INTRODUCTION — This topic discusses the evaluation and initial management of injuries to the cervical spinal column in adults, including how to determine the need for imaging. The importance of early recognition and appropriate management of such injuries is underscored by their association with spinal cord injury.
Other aspects of spine injury are reviewed separately:
●Imaging of suspected cervical spine injury (see "Imaging of adults with suspected cervical spine injury")
●Descriptions of spinal column fractures; thoracic and lumbar spine injuries (see "Spinal column injuries in adults: Definitions, mechanisms, and radiographs" and "Evaluation of thoracic and lumbar spinal column injury")
●Spinal cord injuries (see "Acute traumatic spinal cord injury" and "Anatomy and localization of spinal cord disorders")
●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")
EPIDEMIOLOGY AND ANATOMY — The epidemiology and clinically important anatomy related to cervical spine injuries are discussed separately. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Epidemiology' and "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Anatomy'.)
MECHANISMS, CLASSIFICATION SCHEMES, AND TYPES OF INJURY — Common mechanisms of injury, classification schemes, and important types of cervical spinal column injuries are discussed separately. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Mechanisms of injury' and "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Cervical spinal column injury'.)
INITIAL MANAGEMENT
Spinal immobilization — First responders should be vigilant for spinal column injury in trauma patients, especially in the setting of a motor vehicle collision, assault, fall from a height, or sports-related injury. For any patient with a possible cervical spine injury, spinal immobilization should be initiated at the scene. The conservative approach is to assume the presence of a cervical spinal column injury in patients who are "found down" with no information about preceding events available. This assumption is prudent in some settings (eg, patient is an older adult, overt signs of head trauma are present). However, spinal immobilization entails its own risks and possible adverse effects (eg, occipital decubitus ulcers, aspiration). Thus, in the absence of a history or clinical signs suggesting head, neck, or upper torso injury, the clinician must use their clinical judgement to determine whether spinal immobilization is warranted.
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). In some locations, emergency medical services directors may allow prehospital personnel to not apply a cervical collar based solely on mechanism and instead use criteria such as National Emergency X-Radiography Utilization Study (NEXUS) in the field. (See 'Patients who are at lower but not negligible risk of injury' below.)
Trauma victims may not think clearly due to head injury, shock, 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.
Some form of cervical spine immobilization and protection should be maintained until an unstable spinal injury is excluded using a validated assessment instrument or appropriate diagnostic imaging. However, upon arrival at the hospital and for long transports, we recommend removing the patient from the backboard and placing them on a stretcher to prevent potential complications [1].
Spinal injury is uncommon in patients with penetrating trauma and rare in those without evidence of neurologic injury [2]. This lower risk and the possibility of harm from immobilization have led some experts to question 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 spinal immobilization in this setting because victims of penetrating trauma may simultaneously sustain blunt head or neck trauma during an assault. This issue is discussed in greater detail separately. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Cervical spine immobilization'.)
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 [3].
Cervical spine injuries are uncommon in cases of self-hanging. Morbidity is primarily due to asphyxiation with cerebral anoxia or soft tissue injury [4,5]. Spinal column injury from hanging is seen in executions involving a drop from a height against a knotted rope.
It should be noted that, while the backboard often used for spinal immobilization is helpful for extricating trauma patients from vehicles, there is no high-quality evidence demonstrating that it prevents spinal injury or improves outcome [1]. Observational evidence suggests that backboards and cervical collars may be associated with complications, such as decubitus pressure ulcers, respiratory compromise, and altered examination findings. We agree with position statements from the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) advocating judicious use of long backboards and recommend that trauma patients be removed from their backboard as quickly as possible [6].
Helmeted patients
●Motorcycle helmet removal – Safe removal of a motorcycle helmet requires that manual cervical spine immobilization be maintained continuously, and this can only be done with two people.
The technique is performed as follows [7]:
•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.
●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'.)
●Ski and snowboard helmet removal – A study of 28 volunteers participating in a ski patrol exercise reported increased movement of the cervical spine when their helmets were removed [8], suggesting that precautions to protect the cervical spine comparable to those described above are warranted when ski helmets are removed.
