Emergency Department Management of Cervical Spine Injuries (Trauma CME)

Table of Contents

 

About This Issue

Given the potential for devastating disability and financial consequences of severe spinal cord injury, it is essential for emergency physicians to be able to act quickly to secure the airway and breathing, perform a neurological assessment, determine appropriate imaging, and expedite disposition. This issue reviews:

The key methods for determining and classifying spinal stability.

What the latest guidelines are recommending regarding spinal immobilization – is it still necessary?

Assessing the mechanism of injury to help determine spinal injury: flexion, extension, hyperextension, or axial loading.

The risks for spinal fracture in certain populations, with minimal or no trauma: the elderly, cancer patients, and those with ankylosing spondyloarthropathies.

The most important features of airway management in patients with spine injuries – including delayed airway obstruction – and the latest evidence on orotracheal intubation techniques.

NEXUS and the Canadian c-spine rule: using clinical decision rules to determine who is safe to discharge without imaging.

Using the Denver criteria to determine when further imaging for blunt cerebrovascular injury is needed.

Whether blood pressure augmentation and steroid therapies will help or hurt.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology and Pathophysiology
   1. Epidemiology
   2. Anatomy
   3. Pathophysiology
7. Differential Diagnosis
   1. Spinal Fracture
   2. Nontraumatic Spinal Compression
   3. Visceral Injuries
   4. Vascular Injury
   5. Muscle Spasm
8. Prehospital Care
   1. Recognition
   2. Immobilization
      1. Summary Recommendations
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Airway
      2. Breathing
      3. Circulation
      4. Disability
      5. Exposure
   3. Secondary Survey
   4. Neurological Assessment
10. Diagnostic Studies
    1. Decision Rules in Imaging
    2. Plain Films
    3. Computed Tomography
    4. Magnetic Resonance Imaging
    5. Assessing Ligamentous Stability
    6. Assessing for Vascular Injury
11. Treatment
    1. Supportive Care
       1. Airway Management
       2. Blood Pressure Augmentation
    2. Medical Therapy
    3. Surgical Therapy
       1. Closed Reduction
       2. Decompression
12. Special Populations
    1. Pediatric Patients
       1. Atlantoaxial Rotatory Fixation
       2. SCIWORA
13. Controversies and Cutting Edge
    1. Stem Cell Treatment
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls for Spinal Cord Injury in the Emergency Department
18. Case Conclusions
19. Clinical Pathway for Emergency Department Management of Blunt Cervical Trauma in Adult Patients
20. Tables, Figures and Appendix
    1. Table 1. Incomplete Spinal Cord Injuries
    2. Table 2. Unstable Spinal Fractures
    3. Table 3. Stable Spinal Fractures
    4. Table 4. Differential Diagnosis of Spinal Injury
    5. Table 5. Guidelines for Prehospital Spinal Immobilization
    6. Table 6. Immediate Life Threats in Spinal Cord Injury
    7. Table 7. The NEXUS Low-Risk Criteria for Cervical Spine Imaging
    8. Table 8. Comparison of NEXUS Criteria and Canadian C-Spine Rule
    9. Table 9. Modified Denver Screening Criteria for Blunt Cerebrovascular Injury
    10. Table 10. Summary of Key Updates in Management of Spinal Injuries
    11. Figure 1. Causes and Demographics of Spinal Cord Injury in the United States
    12. Figure 2. The Denis 3-Column Model of Spinal Stability
    13. Figure 3. Spinal Cord Anatomy and Function
    14. Figure 4. The Canadian C-Spine Rule
    15. Figure 5. Thoracolumbar Imaging Clinical Decision Tool
    16. Figure 6. Atlantoaxial Rotatory Fixation
    17. Appendix. The American Spinal Injury Association Spinal Assessment Worksheet
21. References

Abstract

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.

Case Presentations

EMS calls to alert you that they have 24-year-old man with head trauma, and they are 15 minutes out…

• EMS says the man was found down on the street.
• He has head trauma and a GCS score of 7, but his vital signs are normal.
• You anticipate that this patient will need intubation. The EMS crew asks whether they should intubate in the field and whether he requires spinal immobilization...

A 64-year-old man walks into the ED complaining of left-sided neck pain after he was in a head-on motor vehicle crash several hours ago…

• A resident is examining the patient, who said he was a restrained driver in the MVC, and the airbags did not deploy. He was ambulatory at the scene, and refused to go to the ED at that time, but now complains of left-sided neck pain.
• On exam, he has left-sided paraspinal tenderness to palpation over the cervical and lumbar spinal area without step-offs or deformity. No neurological deficits are noted on exam.
• The resident asks you whether the patient should be placed in a hard collar and whether imaging is appropriate…

A trauma is called overhead: a young woman was thrown from a horse onto her head and back…

• You run to the trauma bay where the young woman has been brought in by EMS. The trauma resident is evaluating her ABCs.
• You see that the patient is awake, has a GCS score of 15, and is answering questions appropriately, but she appears uncomfortable.
• Her blood pressure on the monitor is 80/48 mm Hg. As the resident finishes the primary survey, you note that the patient is unable to lift her lower extremities on command. Her grip strength is weak, and she has gross loss of sensation in the bilateral upper extremities.
• You wonder whether this is a head or a spine injury, and how best to treat her hypotension. Should she receive corticosteroids?

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Clinical Pathway for Emergency Department Management of Blunt Cervical Trauma in Adult Patients

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Tables, Figures and Appendix

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Key References

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

Points & Pearls Excerpt

• In the United States, some 60% of patients with cervical spine injury have complete or incomplete tetraplegia.^3,4
• Unstable fractures are those in which bone deformity is likely to increase and may lead to development or worsening of spinal cord compromise.⁶
• Spinal injuries involving the anterior column tend to be stable; injuries tend to be unstable if multiple columns or the posterior column are injured or disrupted.
• Spinal cord injury (SCI) may occur without spinal fracture; the most clinically important is acute traumatic central cord syndrome, which is typically associated with elderly patients with pre-existing spinal stenosis.