Emergency
Medicine Clinics of North America
Volume 17 • Number 4 • November 1999
Copyright © 1999 W. B. Saunders Company
ORTHOPEDIC EMERGENCIES
EMERGENCY DEPARTMENT EVALUATION AND TREATMENT OF THE NECK AND
CERVICAL SPINE INJURIES
William
J. Frohna MD, FACEP
Department of Emergency Medicine, Washington Hospital Center, the
Department of Emergency Medicine, The George Washington University; the
Department of Emergency Medicine, Children's National Medical Center,
Washington, DC; the Department of Military and Emergency Medicine, Uniformed
Services University of the Health Sciences, Bethesda, Maryland
Address
reprint requests to
William J. Frohna, MD, FACEP
Department of Emergency Medicine
Washington Hospital Center
110 Irving Street, Northwest
Washington, DC 20010
The
patient who arrives at the emergency department (ED) with real or potential
cervical spine injuries is a common problem. Often, this patient arrives in the
busy ED immobilized, uncomfortable, and frightened. In addition, the patient can
have other injuries or conditions, that make the history and physical
examination unreliable. The emergency physician (EP) must be prepared to manage
this patient with potential injuries to the neck and cervical spine efficiently
and effectively. To accomplish this task, the EP must adhere to the basic
principles of trauma management and protect the cervical spine to prevent
additional neurologic injury. The EP must know the complex anatomy of the
cervical spine and understand the mechanism and types of neck and cervical
spine injuries. The EP must be able to recognize and manage associated soft
tissue, vascular, and neurologic injuries. Last, the EP must have an
understanding of immobilization techniques, the utility and limitations of
available imaging modalities, and the management of specific patient
populations at risk for neck and cervical spine injuries (e.g., the athlete).
EPIDEMIOLOGY
The actual incidence of spinal cord injury remains unknown, but it
is estimated that there are 7000 to 10,000 new cases annually. [2] [17]
[47] Most patients (82%) are male, in the 16- to 30-year age group [47]
; however, a second, smaller peak occurs in people who are older than 55 years.
[76]
Most spinal cord injuries (and cervical spine fractures) result
from motor vehicle accidents (42%-56%), falls from a height (19%-30%), gunshots
(12%-21%), and sports-related activities (6%-7%). [111] Overall,
spinal cord injuries occur in 10% to 20% of patients with spinal fractures and
are found in nearly 50% of patients with cervical vertebral injuries. [2]
Involvement of the cervical spine varies with the cause. In a review of 550
fatal and nonfatal spinal cord injuries, 60% involved the cervical spine. [41]
Cervical injuries occurred in 65% of the spinal cord injuries from motor
vehicle collisions; 53% of the cord injuries from falls from a height; 37% of
the cord injuries from gunshot wounds; and 97% of the cord injuries from
diving. [41]
Significant cervical spine injuries can occur following relatively minor trauma
in the elderly [61] and in patients with predisposing arthritic
conditions, such as ankylosing spondylitis, [70] [92]
psoriatic cervical sponyloarthropathy, [112] and rheumatoid
arthritis. [7] It is estimated that cervical fractures occur in 1%
to 3% of blunt trauma patients. [57] [93]
The individual and societal costs of spinal cord injury are
staggering. The average direct cost (1992) in the first year postinjury for a
ventilator-dependent patient with a high cervical injury was $417,067, with
subsequent annual direct costs, after the first year, being $74,707. [47]
It is estimated that the total annual cost to society is over $5 billion. [61]
The individual tragedy and cost of lost productivity are immeasurable and
underline the need for a systematic approach to the treatment of acute injuries
of the cervical spine. [111]
ANATOMY
The spinal column consists of 33 vertebrae: 7 cervical, 12
thoracic, 5 lumbar, 5 sacral (fused), and 4 coccygeal (fused) vertebrae
connected by fibrous ligament. The anterior and posterior longitudinal
ligaments hold the vertebral bodies together. Intervertebral discs separate the
vertebral bodies and provide cushioning and flexibility to the vertebral
column. The spinal cord originates from the caudal medulla oblongata at the
foramen magnum and ends near the L-1/L-2 bony level as the conus medullaris.
The spinal cord is housed in a bony ring made up of two pedicles (or pillars)
on which the roof of the vertebral canal (the lamina) rests. Afferent and efferent
nerve roots pass through the intervertebral foramina.
