Rosen & Barkin's 5-Minute Emergency Medicine Consult (664 page)

• Neck pain, tenderness on palpation
  
• Numbness, weakness, paresthesias of upper or lower extremities
  
• Always assume a C-spine injury in any patient with:
  
  • Altered mental status (unconscious, intoxicated, on drugs, or hypoxic) following trauma or if events are unknown but trauma is likely
    
  • Inability to communicate (mentally retarded, language barrier, or intubated) following trauma or if events are unknown but trauma is likely
    
  • Distracting injury
    
  • Blunt trauma involving head or neck
    
• Incomplete cervical cord syndromes (see separate chapter):
  
  • Brown-Séquard syndrome: Hemisection of cord from penetrating injury (ipsilateral motor paralysis/contralateral sensory hypesthesia)
    
  • Anterior cord syndrome: Cervical flexion injury causing cord contusion (paralysis/hypesthesia with sparing of position/touch/vibratory sensations)
    
  • Central cord syndrome: Patients with cervical degenerative arthritis with forced hyperflexion (deficits greater in upper extremities relative to lower extremities)
    

• Obtain history of head or neck trauma.
  
• Identify history of ankylosing spondylitis or other brittle bone diseases.
  
• Specific symptoms:
  
  • Neck pain
    
  • Weakness
    
  • Numbness or tingling
    
  • Stinger
    

• Direct visualization of neck for bruising or deformity
  
• Palpation over the spinous processes
  
• Motor, sensory, and reflex exam of upper and lower extremities
  

Complete physical exam and radiographic imaging if clinically indicated

• Standard radiographs include 3 separate views: Lateral, anteroposterior, and open-mouth views of the odontoid while still immobilized.
  
• Lateral radiograph must include C1–T1; a swimmer’s view may be necessary to view lower levels.
  
• Supine oblique views may help in identifying subtle rotational injuries.
  
• CT should be obtained when C-spine fractures, dislocations, or soft tissue swelling is seen on plain films or for unexplained neck pain/neurologic deficit with normal radiograph.
  
• CT (helical) is considered a good alternative to plain films and is favored in certain patients, including intubated victims of blunt trauma.
  
• Flexion–extension views may be needed to evaluate for dynamic ligamentous injuries if static radiographs are negative and the alert, cooperative patient still complains of pain.
  
• MRI has become a valuable tool in evaluating patients with neurologic deficits, including spinal cord injury without radiographic abnormality.
  

• Cervical muscle strain injury (whiplash)
  
• C-spine dislocation
  
• Cervical fracture dislocation
  
• Complex or simple cervical fractures
  

TREATMENT

• If C-spine injury suspected, immobilize with a hard collar, neck pads, and backboard.
  
• Immobilized patients require constant observation in case of vomiting.
  
• Immobilize C-spine in patients with penetrating neck wounds only if a neurologic deficit is present.
  
• If the weapon is still embedded, immobilize the neck to avoid further injury and do not remove the impaling object unless it directly impedes breathing.
  

• Immobilize the spine using a rigid collar and backboard plus tape/towels or lightweight foam pads along the side of the neck.
  
• Stabilize the airway, establish IV access, and support circulation:
  
  • Preferred method is careful orotracheal rapid sequence intubation with inline spinal immobilization.
    
  • Fiberoptic intubation set should be at the bedside and considered if available.
    

• Assess patient for other injuries; remember that the abdominal exam in a C-spine–injured patient is unreliable and further objective testing is indicated.
  
• Patients with ankylosing spondylitis or other brittle bone diseases are at risk for fracture and cord injury with even trivial mechanisms.
  
• Patients may be clinically cleared and do not require C-spine radiograph (based on NEXUS) if they:
  
  • Have no altered level of alertness
    
  • Are not intoxicated
    
  • Have no tenderness in the posterior midline cervical spine
    
  • Have no distracting painful injury
    
  • Have no focal neurologic deficit
    
• If a neurologic deficit is present, consult neurosurgery.
  