Prehospital personnel should attempt to place a cervical collar, realizing that it may be impossible. To further minimize head motion, towel rolls, foam head blocks, and tape may be used.
Emergency department management — Resuscitation of the trauma patient is reviewed separately. Management details pertaining to possible cervical spinal column injury are discussed below. (See "Initial management of trauma in adults".)
The different types of spinal column injuries are described separately. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs".)
Airway management — Despite the dearth of supporting evidence, we believe clinicians should continue to use in-line stabilization whenever they intubate a patient with a possible spinal column injury until compelling scientific data from randomized trials demonstrate its ineffectiveness. However, the preeminent concern is to protect the airway and oxygenate the patient, and some loss of in-line stabilization is acceptable if necessary to accomplish these ends.
The emergency clinician should anticipate airway management problems in patients with cervical spinal column injury [9]. Unstable lesions above C3 may cause immediate respiratory paralysis, and lower cervical lesions may cause delayed phrenic nerve paralysis from ascending edema of the spinal cord. 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".)
According to the American College of Surgeons' Advanced Trauma Life Support (ATLS) guidelines, orotracheal intubation is the preferred method of airway management for patients with traumatic cardiopulmonary arrest, even with evidence of spinal injury [10]. Orotracheal intubation in conjunction with rapid sequence intubation is recommended for patients who are breathing but unconscious and in need of airway control or ventilatory support [11]. In-line spinal stabilization should be maintained throughout the procedure to minimize spinal column movement. (See "Initial management of trauma in adults", section on 'Airway' and "Rapid sequence intubation for adults outside the operating room" and "Direct laryngoscopy and endotracheal intubation in adults" and "Video laryngoscopes and optical stylets for airway management for anesthesia 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 [12]. They find little evidence to support the contention that orotracheal intubation without in-line stabilization is unsafe in spinal column injury patients. In addition, in-line stabilization impairs the clinician's view when direct laryngoscopy is performed, increasing the risk for failed intubation and severe hypoxemia, which are associated with poor outcomes in central nervous system injury.
The potential difficulty caused by in-line stabilization during laryngoscopy has become less important with increasing use of video laryngoscopes and other sophisticated airway management tools that improve the clinician's view of the larynx while reducing cervical spine motion. (See "Devices for difficult emergency airway management in adults outside the operating room", section on 'Advanced laryngoscopes'.)
Spinal and neurogenic shock — Transient loss of spinal cord function, sometimes manifested as areflexia and termed "spinal shock," can occur following spinal column injury. By contrast, hypotension from neurogenic shock may occur from injury to the spinal cord, especially the superior portion. However, hemorrhage remains the primary concern in hypotensive trauma patients. Hypotension related to spinal shock may be accompanied by bradycardia.
Neurogenic shock and the management of trauma-related shock are discussed separately. (See "Acute traumatic spinal cord injury", section on 'Cardiovascular complications' and "Approach to shock in the adult trauma patient".)
Secondary trauma survey — The secondary survey is a standard part of the trauma evaluation and includes a careful inspection of the patient's entire body, beginning with the head. The secondary survey is discussed in detail separately; aspects of the secondary survey of particular importance to patients with a possible cervical spine injury are discussed below. (See "Initial management of trauma in adults", section on 'Secondary evaluation and management'.)
Some authorities claim that signs of injury above the clavicles are associated with an increased risk of cervical spinal column injury [10]. Based on case series, approximately 5 to 10 percent of patients with significant head and facial trauma sustain associated cervical spine injuries [13,14]. Other studies call this association into question and emphasize the importance of physiologic indicators, such as depressed neurologic function [15]. In one retrospective series of 447 consecutive patients with moderate or severe head injury, those with a Glasgow Coma Scale (GCS) score below 8 were more likely to have sustained a cervical spine injury (odds ratio [OR] 2.77; 95% CI 1.11-7.73) [16].
During the secondary survey, the entire spine and paraspinal musculature should be 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.
