Highlights & Basics
- Acute cervical spine trauma requires a high index of suspicion and thorough investigation to detect bone or ligament damage that can otherwise result in spinal cord injury.
- Mechanism of injury is highly variable, ranging from seemingly innocuous falls to high-energy motor vehicle crashes.
- Possible presentations include neck pain, limited range of motion, and/or neurological deficit.
- Assessment for spinal injury should be done immediately after the patient's cervical spine has been protected with manual inline spinal motion restriction.
- Patients with acutely altered level of consciousness (Glasgow Coma Scale [GCS] <15), neurological deficit, high-risk injury mechanism, distracting injuries, neck pain or tenderness, or decreased range of motion of the cervical spine require a cervical collar, spinal precautions and urgent cervical spine imaging.
- The use of methylprednisolone, which is time-sensitive, is an intervention whose efficacy is debated among professionals. Early consultation with a specialist is advisable to avoid delays that may affect patient outcome.
Quick Reference
History & Exam
Key Factors
concordant mechanism of injury
neck pain
sacral sparing
associated traumatic injury
posterior cervical tenderness
Other Factors
male sex
age 18 to 25 years
intoxication
numbness, tingling, or weakness of extremities
bowel or bladder dysfunction
motor weakness
sensory loss
reduced or painful cervical range of motion (ROM)
loss of anorectal tone and perianal sensation
spasticity
hyperreflexia
Babinski sign
Hoffman sign
neurogenic shock
spinal shock
respiratory change
cranial nerve deficit
Diagnostics Tests
1st Tests to Order
multidetector computed tomography (MDCT) axial CT cervical spine with 3D reconstructions
Other Tests to consider
cervical spine x-ray series
MRI cervical spine
CT myelogram
CT angiography (CTA) and MR angiography (MRA)
flexion-extension (F/E) cervical spine x-rays
nerve conduction studies
electromyography
Treatment Options
presumptive
acute neck pain with altered neurological status: at initial presentation
spinal motion restriction (SMR) and urgent assessment
acute
low probability of neurological injury: following initial assessment
low probability of neurological injury: following initial assessment
with persistent musculoskeletal symptoms
with persistent headache
elderly
Definition
Classifications
Odontoid dens fracture
- Type I: fracture of the upper part of the odontoid dens
- Type II: fracture at the base of the odontoid dens
- Type III: fracture affecting the body of the axis.
Hangman fracture
- Type I: fracture without an angular deviation and translational deviation of <3.5 mm, which occurs due to hyperextension and axial compression
- Type II: fracture with a significant translational or angular deviation, which occurs due to hyperextension and axial compression combined with a mechanism of flexion-compression
- Type IIa: fracture with a small translational deviation and wide angulation, with an increase in posterior disk space between C2-C3 upon application of traction, which occurs due to a flexion-distraction
- Type III: fracture with a large translational and angular deviation, which is associated with unilateral or bilateral dislocation of the C2-C3 joint facets and occurs due to a flexion-compression mechanism.
AOSpine subaxial cervical spine injury classification system
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
- Location within the spine (e.g., craniocervical junction, atlantoaxial, subaxial)
- Forces applied to the spine (e.g., flexion injuries, extension injuries)
- Resulting fracture patterns (e.g., facet dislocation, fracture dislocation injury).
- Occipital condyle fractures
- Jefferson fractures and other atlas (C1) fractures, including fractures of the lateral mass
- Atlantoaxial dislocation
- Fractures of C2: hangman fractures (spondylolisthesis of C2), odontoid fractures, Image lateral body fractures.
- Clay-shoveler fracture
- Simple wedge compression fracture
- Bilateral facet dislocation
- Flexion teardrop fracture.
Pathophysiology
Images
CT reconstruction demonstrating undisplaced odontoid fracture
Common fracture patterns with severe cervical spine trauma. Top row: cervical burst fracture at C5 level; left: axial CT image showing a fracture of C5 vertebral body; right: mid-sagittal T2-weighted MRI showing retropulsion of the body of C5 with spinal cord compression, T2-weighted signal changes within the spinal cord and T2-weighted signal changes within the posterior ligamentous complex indicating disruption of these ligaments. Bottom row: fracture dislocation C6-C7 level. From left to right: lateral x-ray, axial CT through C6/C7 facet level, and T2-weighted mid-sagittal MRI demonstrating spinal cord compression and T2-weighted signal change within the spinal cord
Normal cervical spine: lateral, AP, and open-mouth odontoid view
Diagnostic Approach
- Determining which patients need cervical spine imaging after trauma
- Deciding whether the most appropriate imaging is by dynamic cervical spine x-rays (flexion-extension views), computed tomography (CT), or magnetic resonance imaging (MRI)
- Excluding dynamic or ligamentous instability in patients who are comatose or have reduced consciousness level.
