cervical spine injury, 27 adult patients (3.3 percent) had SCIWORA [51].

A retrospective review of 166 patients with cervical spine injury managed over a 16-year period at a single trauma center reported the rate of SCIWORA to be 4.2 percent (7/166) [47]. MRI abnormalities were identified in five of the six patients examined.

A retrospective review of 127 trauma patients with central spinal cord injury reported the prevalence of SCIWORA to be 32.2 percent [48]. Most SCIWORA injuries occurred in older patients and involved minor mechanisms; SCIWORA injuries in younger patients generally involved high-energy mechanisms.

The reasons for the discrepancies in the reported rates of SCIWORA remain unclear. Increased rates may reflect a true increase in incidence, an increase in reporting, or the heterogeneity of definitions used to define SCIWORA [52,53]. Some define SCIWORA as any spinal cord injury not seen on radiography or CT, while others include the absence of signs of injury on MRI.

True SCIWORA is seldom associated with permanent neurologic injury in adults [54]; however, cervical spinal subluxation may occur when the ligamentous complexes rupture without an associated bony injury.

Only a small proportion of patients (typically <1 percent) with an unreliable clinical examination and a negative CT demonstrate an injury requiring surgical stabilization on MRI [55-58]. As an example, a retrospective series of 712 patients who underwent an MRI following a negative CT noted that 3 patients (0.4 percent) required operative management because of a newly identified unstable injury [56]. In a meta-analysis of 1550 patients with a negative CT following blunt trauma, MRI altered management in 6 percent, with 5 percent requiring prolonged immobilization and 1 percent requiring surgical stabilization [55].

Additional imaging — In a patient with suspected ligamentous injury or SCIWORA of the cervical spine with an adequate, normal CT study, we obtain cervical spine MRI without contrast [55-57]. We do not obtain lateral radiographs of the cervical spine with the neck in flexion and extension in the acute setting. However, the approach to imaging patients with suspected SCIWORA remains controversial. No randomized trials have directly compared CT plus MRI with CT alone, and other approaches to imaging may be reasonable. (See "Suspected cervical spine injury in adults: Choice of imaging", section on 'Further evaluation with magnetic resonance imaging'.)

Similar to patients with cervical spine fracture, for patients with SCIWORA, we maintain immobilization of the spine until additional imaging is completed and consultation with spine surgery is obtained. (See 'Further management and disposition' below.)

Much of the older literature evaluating CT involves approaches and technology that have been superseded by more accurate protocols using multidetector CT and multiplanar reconstructions. Additionally, the reference standard for establishing spinal instability is a requirement for prolonged external spinal immobilization or surgery, a determination that varies among institutions and surgeons. Thus, systematic reviews and practice guidelines have been inconsistent due in part to the limitations and heterogeneity of available studies.

CERVICAL SPINE CLEARANCE (REMOVAL OF CERVICAL COLLAR) — Clearance of the cervical spine refers to removal of the cervical collar and should be performed as soon as possible, and ideally within 48 hours in obtunded patients. Prolonged use of a hard cervical collar can increase the risk of occipital pressure ulcers, increase difficulty of pulmonary toilet, decrease cerebral venous return, increase intracranial pressure, and interfere with procedures (eg, central line placement) [59]. When rapid cervical spine clearance is not possible, the stretcher should be placed in slight reverse Trendelenburg position, if possible, to decrease aspiration risk.

Alert patient – We clear the cervical spine in an alert, cooperative, and nonintoxicated patient with any of the following:

Negative National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria or Canadian C-spine Rule (CCR). (See 'Clinical decision rules' above.)

No neurologic signs or symptoms referred to the cervical spine (table 1 and table 2 and table 3) and a normal cervical spine computed tomography (CT) obtained with a multidetector scanner with multiplanar reformations. (See "Suspected cervical spine injury in adults: Choice of imaging", section on 'CT performance and test characteristics'.)

If imaging was normal but with a modality other than multidetector CT, then the patient should have no high-risk features of injury (see 'Approach to patient selection' above), no neurologic signs or symptoms referred to the cervical spine (table 1 and table 2 and table 3), no severe posterior neck pain, no focal midline cervical spine tenderness, and be able to rotate their neck actively 45 degrees both left and right.

Obtunded patient or unreliable examination – We remove the cervical collar after a negative cervical spine CT using an advanced multidetector scanner and performed with protocols developed specifically for spinal trauma clearance (ie, axial thickness ≤2 mm). This practice agrees with recommendations from the Eastern Association for the Surgery of Trauma (EAST) management guidelines [59].