A focused but systematic neurologic evaluation should be performed in all patients with a possible spine injury. Clinicians should assess the presence and symmetry of both voluntary and involuntary movements. As examples, priapism may occur with severe spinal cord injury, and an abnormal breathing pattern may indicate a cervical injury, as the diaphragm is innervated by the phrenic nerve [17]. During the neurologic examination, particular attention should be paid to the symmetry of strength, sensation, reflexes, and proprioception in the arms and legs. Any sensory deficits, including the dermatome where they occur, should be noted. Bowel or bladder incontinence or retention is an important finding. 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'.)
Although previous iterations of ATLS advocated performing a digital rectal examination on all trauma patients during the secondary survey, there is no clear evidence that the examination is an accurate means for detecting spinal cord injury [18-21]. ATLS does not mandate a rectal examination during the secondary survey. In specific circumstances, such as pelvic trauma, the rectal examination may provide useful clinical information about the trauma patient. (See "Pelvic trauma: Initial evaluation and management", section on 'Physical examination'.)
Certain conditions predispose patients to cervical spinal column injury, and thus, it is important to obtain the past medical history. As examples, Down syndrome patients are predisposed to atlanto-occipital dislocation, and patients with rheumatoid arthritis are prone to rupture of the transverse ligament of C2. (See "Down syndrome: Clinical features and diagnosis" and "Cervical subluxation in rheumatoid arthritis".)
MANAGEMENT OF SPINAL CORD INJURY — The management of spinal cord injury, including the use of glucocorticoids, the National Acute Spinal Cord Injury Study (NASCIS) results, recommendations from neurosurgical societies, and complete versus incomplete spinal cord injury are all discussed separately. (See "Acute traumatic spinal cord injury".)
The signs of spinal cord injury and spinal cord syndromes are summarized in the following tables (table 1 and table 2 and table 3).
Details regarding managing complications associated with spinal cord injuries, as well as definitive surgical management, are found separately. (See "Acute traumatic spinal cord injury", section on 'Decompression and stabilization' and "Chronic complications of spinal cord injury and disease".)
DETERMINING THE NEED FOR IMAGING — Some debate continues regarding the most efficient and effective method of cervical spine imaging after blunt trauma; no standard approach has been explicitly defined. The approach we describe here is based upon available studies and our clinical experience (algorithm 1). The selection and performance of the appropriate imaging study are reviewed separately. (See "Imaging of adults with suspected cervical spine injury".)
Regardless of the approach selected, clearance of the cervical spine should be performed as soon as possible (ideally within 48 hours) in obtunded patients. Prolonged use of a hard cervical collar increases the difficulty of pulmonary toilet and the risk for developing occipital decubitus ulcers. When possible, stretchers should be placed in slight reverse Trendelenburg position (stretcher angled with head up and feet down (figure 1)) to decrease aspiration risk.
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. The results of two large, prospective observational studies suggest that computed tomography (CT) can identify all clinically significant cervical spine fractures in intoxicated patients provided their gross motor function is intact [22,23].
Assessing the risk of injury — A clinical decision rule using three injury mechanisms and three clinical parameters identifies patients who have sustained severe trauma and are at high risk of cervical spine injury [24]. The presence of any of the following indicates a patient at high risk of injury and mandates imaging of the cervical spine (in addition to any other needed imaging studies):
●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 computed tomography
●Neurologic symptoms or signs referred to the cervical spine (table 1 and table 2 and table 3)
●Pelvic or multiple extremity fractures (see "Pelvic trauma: Initial evaluation and management")
Various studies support the use of one or more of the criteria listed above, and we believe they provide reasonable guidance about the risk for significant injury of the cervical spine; however, no subsequent trials have validated the use of all six criteria.
Patients who are at high risk of injury — 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: Definitions, mechanisms, and radiographs" and "Imaging of adults with suspected cervical spine injury".)
Hemodynamically unstable trauma patients often proceed rapidly to the operating room. These patients are presumed to have an unstable cervical spine injury, and spinal immobilization is maintained until radiographic evaluation, generally by CT, can be performed postoperatively. Of note, cervical spine injuries are uncommon in patients with isolated penetrating neck trauma who do not manifest neurologic deficits or altered mental status. (See "Penetrating neck injuries: Initial evaluation and management".)
For patients who have sustained major trauma and are undergoing CT imaging to assess for internal injury of the head, chest, or abdomen, we perform CT of the cervical spine.
