The majority of the nearly 18,000 new cases of spinal cord injury in the United States each year involve the cervical spine. Although the morbidity, mortality, and healthcare costs associated with these injuries is very high, quality evidence to guide emergency management is limited. Recent changes to guidelines have called into question decades of practice, including prehospital spinal immobilization protocols, timing of surgery, and pharmacotherapy. A systematic approach to the diagnosis and management of the spine-injured patient is outlined in this review, with a focus on recent updates and management of emergent complications.
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Following are the most informative references cited in this paper, as determined by the authors.
2. “National Spinal Cord Injury Statistical Center, Facts and Figures at a Glance.” 2021. Accessed September 10, 2021. (Prospective longitudinal study; 34,734 patients)
7. * Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res. 1984;&NA;(189):65-76. (Cohort study; 412 patients)
22. * Theodore N, Hadley MN, Aarabi B, et al. Prehospital cervical spine immobilization after trauma. Neurosurgery. 2013;72(suppl_3):22-34. (Systematic review and guideline) DOI: 10.1227/NEU.0b013e318276edb1
27. * Hauswald M, Ong G, Tandberg D, et al. Out-of-hospital spinal immobilization: Its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214–219. (Retrospective cohort study; 454 patients) DOI: 10.1111/j.1553-2712.1998.tb02615.x
28. * Oto B, Corey DJ, Oswald J, et al. Early secondary neurologic deterioration after blunt spinal trauma: a review of the literature. Acad Emerg Med. 2015;22(10):1200-1212. (Systematic review) DOI: 10.1111/acem.12765
30. * McDonald NE, Curran-Sills G, Thomas RE. Outcomes and characteristics of non-immobilised, spine-injured trauma patients: a systematic review of prehospital selective immobilisation protocols. Emerg Med J. 2016;33(10):732-740. (Systematic review) DOI: 10.1136/emermed-2015-204693
59. * ASIA and ISCoS International Standards Committee. The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)—what’s new? Spinal Cord. 2019;57(10):815-817. (Practice guideline) DOI: 10.1038/s41393-019-0350-9
61. * Stiell IG, McKnight RD, Schull MJ, et al. The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. New Engl J Med. 2003:9. (Prospective cohort; 8283 patients) DOI: 10.1056/NEJMoa031375
92. * Cabrini L, Baiardo Redaelli M, Filippini M, et al. Tracheal intubation in patients at risk for cervical spinal cord injury: a systematic review. Acta Anaesthesiol Scand. 2020;64(4):443-454. (Systematic review and meta-analysis; 1972 patients) DOI: 10.1111/aas.13532
101. *Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury: results of the second national acute spinal cord injury study. N Engl J Med. 1990;322(20):1405-1411. (Randomized controlled trial; 487 patients) DOI: 10.1056/NEJM199005173222001
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Keywords: cervical, spine, spinal cord, injury, MVC, motor vehicle crash, neck pain, head, trauma, compression, fracture, flexion, hyperextension, burst, immobilization, motion restriction, guidelines, paresthesia, airway, intubation, NEXUS, Canadian C-Spine, Denver screening, SCIWORA
In This Episode
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the October 2021 issue of Emergency Medicine Practice: Emergency Department Management of Cervical Spine Injuries (Trauma CME)
Geoffrey Jara-Almonte, MD; Chandni Pawar, MD
Michael Abraham, MD, MS, FAAEM; Jared Ham, MD
October 1, 2021
October 31, 2024
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits
Date of Original Release: October 1, 2021. Date of most recent review: September 10, 2021. Termination date: October 1, 2024.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: The AAFP has reviewed Emergency Medicine Practice, and deemed it acceptable for AAFP credit. Term of approval is from 07/01/2021 to 06/30/2022. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr Jara-Almonte, Dr. Pawar, Dr. Abraham, Dr. Ham, Dr. Jagoda, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
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Cover Image: Lateral x-ray of cervical spine showing bilateral facet joint dislocation. Illustration by Yok_onepiece.