• If the radiographs or CT is abnormal, consult neurosurgery or the orthopedic spine service.
  
• If the radiographs are normal but the alert and cooperative patient is having severe neck pain, consider flexion–extension films, CT, or MRI; if abnormal, consult neurosurgery.
  

High-dose steroid protocol for patients with neurologic deficits due to fractures or dislocations.

Methylprednisolone: 30 mg/kg IV bolus then 5.4 mg/kg/h over the next 23 hr; begin within 8 hr of injury

FOLLOW-UP

• C-spine fractures or dislocations associated with a neurologic deficit or any unstable fracture or dislocation should be admitted to the ICU or a monitored setting.
  
• Stable C-spine fractures or dislocations should be admitted.
  
• Isolated spinous process fractures that are not associated with any neurologic deficit or instability on plain films.
  
• Simple cervical wedge fractures with no neurologic deficit.
  

• Patients with acute cervical strain “whiplash”
  
• Musculoskeletal injuries that are associated with mild to moderate pain, no neurologic deficit, and normal radiographs
  

• The patient with a radiographically normal C-spine but continuous pain may be discharged with a hard collar and appropriate orthopedic follow-up.
  
• Patients with persistent symptoms from stinger should be followed up in 3–4 wk for EMG.
  

Return to ED for evaluation if pain increases or numbness, weakness, stingers, or other clinical changes develop.

• Trivial neck injuries in patient with ankylosing spondylitis or other brittle bone diseases may result in significant injuries.
  
• All the NEXUS criteria need to be applied to safely rule out a clinically significant spinal fracture without imaging.
  

• Committee on Trauma.
  Cervical Spine: Advanced Trauma Life Support.
  8th ed. Chicago: American College of Surgeons; 2008.
  
• Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.
  N Engl J Med
  . 2000;343:94–99.
  
• Richards PJ. Cervical spine clearance: A review.
  Injury.
  2005;36:248–269.
  
• Sama AA, Keenan MAE. Cervical spine injuries in sports: Emedicine. Available at
  http://emedicine.medscape.com/article/1264627-overview
  .
  
• Van Goethem JW, Maes M, Ozsarlak O, et al. Imaging in spinal trauma.
  Eur Radiol
  . 2005;15:582–590.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Ankylosing Spondylitis
  
• Head Trauma, Blunt
  
• Spinal Cord Syndromes
  

CODES

• 805.00 Closed fracture of cervical vertebra, unspecified level
  
• 839.00 Closed dislocation, cervical vertebra, unspecified
  
• 959.09 Injury of face and neck
  

BASICS

• Relatively rare, present in 1–2% of patients with severe blunt trauma
  
• Children <8 yr of age are more likely to have upper cervical spine injuries (C1–C3) and are at risk of growth plate injuries:
  
  • Spinal fulcrum is higher (C2–C3 at birth)
    
  • Relatively larger head to body
    
  • Weaker cervical musculature
    
  • Ligamentous laxity
    
  • Immature vertebral joints
    
• Children >8 yr of age:
  
  • Increased incidence of pancervical injuries
    
  • Vertebral body and arch fractures
    
  • Lower cervical spine injuries more common
    
• Special considerations:
  
  • Down syndrome
    
  • Klippel–Feil syndrome
    
  • Morquio syndrome
    
  • Larsen syndrome
    
• Spinal cord injury without radiographic abnormality (SCIWORA):
  
  • Based on study population, incidence from 4.5–35% of children with spinal injuries
    
  • More common in children <8 yr of age
    
  • May present as definite spinal cord injury:
    
    • Spinal shock
      
    • Neurologic deficits
      
  • Symptoms may be transient and have resolved by time of evaluation:
    
    • Paresthesias
      
    • Burning sensation of hands
      
    • Weakness
      
  • Symptoms often occur immediately after injury but may have delayed onset (i.e., minutes to days).