Multiple studies suggest that it is safe to forego magnetic resonance imaging (MRI) if a high-quality cervical spine CT is negative. A systematic review of five studies using multidetector CT to assess obtunded adult trauma patients (follow-up was completed for 1017 patients) reported that no unstable injuries were missed. Another systematic review included an analysis of seven higher-quality studies (defined by their prospective design, low risk of bias, and use of modern CT imaging technology and interpretation) involving 1686 patients and reported no missed cervical spine injuries of clinical significance [60]. Other reviews have reached similar conclusions [61,62].

In two large, prospective observational studies, cervical spine CT identified all clinically significant cervical spine fractures in intoxicated patients provided their gross motor function was intact [63,64].

FURTHER MANAGEMENT AND DISPOSITION

General approach — Initial management is based on the stability of the spinal column injury as well as any associated spinal cord injury. Immobilization of the spine is maintained until an unstable injury is diagnosed or excluded with imaging. Stability determination and outcome prognostic indicators are based upon clinical presentation, associated injuries, and radiographic findings. Unstable injuries are listed in the table and discussed in greater detail separately (table 4). (See "Spinal column injuries in adults: Types, classification, and mechanisms".)

The management of spinal cord injury, including the use of glucocorticoids, the National Acute Spinal Cord Injury Study (NASCIS) results, recommendations from neurosurgical societies, definitive surgical management, and complete versus incomplete spinal cord injury are discussed separately. (See "Acute traumatic spinal cord injury".)

Disposition — The disposition of patients with spinal column injury depends primarily upon fracture stability and concomitant injuries.

Unstable injury — If a spinal column injury is deemed unstable, hospital admission and spine surgery consultation are mandatory. If consultation is not available onsite, immediate transfer must be arranged to a center that can provide these services. Patients with unstable fractures have commonly sustained multisystem trauma, and the extent of their other injuries determines whether they require admission to an intensive care unit or other monitored setting.

Conservative treatment of cervical fractures consists of closed reduction under fluoroscopic guidance and halo-vest immobilization. The halo is constructed of graphite or metal and is secured to the frontal and parietal areas of the skull with metal pins. The halo is the most common external device applied for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3 [65]. Minor potential complications of halo fixation include localized infection, pressure sores, scarring, and pin loosening [66]. More serious complications include osteomyelitis, subdural abscess, nerve palsies, pin penetration, and continued spinal instability (ie, nonunion).

There are many surgical fixation options including pedicle screw fixation (includes posterior fixation of one level versus two levels) [67], direct internal fixation of unstable atlas fractures [68], and anterior-only and posterior approaches for unstable subaxial facet dislocation [69]. The choice of surgical approach is beyond the scope of this topic, and the surgical management of traumatic spinal cord injury is discussed separately. (See "Acute traumatic spinal cord injury", section on 'Surgery'.)

Stable injury — If computed tomography (CT) demonstrates minor spinal fracture patterns and there is no neurologic deficit, outpatient management may be possible. Isolated transverse process fractures identified by CT appear to be one example of fractures suitable for outpatient management [70,71]. Additionally, stable compression fractures without a broken posterior ligament and no kyphosis can be managed nonoperatively with external cervical immobilization (ie, cervical collar) [72]. Treatment should include analgesics, and follow-up care should be arranged in all instances because even minor spinal column injuries may be associated with prolonged disability. If there is any ambiguity regarding spinal stability, spine surgery consultation is warranted.

The management of patients with neck pain without fracture or unstable soft tissue injury is discussed separately. (See "Management of nonradicular neck pain in adults".)

COMMON PITFALLS IN MANAGEMENT

Failure to immobilize the spine. (See 'Spinal immobilization (prehospital and emergency department)' above.)

Failure to suspect spinal column injury in a multitrauma patient due to inability to evaluate neurologic deficits or neck or back tenderness.

Failure to perform computed tomography (CT) in patients who meet clinical criteria (National Emergency X-Radiography Utilization Study [NEXUS] or Canadian C-spine Rule [CCR]) for imaging of the cervical spine after high-risk mechanisms of injury. (See 'Approach to patient selection' above.)

Failure to reevaluate the patient for additional potential injuries when imaging identifies a spinal fracture and obtain imaging of other spinal regions or the entire spine, if needed.

Failure to obtain specialty consultation when there is a fracture, instability, or neurologic deficits.