In cases of less severe trauma, the history, physical examination, and clinical decision rules are used to determine what spinal imaging is necessary.
Patients who sustain a minor fall or collision but nevertheless are at increased risk for spinal column injury and often warrant imaging include those with severe osteoporosis, advanced arthritis, cancer, and degenerative bone disease. Imaging, preferably with CT, is prudent if disproportionate midline neck or back pain, focal spine tenderness, upper extremity paresthesias, or other suggestive symptoms are present. It is possible for patients with a clinically significant cervical spine fracture to be ambulatory with an intact neurologic examination [25]. 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 the entire spinal column should be evaluated with diagnostic imaging. This issue is discussed separately. (See "Evaluation of thoracic and lumbar spinal column injury", section on 'Decision rules for imaging thoracic or lumbar spine injury'.)
Patients who are at lower but not negligible risk of injury — Patients who have sustained less severe trauma have a lower but not negligible risk of cervical spine injury (see 'Assessing the risk of injury' above). For these patients, the history, physical examination, and clinical decision rules are used to determine whether imaging is necessary. For patients deemed in need of imaging to assess possible injury, the selection and performance of the appropriate imaging study are reviewed separately. (See "Imaging of adults with suspected cervical spine injury".)
Clinical decision rules applicable — Both the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria and the Canadian C-spine Rule (CCR) are well validated and sensitive, and either can be used to determine the need for cervical spine imaging in adult trauma patients not at high risk but also not at negligible risk of injury. These rules are NOT applicable to the following patients:
●With direct blows to the neck
●With penetrating trauma
●NEXUS is not applicable to adults >60 years
NEXUS low-risk criteria — The first decision rule to be developed was the NEXUS low-risk criteria (NLC), which were prospectively validated in a large, multicenter, observational study [26]. All patients with blunt trauma who underwent imaging (ie, radiography, CT, or magnetic resonance imaging [MRI]) of the cervical spine at any of the 21 participating emergency departments were included.
The NLC decision instrument stipulates that imaging is not necessary if patients younger than 60 years satisfy 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 NEXUS investigators evaluated 34,069 blunt trauma patients who underwent imaging of the cervical spine comprised of either a three-view cervical spine radiograph, cervical spine CT, or MRI. Of these patients, 818 (2.4 percent) had sustained a cervical spinal column injury. Sensitivity, specificity, and negative predictive value of the NLC were found to be 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.
According to the NLC researchers, examples of a "painful distracting injury" include long bone fractures, visceral injury requiring surgical consultation, large lacerations, crush injuries, and large burns [27]. They add that an emergency clinician may categorize any injury thought "to have the potential to impair the patient's ability to appreciate other injuries" as a painful distracting injury. Some researchers 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 [28], but we feel such a conclusion is premature. In a study that assessed each component of the NLC, the authors noted that a substantial number of patients with a significant cervical spinal column injury met only one criterion, including 39 with only a distracting injury [29]. In this study, the overall sensitivity of the NLC for detecting cervical injury declined to 93.5 percent when painful distracting injury was removed from the list of criteria.
Older adult trauma patients are at higher risk of cervical spine injury due to their weaker bones, comorbidities, and other factors, and the NLC do not apply to this population (patients over 60 years were excluded from the original study population) [30,31]. A low threshold should be used to determine the need for imaging studies in geriatric trauma patients. According to a prospective study comparing the NLC in 320 elder (age >65, median = 75) versus 2465 non-elder (median age = 36) blunt trauma patients, sensitivity for cervical spine fracture was 65.9 percent in the older group and 84.2 in the younger group, using CT as the gold standard [30]. The authors concluded that the NLC are not appropriate for assessment of the elder population. (See "Geriatric trauma: Initial evaluation and management", section on 'Cervical spine injury'.)
Altered level of consciousness is defined in the NLC as follows [27]:
●Glasgow Coma Scale (GCS) score below 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 application of the NLC, assuming the patient meets all other criteria.
Canadian C-spine Rule — Due to the low specificity of the NLC (12.9 percent), some researchers expressed concern that use of these criteria might increase the use of cervical spine imaging in some regions of the United States and in the majority of countries outside of the United States. These researchers subsequently developed the CCR based upon three clinical questions derived from 25 clinical variables associated with spine injury [32].