Cervical spinal motion restriction (SMR)
- Acutely altered level of consciousness (Glasgow Coma Scale [GCS] <15, evidence of intoxication)
- Focal neurological signs and/or symptoms (e.g., subjective limb weakness, numbness, tingling, or dysesthesia)
- Anatomic deformity of the spine
- Distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc) or any similar injury that impairs the patient's ability to contribute to a reliable examination.
- Awake and alert (GCS = 15)
- Normal neurological exam
- No high-risk injury mechanism
- No neck tenderness
- Free range of cervical motion.
Factors predictive of severe cervical spine injury
Lower cervical spine fractures
- Type A - Compression injuries
- A0: No bony or minor injury
- A1: Single endplate fracture; posterior vertebral wall spared
- A2: Both endplates fractured; posterior vertebral wall spared
- A3: Single endplate fracture involving posterior vertebral wall
- A4: Both endplates fractured involving posterior vertebral wall
- Type B - Tension-band injuries
- B1: Predominately bony posterior tension-band injury
- B2: Complete disruption of posterior capsuloligamentous or bony-capsuloligamentous structures
- B3: Anterior tension-band injury
- Type C - Translational injuries
- C: Displacement or translation of vertebral body relative to another in any direction
- F1: Not displaced; fragment <1 cm; <40% lateral mass involved
- F2: Displaced or fragment >1 cm or >40% lateral mass involved
- F3: Floating lateral mass (complete bony disconnection)
- F4: Subluxed/perched/dislocated facet (inferior articular process of rostral vertebra rests on or anterior to superior articular process of caudal vertebra)
- N0: Intact
- N1: Transient deficit completely resolved at time of assessment
- N2: Radiculopathy
- N3: Incomplete spinal cord injury (spared function below injury)
- N4: Complete spinal cord injury (no spared function below injury)
- NX: Undetermined
- + Designates ongoing compression
- M1: Partial posterior capsuloligamentous injury
- M2: Critical disk herniation (extruded nucleus pulposus)
- M3: Spine-stiffening disease (i.e., diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum)
- M4: Vertebral artery injury
History
Physical exam
Cervical spine imaging
- Altered mental status (GCS <15)
- Neurological deficit (i.e., subjective limb weakness or paralysis, numbness, tingling, or dysesthesia)
- High-risk injury mechanism
- Neck tenderness present
- Decreased range of motion of the cervical spine.
Further investigation and referral
- Keep in cervical spine collar
- Remove cervical spine collar until normal dynamic cervical spine x-ray is obtained
- Remove cervical spine collar once normal MRI cervical spine is obtained.
Clearance of the cervical spine in obtunded patients
Clearance of the cervical spine: special considerations in older patients
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- No history of trauma.
- May have symptoms of secondary infection (pain with fever, tachycardia), neoplasia (e.g., unrelenting pain, especially at night), or inflammation (e.g., arthritides), or there may be no identifiable etiology.
- Infective etiologies include meningitis, vertebral osteomyelitis, diskitis, and epidural abscess.
- Neoplastic lesions can be primary or metastatic, and any patient with a prior history of cancer should be evaluated for recurrence.
- Patients with osteoarthritis and rheumatoid arthritis may have signs and symptoms of arthritis in other joints.
Differentiating Tests
- Cervical spine x-ray or CT scan: cancer - single or multiple lesions with bony destruction; osteoarthritis - cervical spondylosis or normal.
- Cervical spine MRI: cancer - single or multiple lesions with bony destruction; infection - infected areas of bone (vertebral osteomyelitis) or signs of abscess (epidural abscess).
- Bone scan: metastatic neoplastic lesions in the spine.
- ESR, CRP: elevated in infection, malignancy, or inflammatory arthritis.
- CBC: elevated WBC in infection.
Degenerative cervical spine disease
Differentiating Signs/Symptoms
- No history of trauma.
- Symptoms may be similar to neck trauma, including axial neck pain and neurological complications such as radiculopathy and myelopathy.