Failure to consider a cervical spine fracture in an ambulatory patient with an intact neurologic examination, since these patients can still have a clinically significant cervical spine fracture.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Cervical spine injury".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

Basics topic (see "Patient education: Neck fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

Spine immobilization – Suspect a cervical spinal column injury in any trauma victim, especially in the setting of motor vehicle collisions, assaults, falls, and sports-related injuries. Older adults are at higher risk and can sustain such injury from a simple fall from standing. Spinal immobilization, including rigid cervical collar, sometimes a backboard (or stretcher), and lateral head supports for transport should be initiated at the scene and maintained until an unstable spinal injury is excluded. Techniques for safe helmet removal are described above. (See 'Spinal immobilization (prehospital and emergency department)' above.)

Mechanisms and injury types – The clinical anatomy, common mechanisms of injury, and major types of clinical spinal column injury are reviewed separately. (See "Spinal column injuries in adults: Types, classification, and mechanisms".)

Trauma and airway management – The priorities of trauma management do not change in the setting of potential spinal column injury. In-line stabilization should be maintained during intubation; however, the preeminent concerns remain airway protection and oxygenation. Anticipate airway management problems in patients with cervical spinal column injury. Unstable lesions above C3 to C5 may cause immediate respiratory paralysis; lower cervical lesions may cause delayed respiratory distress. (See 'Airway management' above and "Initial management of trauma in adults".)

Secondary survey – The secondary survey should include palpation of the entire spine and paraspinal musculature for areas of tenderness or deformity; a step-off in the spine may indicate vertebral subluxation or fracture. Widening of an interspinous space indicates a tear in the posterior ligament complex and a potentially unstable spinal injury. A focused but systematic neurologic evaluation should be performed in all patients with a possible spine injury (table 1). (See 'Secondary trauma survey' above.)

Spinal cord injury – The spinal cord syndromes and manifestations based on level of injury are summarized in the following tables (table 2 and table 3). The diagnosis and management of spinal cord injury are discussed separately. (See "Acute traumatic spinal cord injury".)

Determining the need for imaging – Our approach to determining if a patient with blunt trauma needs cervical spine imaging is presented in the algorithm (algorithm 1). We obtain cervical spine computed tomography (CT) without contrast (in addition to any other needed imaging studies) in a patient with any of the following (see 'Approach to patient selection' above):

The presence of any of the following, which suggests high risk of cervical spine injury:

-High-speed (≥56 kph [35 mph] combined impact) motor vehicle crash

-Death at scene of motor vehicle crash

-Fall from height (≥3 m [10 feet])

-Significant closed head injury or intracranial hemorrhage seen on CT

-Neurologic symptoms or signs (eg, weakness, numbness, paresthesias) referred to the cervical spine (table 1 and table 2 and table 3)

-Pelvic or multiple extremity fractures

Disproportionate midline neck or back pain, focal spine tenderness, upper extremity paresthesias, or other suggestive symptoms

History of severe osteoporosis, advanced arthritis, cancer, degenerative bone disease, Down syndrome, or rheumatoid arthritis

Patients who have sustained major trauma and are undergoing CT imaging to assess for head, chest, or abdomen injury

In a patient ≤65 years old who has sustained less severe trauma (eg, minor fall or motor vehicle collision),and has posterior neck pain, does not meet any of the above criteria, and does not have a direct blow to the neck or penetrating trauma, we use either of the following clinical decision rules to determine the need for cervical spine imaging:

National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria (see 'NEXUS low-risk criteria' above)

Canadian C-spine Rule (CCR) (see 'Canadian C-spine Rule' above)

Selection and performance of the appropriate imaging study are reviewed separately. (See 'Initial imaging' above and "Suspected cervical spine injury in adults: Choice of imaging".)

Spinal cord injury without radiographic abnormality (SCIWORA) – We perform cervical spine magnetic resonance imaging (MRI) without contrast in an alert patient with suspicion for SCIWORA, which includes those with normal CT imaging but upper extremity paresthesias or focal neurologic findings (eg, upper extremity weakness) (table 1 and table 2 and table 3). (See 'Spinal cord injury without radiographic abnormality' above.)

Cervical spine clearance – In an alert patient, the cervical spine can be cleared with either the NEXUS or CCR (if applicable) or with imaging (CT scan is preferred). In an obtunded patient, we agree with the Eastern Association for the Surgery of Trauma (EAST) guidelines, which recommend cervical collar removal after a negative high-quality (ie, axial thickness ≤2 mm) CT of the cervical spine. (See 'Cervical spine clearance (removal of cervical collar)' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert S Hockberger, MD, FACEP, who contributed to an earlier version of this topic review.

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References

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