The upper cervical spine is an important anatomic region for the
EP to understand. The occipitoatlantoaxial complex is unique in its articular
and ligamentous relationships. [39] It protects the upper cervical
spine while allowing a wide range of motion. [42] It is made up of
the articulations between the base of the skull, atlas (C-1) and axis (C-2);
and several strong ligaments. The occipital condyles articulate with the
corresponding concavities in the lateral masses of the atlas. This allows for
flexion and extension but no rotation. The articular surfaces of the atlas and
axis are convex to each other, permitting flexion, extension, and especially
rotation to occur between the atlas and axis. [39] The tectorial
membrane (the continuation of the posterior longitudinal ligament) passes
behind the dens and attaches to the anterior aspect of the foramen magnum. Its
primary function is to stabilize extension of the occiput on the atlas. [42]
The transverse ligament is the primary stabilizer for anterior atlantoaxial
translation. [42] It attaches to the medial side of the lateral
masses of C-1 and passes behind the odontoid process. Disruption of this
ligament is a very unstable injury; however, the ring of the atlas is about 3
cm in anteroposterior diameter with 1 cm occupied by the dens, 1 cm by the
spinal cord, and 1 cm of potential space that can accommodate some displacement
of the dens without cord damage. [2] The accessory ligaments also
arise from the medial surface of the lateral masses and attach to the lower
dens. The alar ligaments pass from the tip of the dens to the medial aspect of
the occipital condyles. Their function is to limit axial rotation. [42]
The mechanically unimportant apical dental ligament attaches the tip of the
dens to the inner surface of the foramen magnum. [39]
The anatomy of the lower cervical spine is best understood when
discussed in the context of stability. Mechanical stability can be visualized
by using the two-column concept. [61] The anterior column is formed
by the vertebral bodies and intervertebral disks that are held in alignment by
the anterior and posterior longitudinal ligaments. The pedicles, laminae,
articulating facets, and spinous processes form the posterior column. It is
held in alignment by the nuchal ligament complex (e.g., supraspinous,
interspinous, and infraspinous ligaments), the capsular ligaments, and the
ligamentum flavum. The injured cervical spine is considered mechanically
unstable when both columns are disrupted at the same level; however,
determining mechanical stability is often difficult. [42]
Recognizing and treating potential mechanical and neurologic instability and
preventing progression of injuries should be the goal of the EP.
Understanding the anatomy of the spinal cord is vital to the
initial assessment and management of the patient with a cervical spine injury.
There are three main spinal cord tracts that can be assessed clinically: (1)
the corticospinal tract, (2) spinothalamic tract, and (3) posterior columns are
paired tracts that can be injured on one or both sides. The corticospinal tract
lies in the posterolateral segment of the cord and controls motor function on
the same side of the body. Although a single motion is often governed by
muscles receiving innervation from several spinal segments, testing the
presence and strength of these motions allows a rapid baseline assessment of
motor function to be obtained. [61] The spinothalamic tract, located
in the anterolateral cord, transmits pain and temperature (and some light
touch) sensation from the opposite side of the body. The posterior columns
carry proprioception, vibration sense, and light touch from the same side of
the body. Sensation can be tested using light touch (posterior columns) with a
cotton wisp followed by pin-prick testing (spinothalamic tract) to determine
the sensory dermatome involved..
INITIAL MANAGEMENT
Management of the multiply injured trauma patient with potential
cervical spine injury must proceed in an organized manner. The process should
follow the ABCDEs of trauma care developed by the American College of Surgeons'
Committee on Trauma in the Advanced Trauma Life Support (ATLS) for Doctors [28]
program. This program stresses the simultaneous recognition and management of
life-threatening conditions in the primary survey, followed by resuscitation,
secondary survey, and definitive care. Airway maintenance with cervical spine
protection is the first step in the ABCDEs of the primary survey. The important
management principle for the cervical spine is protection of the spine and
spinal cord with immobilization devices or by manual in-line immobilization. [28]
Figure 6 (Figure Not Available) provides an approach to the management of the
trauma patient with suspected cervical spine injury. [61]
Performance of cervical spine radiographs should not delay performance of the
primary survey or resuscitation and should be obtained as soon as
life-threatening injuries have been identified and controlled. [28]
Airway Management
The emergency physician must identify the patient whose airway is
in jeopardy. The trauma patient with potential cervical spine injury can have
many reasons for airway compromise. Maxillofacial injuries, foreign bodies
(e.g., teeth, dentures), blood and secretions, cervical cord lesions, and
associated head, neck, or chest injuries can jeopardize the airway of the
trauma patient. Initial airway management should include basic maneuvers such
as the chin-lift, jaw thrust, placement of a nasal or oral airway, and
suctioning.
Choosing the optimal technique for definitive, emergency airway
management is often perceived as a clinical dilemma owing to the belief that
orotracheal intubation is hazardous in the presence of a cervical spine injury.
[122] Rhee et al [99] and Einav [37] conclude
that operator skill and comfort in performing a specific airway technique
should guide the selection of a particular method of definitive airway control.
These and other authors [30] [110] [114] have
shown orotracheal intubation with in-line immobilization to be a safe,
effective method for definitive airway management. Using a cadaver model,
Gerling et al [50] showed no significant vertebral body movement
during orotracheal intubation with manual in-line stabilization but found a
significant amount of distraction during orotracheal intubation with cervical
collar immobilization. In addition, the authors report no significant
difference in vertebral body movement when using different laryngoscope blades.