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 high-risk characteristics listed in condition one above, assess for any low-risk factor that allows for safe assessment of neck motion. The low-risk factors are as follows:
•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
Any patient who does not meet at least one of the low-risk conditions listed here must be assessed with imaging. Such patients are NOT suitable for testing of neck motion.
If a patient meets any of the low-risk conditions, 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.
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 [32]. In 2003, the CCR was prospectively studied in the emergency departments of nine Canadian tertiary care hospitals. Of 8283 patients, 162 were found to have clinically significant injuries, and the sensitivity, specificity, and negative predictive values of the CCR were 99.4 (95% CI 96-100), 45.1 (95% CI 44-46), and 100 percent, respectively [33].
The investigators reported that the CCR would have missed one patient with a clinically important cervical spine injury, while the NLC would have missed 16. The CCR has also been validated in larger hospital-based studies and in an out-of-hospital study of paramedics [34,35].
NEXUS versus Canadian C-spine Rule — Both the NLC 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.
In contrast with NEXUS (where the NLC had a sensitivity of 99.6 percent and specificity of 12.9 percent), in a subsequent Canadian study, the NLC demonstrated a lower sensitivity of 90.7 percent and a higher specificity of 36.8 percent [33]. These discrepancies may stem from differences in study design. As an example, inclusion criteria differ for the two trials: the Canadian group excluded those under the age of 16 years and subjects with a GCS of less than 15, whereas these subjects were included among the NEXUS cohort. In addition, NEXUS investigators 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 [36].
Clinical decision rules not applicable — Clinical judgment is used to determine the need for imaging when clinical decision rules cannot be applied. Of note, the NLC cannot be applied to patients over 60, the CCR mandates imaging for all patients 65 or older, and neither rule can be used for children. (See "Geriatric trauma: Initial evaluation and management" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)
Imaging should be obtained in patients with symptoms or abnormal neurologic examination findings referable to the cervical spine. Imaging is prudent for patients with disproportionate midline neck or back pain, focal spine tenderness, upper extremity paresthesias, or other suggestive symptoms. Other patients who are at increased risk for spinal column injury and often warrant imaging include those with severe osteoporosis, advanced arthritis, cancer, and degenerative bone disease.
Cervical spine injuries are uncommon in patients with penetrating trauma who do not manifest neurologic deficits or altered mental status.
SUSPECTED SPINAL CORD INJURY WITHOUT RADIOGRAPHIC ABNORMALITY — Spinal cord injury without radiographic abnormality (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 computed tomography (CT) examination. True SCIWORA is seldom associated with permanent neurologic injury in adults [37]; however, cervical spinal subluxation may occur when the ligamentous complexes rupture without an associated bony injury.
Clinicians should suspect a cervical ligamentous injury or SCIWORA in an alert patient with severe neck pain, persistent midline tenderness, or upper extremity paresthesias; or if focal neurologic findings (eg, upper extremity weakness) are present despite a normal CT examination. When to suspect such injury in the obtunded patient is a difficult clinical question without a clear answer, and approaches vary.
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 [38-41], 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 [42].
●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) [38]. 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 [39]. 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 [43,44]. 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.
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 [45-47]. As an example, a retrospective series of 712 patients who underwent an MRI following a negative CT noted that the management was changed to surgery in 3 patients (0.4 percent) because of a newly identified unstable injury [46]. 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 [45].
Approach to imaging — The approach to imaging patients with suspected SCIWORA remains highly controversial. If CT does not reveal signs of injury but concern for an isolated ligamentous injury or SCIWORA of the cervical spine persists in either an alert or obtunded patient, we suggest performing an MRI without contrast. However, no randomized trials have directly compared CT plus MRI with CT alone, and other approaches to imaging may be reasonable.
Much of the older literature evaluating CT involves older approaches and technology that have been superseded by more accurate protocols using multidetector CT and multiplanar reconstructions. Moreover, 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.