Differentiating Tests
- Cervical spine x-ray: presence of degenerative joint disease or degenerative disk disease.
- Cervical MRI: bone destruction, spinal cord or nerve compression, intradural or epidural process.
Acquired torticollis
Differentiating Signs/Symptoms
- No history of trauma.
- Involuntary twisting or deviation of the neck, abnormal head posture, presence of sensory trick (patient can resolve symptoms by touching neck or face), normal neurological exam.
Differentiating Tests
- Cervical spine x-ray: usually normal; may demonstrate C1-C2 subluxation.
- CT cervical spine: may demonstrate rotatory subluxation.
- MRI of the brain and cervical spine: usually normal. If chronic, may have cervical muscle asymmetry and nerve root compression.
Treatment Approach
Immediate management
Uncomplicated neck injury
Neck injuries with high probability of neurological injury following initial assessment
- The use of methylprednisolone
- Reversal of anticoagulation (should the patient be taking such medications)
- The requirement for emergency transport to a specialized center.
Trauma in the arthritic spine
Trauma in the aging spine
Treatment Options
acute neck pain with altered neurological status: at initial presentation
spinal motion restriction (SMR) and urgent assessment
Comments
- All trauma patients should be evaluated based on the principles of Advanced Trauma Life Support®, independent of whether a spinal cord fracture or spinal cord injury is suspected or confirmed.[11] If there is evidence of any of the following in a patient, after an incident thought to be compatible with a possible cervical spine injury, the clinician should apply SMR including a rigid cervical collar.[11] [21] Acutely altered level of consciousness (Glasgow Coma Scale [GCS] <15, evidence of intoxication); focal neurological signs and/or symptoms, anatomic deformity of the spine; distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc) or any similar injury that impairs the patient's ability to contribute to a reliable examination).
- Urgent cervical spine imaging is warranted in the following situations: altered mental status (GCS<15), neurological deficit, high-risk injury mechanism, neck tenderness; decreased range of motion of the cervical spine.[11]
- Following initial assessment, the patient's management will be determined by the findings on examination and imaging, and the injury will be managed either as for uncomplicated neck injuries, with a low probability of neurological injury, or as for injuries requiring urgent neurosurgical and/or orthopedic intervention.
low probability of neurological injury: following initial assessment
nonsteroidal anti-inflammatory drug (NSAID) and follow-up
Primary Options
- ibuprofen
400-800 mg orally every 6-8 hours when required, maximum 3200 mg/day
- ibuprofen
- naproxen
250-500 mg orally twice daily when required, maximum 1250 mg/day
- naproxen
Comments
- Injuries to the cervical spine with a low probability of neurological sequelae are most often associated with minimal- to moderate-severity vehicle crashes and do not involve neurological signs or symptoms. They are generally injuries without fracture, dislocation, disk herniation, or other bony or soft-tissue injuries. These injuries most often resolve spontaneously or with minimal conservative therapy, typically within 3 months.
- Restoration of normal motion to the spine is of great importance, and to this end cervical collars are largely counterproductive and typically contraindicated, as is bed rest.
- Referral for physical therapy should be considered, and should be done 3 times a week for 4 weeks. Physical modalities include home range-of-motion exercises to tolerance (should not cause pain). The patient should be reevaluated within 4 weeks.
- NSAIDs can be prescribed. There are no studies that support the use of muscle relaxants in the acute phase.
short-term opioid analgesia
Primary Options
- tramadol
50 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day
- tramadol
Secondary Options
- oxycodone/acetaminophen
5-10 mg orally (immediate-release) every 4-6 hours when required
- oxycodone/acetaminophen
Comments
- May be helpful for patients with moderate- to high-intensity pain, although imaging studies, including flexion/extension x-ray views, should be performed to rule out ligament injury or fracture prior to starting any treatment in these patients.
- Moderate pain can be treated with tramadol, and severe pain with hydrocodone or oxycodone plus acetaminophen.
