Makindo Medical Notes

A delay in diagnosis occurs that puts the patient at risk for progressive instability and neurologic deterioration. Note that to adequately assess a patient, he/ she must be awake and alert, non-intoxicated and without distracting injury

Anatomy

• There are 7 cervical vertebrae separated by intervertebral disks
• Joined by a complex network of ligaments holding as a single unit.

Aetiology

• Accidental falls, Motor vehicle/transport injuries
• Cervical spine commonest site of spinal injury

Commonest Site of Injury

• Atlantoaxial region and C6 and C7.
• Most common missed injuries are odontoid, teardrop, facet and Hangman's fractures.
• Approximately 85-90% of cervical spine injuries are evident in lateral view
• Lateral X-ray is the most useful view from a clinical standpoint.

Consider C-Spine injury if any of the following

• Multi system/major trauma
• Altered LOC
• Blunt injury above clavicles
• Neck pain, deformity, bruising
• Neurological defects

C-spine 3-point immobilisation

• First a rigid collar is applied. This primarily helps by stopping the patient flex or extend their neck.
• Secondly, sand-bags are placed on either side of the patients head - this stops the patient from turning their head.
• Thirdly, the patient's forehead and chin are immobilised by attaching secure tape over their heads and to the bed.

CT should be used as the primary imaging modality for excluding cervical spine injury in adults following blunt trauma if any of the following criteria are met

• GCS below 13 on initial assessment (level 2 evidence)
• Intubated patients (level 2 evidence)
• Inadequate plain film series (level 2 evidence)
• Suspicion or certainty of abnormality on plain film series*(level 2 evidence)
• Patient being scanned for head injury or multi-region trauma (level 2 evidence)
• Patient has dementia (or a chronic disability precluding accurate clinical assessment) (level 5 evidence)
• Patient has new neurological signs or symptoms (level 2 evidence)
• Patient has severe neck pain ( =7/10 severity) (level 4 evidence)
• Patient has a significantly reduced range of neck movement (level 4 evidence)
• Patients with known vertebral disease (eg ankylosing spondylitis, rheumatoid arthritis, spinal stenosis, or previous cervical surgery) (level 4 evidence)
• *As a minimum the CT should cover the area from the craniocervical junction to the thoracocervical junction since selective scanning may miss injuries.
• Guidelines should be agreed with local radiologists as to the most appropriate primary imaging modality for patients aged = 65 years.

Indications for MRI of the cervical spine

• MRI should be used to exclude cervical spine injury* in adults following blunt trauma if any of the following criteria are met (level two evidence):
• 1. Neurological signs and symptoms referable to the cervical spine
• 2. Suspicion of vertebral artery injury ( eg spinal column displacement, foramen transversarium or lateral process fracture, posterior circulation syndromes).
• 3. MRI should also be used to exclude cervical spine injury* in adults with severely restricted neck movement or severe pain (=7/10) despite a normal CT (level four evidence).
• NB: MRI should always be used in conjunction with another modality, preferably CT, in order not to miss bony injuries.

Modified Canadian cervical spine rule

• Cervical spine imaging should be requested for the following patients that have been subjected to blunt trauma with a mechanism that may have injured the neck:
• GCS<15 on assessment in the ED (level one evidence)
• Paralysis, focal neurological deficit, or paraesthesia in the extremities ( level one evidence)
• Patients with abnormal vital signs (systolic BP <90mmHg or respiratory rate outside of the range 10-24 breaths per minute) (level five evidence)
• Urgent requirement to identify a cervical spine fracture ( eg prior to surgery) (level five evidence)
• Severe neck pain ( = 7/10 severity) (level four evidence)

Patients with neck pain and any of the following high-risk factors (level one evidence unless otherwise stated):

• a fall from greater than one metre or five stairs
• an axial load to the head e.g. diving
• a high-speed motor vehicle collision (combined speed >60mph)
• a rollover motor vehicle accident
• ejection from a motor vehicle
• an accident involving motorised recreational vehicles
• a bicycle collision
• age 65 years or more
• injured more than 48 hours earlier (level five evidence)
• re-attending with the same injury (level five evidence)
• known vertebral disease (eg ankylosing spondylitis, rheumatoid arthritis, spinal stenosis, or previous cervical surgery) (level four evidence)
• Patients with a dangerous mechanism of injury (see above) and either a visible injury above the clavicles or a severely painful ( = 7/10 severity) thoracic injury even if there is no neck pain or tenderness (level four evidence)

If none of the high-risk factors above is present and any of the following low-risk factors are identified then the patient can have their collar removed and their range of movement assessed (level one evidence):

• simple rear-end motor vehicle collision (but not if pushed into another vehicle, or if hit at high speed or by a large vehicle)
• sitting position in ED
• ambulatory at any time since injury
• delayed onset of neck pain (ie not immediate)
• absence of midline cervical spine tenderness Patients stratified to a low-risk category that can actively rotate their necks 45 degrees to the left and right should be considered to have had a significant cervical spine injury excluded without need for imaging. Patients that are unable to rotate their neck 45 degrees in both directions or report severe pain ( = 7/10 severity) on doing so should have cervical spine imaging performed.

Management

• Depends on which of the seven cervical vertebrae is damaged and the kind of fracture sustained. A minor compression fracture can be treated with a cervical brace worn for 6 to 8 weeks until the bone heals.
• A complex or extensive fracture may require traction, surgery, 2 to 3 months in a rigid cast, or a combination of these treatments.