Some series have reported that a small proportion of patients (usually <1 percent) are diagnosed on MRI with unstable spinal column injuries not apparent on CT [46-48]. As an example, a retrospective series of 712 patients who underwent MRI following a negative CT (performed according to contemporary multidetector CT protocol) noted that management was changed to surgery in 3 patients (0.4 percent) because an unstable injury was identifiable on MRI but not CT [46]. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs".)
One alternative approach uses CT alone, and a negative result is considered sufficient to clear the cervical spine of injury [49]. Some evidence suggests that foregoing MRI if the CT is negative is safe. The practice management guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend cervical collar removal after a negative study using an advanced multidetector CT performed according to protocols developed specifically for spinal trauma clearance [49]. 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 [50]. Other reviews have reached similar conclusions [51,52].
DEFINITIVE MANAGEMENT AND DISPOSITION — The disposition of patients with spinal column injury depends primarily upon fracture stability and concomitant injuries.
Unstable injury — Immobilization of the spine is maintained until an unstable injury is diagnosed or excluded with imaging. Unstable injuries are listed in the table and discussed in greater detail separately (table 4). (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs".)
If a spinal column injury is deemed unstable, hospital admission and spine surgery consultation is 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 device applied for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3 [53]. Potential complications of halo fixation include minor problems such as localized infection, pressure sores, scarring, and pin loosening; and more serious issues such as osteomyelitis, subdural abscess, nerve palsies, pin penetration, or continued spinal instability (ie, nonunion) [54].
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 conservative management [55,56]. 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 spinal cord injury, and of patients with neck pain but no fracture or unstable soft tissue injury, is discussed separately. (See "Acute traumatic spinal cord injury" and "Management of non-radicular neck pain in adults".)
OUTCOMES — Prognostic indicators of outcome are based upon clinical presentation, associated injuries, and radiographic findings, all of which help define whether a spinal column injury is stable or unstable. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs".)
COMMON PITFALLS IN MANAGEMENT
●Failure to immobilize the spine
●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
●Failure to image the entire spine when a fracture at one spinal level is demonstrated
●Failure to obtain specialty consultation when there is a fracture, instability, or neurologic deficits
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
●Patients at risk – 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. Patients with rheumatoid arthritis or Down syndrome are at increased risk.
●Spine immobilization – 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 'Initial management' 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: Definitions, mechanisms, and radiographs".)
●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, and some loss of in-line stabilization is acceptable if necessary to accomplish these. Anticipate airway management problems in patients with cervical spinal column injury. Unstable lesions above C3 may cause immediate respiratory paralysis; lower cervical lesions may cause delayed respiratory distress. (See 'Emergency department 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.
●Spinal cord injury – The diagnosis and management of spinal cord injury are discussed separately. The signs of spinal cord injury and spinal cord syndromes are summarized in the following tables (table 1 and table 2 and table 3). (See "Acute traumatic spinal cord injury".)
●Factors associated with high risk of injury – The presence of any of the following indicates a patient at high risk of injury and mandates imaging of the cervical spine (in addition to any other needed imaging studies):
•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 computed tomography (CT)
•Neurologic symptoms or signs referred to the cervical spine (table 1 and table 2 and table 3)
•Pelvic or multiple extremity fractures
●Determining if imaging is necessary – Imaging is indicated in patients who have sustained less severe trauma but clinical evaluation suggests cervical spine injury (algorithm 1). We suggest that either the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria or the Canadian C-spine Rule (CCR) be used to determine the need for cervical spine imaging in lower-risk patients when applicable. These decision rules are descried in the text. Selection and performance of the appropriate imaging study are reviewed separately. (See 'Determining the need for imaging' above and "Imaging of adults with suspected cervical spine injury".)
●Spinal cord injury without radiographic abnormality (SCIWORA) – Clinicians should suspect SCIWORA in an alert patient with severe neck pain, persistent midline tenderness, or upper extremity paresthesias; or if focal neurologic findings (eg, upper extremity weakness) are present despite a normal CT examination. When to suspect such injury in the obtunded patient is a difficult clinical question without a clear answer, and approaches vary. (See 'Suspected spinal cord injury without radiographic abnormality' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert S Hockberger, MD, FACEP, who contributed to an earlier version of this topic review.