- Treatment course: 1-2 weeks only. If pain persists, referral to a pain specialist should be considered.
with persistent musculoskeletal symptoms
physical therapy
Comments
- Patients with musculoskeletal symptoms (including lower back pain, upper-extremity joint pain, and temporomandibular joint pain, each of which are associated with a traffic crash mechanism of rear-impact collision with whole-body accelerations) that persist beyond the first 4 to 6 weeks after a mild-to-moderate injury should be encouraged to undertake a physical therapy program. One study has suggested that the efficacy of intense physical therapy is similar to simply receiving advice from a physical therapist in a single session.[65] Patients should consult with their physicians about the details of any program to ensure it is appropriate.
with persistent headache
specialist referral
Comments
- Persistent headache can be associated with a closed head injury, irritation of the greater occipital nerve, cervical facet injury (C2-4 most typically), or cervical muscle tension.
- If headache persists beyond the initial 4 to 6 weeks of injury, referral to a headache neurologist should be considered.
elderly
conservative measures and/or surgery
Comments
- Unique challenges exist in managing spine trauma in the elderly. Central cord syndrome (CCS) is the most common subtype of incomplete traumatic spinal cord injury defined by cruciate weakness (upper extremities worse than lower extremities) and a variable pattern of sensory loss and bowel/bladder dysfunction.
- Depending on the existing comorbidities, for less severe deficits (ASIA grade D), an initial conservative approach with close clinical follow-up is appropriate, while reserving the option to surgically decompress depending on the extent and temporality of recovery.
- Odontoid fractures are often caused by low-energy falls. Type I (tip of the dens) fractures are rare and typically treated with a collar after ruling out associated transverse atlantal ligament (TAL) injuries or atlantooccipital dislocation. Type III fractures may be treated with either a halo vest (TAL intact, not significantly displaced and stable in a halo) or surgery (anterior odontoid screw or posterior fusion). Type II fractures are the most common type and are treated similarly to type III fractures with a halo or surgery; however, halo vests are associated with substantial morbidity and mortality in the elderly.
- Upfront surgical intervention is now considered a reasonable approach in elderly patients (>65 years old) who would otherwise be treated in a halo. If the surgical risk is too high, a rigid collar and close clinical and radiographic follow-up may be a reasonable approach to achieve a fibrous nonunion across the fracture site while sparing the morbidity of a halo.
high probability of neurological injury: following initial assessment
spinal motion restriction + emergency neurosurgical referral
Comments
- Potentially urgent cervical injuries include fracture, dislocation, disk herniation, and other bony and soft-tissue injuries that are associated with a high probability of neurological injury. They are more likely to be associated with a history of a higher-energy injury mechanism, often including a head or face strike. These patients may present similarly to those with uncomplicated neck injuries, but will typically have a neurological deficit. If there is evidence of any of the following in a patient, after an incident thought to be compatible with a possible cervical spine injury, the clinician should apply SMR including a rigid cervical collar.[11] [21] Acutely altered level of consciousness (Glasgow Coma Scale [GCS] <15, evidence of intoxication); focal neurological signs and/or symptoms, anatomic deformity of the spine; distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc) or any similar injury that impairs the patient's ability to contribute to a reliable examination).
- Patients who have sustained an injury requiring surgical treatment and who are also taking anticoagulant medications may require reversal of their anticoagulant status. An urgent discussion should be held between the treating physician and the surgeon to decide on a management plan.
- Ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis are associated with unique fracture patterns and management paradigms after spinal trauma. Hyperextension-distraction fractures resulting from minor trauma can produce severe spinal cord injuries requiring urgent decompression and long-segment instrumented fusions. Key to early management is application of spinal motion restriction to prevent further injury, followed by urgent surgical consultation.
- Patients with fractures and central cord syndrome (CCS) should be definitively treated through internal and/or external immobilization in consultation with a surgical service. AOSpine 2017 guidelines concluded that early decompression (≤24 hours after injury) for adult patients presenting with spinal cord injury irrespective of level should be offered, although the quality of evidence for the recommendation was low.[59] In one meta-analysis, patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury, as measured by an improvement in total motor scores, light touch scores, and pinprick scores. Patients who had early decompression also had better AIS grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery.[60]
intravenous methylprednisolone
Primary Options
- methylprednisolone sodium succinate
30 mg/kg intravenously as a loading dose, followed by 5.4 mg/kg/hour intravenous infusion for 23 hours
- methylprednisolone sodium succinate
Comments
- If there is a rapid onset of paresis and a potential delay in specialist consultation, treatment with intravenous methylprednisolone should be considered. High-dose methylprednisolone has been shown to be the only efficacious pharmacologic option when administered within 8 hours of injury in the context of acute spinal cord injury (SCI).[56] [66] Although studies have identified a subgroup of patients who demonstrated better motor scores after receiving methylprednisolone within 8 hours of injury compared with placebo, side effects included infection, gastrointestinal bleeding, hyperglycemia and death.[66] The American College of Surgeons state that the use of methylprednisolone within 8 hours following SCI cannot be definitively recommended.[11]
- Where is it used, there is variability in the decision to administer methylprednisolone and which specific protocol to use.[11] [58] [67] If there is a penetrating SCI, then methylprednisolone should not be administered.[11] The infusion of methylprednisolone should not exceed the 24-hour period given the increased risk of adverse events such as pneumonia and sepsis.[56]
Prevention
Primary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
This best practice guidelines reviews pre-hospital spinal motion restriction, cervical collar clearance, and appropriate imaging for spinal injury. It includes details about the classification systems for both spinal column injury and spinal cord injury. The indications for nonoperative and operative management are discussed for both blunt and penetrating spinal injuries.Published by
American College of Surgeons
Published
2022
Summary
This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.Published by
American College of Surgeons Committee on Trauma (ACS-COT); American College of Emergency Physicians (ACEP); National Association of EMS Physicians (NAEMSP)
Published
2018
Summary
These guidelines make recommendations for appropriate imaging modalities for various presentations of cervical spinal trauma and provided strong literature support. A thorough discussion of relevant literature surrounding the common imaging modalities are provided including radiography, CT, CT myelography, CT angiography, MRI, MR angiography and arteriography.Published by
American College of Radiology
Published
2018
Summary
These guidelines recommend the use of MRI in spinal cord injury in the adult population prior to surgical intervention to improve the clinical decision. MRI is recommended either before or after surgical intervention to assist in predicting the neurological outcome.Published by
Global Spine Journal
Published
2017
Summary
Update of 2001 AANS/CNS guidelines. Developed using an evidence-based approach employing a strict process of literature review, with ranking of published papers by strength of study design. Discusses the diagnosis of acute cervical spine injuries.Published by
American Association of Neurological Surgeons; Congress of Neurological Surgeons
Published
2013
Treatment
Summary
This best practice guidelines reviews pre-hospital spinal motion restriction, cervical collar clearance, and appropriate imaging for spinal injury. It includes details about the classification systems for both spinal column injury and spinal cord injury. The indications for nonoperative and operative management are discussed for both blunt and penetrating spinal injuries.Published by
American College of Surgeons
Published
2022
Summary
This guidance is based on the available evidence. Patients with head injury have risks for cervical spine injury as well. This guidance describes criteria for full cervical spine immobilisation in those with head injury. It also describes criteria for performing CT cervical scan in adults and children. CT should cover any areas of concern or uncertainty on x-ray. MR imaging is also required if there are neurological signs referable to the cervical spine.Published by
National Institute for Health and Care Excellence (UK)
Published
2019
Summary
This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.Published by
American College of Surgeons Committee on Trauma (ACS-COT); American College of Emergency Physicians (ACEP); National Association of EMS Physicians (NAEMSP)
Published
2018
Summary
Evidence-based guideline to complement National Institute for Health and Care Excellence guidelines on major trauma. Recommendations include: 1) strict spinal immobilization at all times, 2) stabilize airway, breathing, and circulation prior to other treatments, 3) transfer patients with suspected acute traumatic spinal cord injury (SCI) to a major trauma center, 4) CT as the first-line imaging modality in suspected SCI.Published by
National Institute for Health and Care Excellence (UK)
Published
2016
Summary
The guidelines recommend that early surgery (≤24 hours after injury) should be considered for patients with spinal cord injury regardless of level of injury as well as for patients presenting with central cord syndrome.Published by
Global Spine Journal
Published
2017
Summary
There is variability in the decision to administer methylprednisolone and which specific protocol to use. These guidelines recommend high-dose methylprednisolone for spinal cord injury patients presenting within 8 hours of initial injury. The guidelines recommend against the administration of methylprednisolone for patients presenting outside of the 8 hours post-injury window, and further against use of 48-hour infusion to any patients with spinal cord injury.Published by
Global Spine Journal
Published
2017
Summary
Update of 2001 AANS/CNS guidelines. Developed using an evidence-based approach employing a strict process of literature review, with ranking of published papers by strength of study design. Discusses treatment of patients with acute cervical spine injury.Published by
American Association of Neurological Surgeons; Congress of Neurological Surgeons
Published
2013