The current ATLS guidelines [26] list orotracheal
intubation with in-line manual cervical spine immobilization as the initial
definitive airway procedure in the apneic patient. In the breathing patient who
requires a definitive airway, nasotracheal or orotracheal intubation is
recommended followed by orotracheal intubation with pharmacologic adjuncts if
one is unable to intubate. Other potentially useful oral airway adjuncts for
use in the trauma patient with cervical spine injury include fiberoptic
intubation, [25] the Bullard laryngoscope, [1] [25]
[56] [124] and the light wand or transillumination
technique. [125] One must be prepared to perform a surgical airway
in trauma patients with potential cervical spine injuries who cannot be
intubated by other means.
Immobilization
Prehospital
Care
Prehospital personnel must suspect potential cervical spine injury
in any trauma victim and in any patient with altered mental status of uncertain
cause. [61] With these liberal guidelines, cervical spine
immobilization is one of the most frequently performed prehospital procedures. [34]
It is estimated that nearly 5 million patients receive spinal immobilization
annually at a cost of $15 per person or $75 million a year in the United
States. [93] These costs do not include the added scene time,
patient discomfort, personal frustration between paramedics and uninjured
patients, and the hospital visit following liberal immobilization. Recently,
Hauswald et al [57] examined the effect of emergency out-of-hospital
spinal immobilization on neurologic injury by comparing trauma patients in
Malaysia (no prehospital emergency medical services [EMS]) with a group of
trauma patients in New Mexico (with prehospital spinal immobilization). They
found less neurologic disability in the unimmobilized Malaysian patients. Sahni
et al [107] found excellent agreement between paramedics and
physicians when evaluating simulated patients with potential cervical spine
injury. The information from this study and future studies could allow
development of prehospital cervical spine clearance protocols. At the present
time, however, liberal use of prehospital spinal immobilization is the rule.
Although there are a variety of commercially available
immobilization devices, rigid cervical collars in conjunction with long
backboards and straps or tape remain the standard equipment. [34]
Additionally, foam blocks, towels, intravenous fluid bags, and sandbags have
been used to augment standard equipment and improve immobilization. Prehospital
personnel must also follow the ABCDEs of trauma care [61] and
identify and manage life-threatening injuries while protecting the cervical
spine.
Emergency
Department
Trauma patients who arrive immobilized must be evaluated quickly
by the EP to determine extent of injury, probability of cervical spine injury,
and adequacy of immobilization apparatus. As previously noted, the ABCDEs of
trauma care must be followed. The awake and cooperative patient in whom
radiographs are indicated should have continued immobilization and be cautioned
against movement until the studies are complete. The uncooperative,
head-injured, intoxicated, or multiply injured patient must have his or her
spine protected by head, neck, and body immobilization until radiographs are
obtained and a reliable clinical examination is performed. Such a patient may
require manual immobilization in addition to the cervical collar, tape, straps,
and backboard. Additionally, sedation with or without paralysis may be required
for those patients who are a danger to themselves from excessive movement. [61]
In approximately 10% of patients with a cervical spine fracture, a second
associated, noncontiguous spinal column fracture can be present. [29]
Thus, immobilization of these patients should continue until the entire spinal
column has been radiographically screened.
Shock
Shock (or hypotension) in the multiply injured trauma patient
should initially be considered to be hemorrhagic in origin. Patients with
hemorrhagic shock typically exhibit tachycardia and peripheral
vasoconstriction. Patients with neurogenic shock are hypotensive, bradycardic
(especially in relationship to their blood pressure), flaccid, and areflexic;
they have warm, pink skin with good pulses. Intravenous fluid should be
administered while following vital signs, urine output, and mental status.
Central venous pressure (CVP) monitoring can be helpful in assessing the
patient's intravascular volume. Neurogenic shock often responds to a
crystalloid fluid bolus and Trendelenburg positioning, [61] but vasopressors
may be required. [29]
IMAGING OF THE CERVICAL SPINE
The
EP must practice cost-effective, time-efficient medicine. The decision to
perform cervical spine radiographs in the severely injured, neurologically
impaired patient is not an issue. There are questions that remain, however: Do
cervical spine radiographs need to be performed on every victim of multiple
trauma? Is an injury above the clavicles an indication to obtain cervical spine
radiographs? What is the initial imaging study of choice? How many plain
radiographic views are necessary? What are the radiographic signs of cervical
spine injury and are they reliable? What ancillary imaging studies are
available and what are their indications and limitations?
Costs of Imaging the
Cervical Spine
Obtaining cervical spine radiographs in all victims of blunt
trauma can be a time-consuming and costly process that exposes the patient to
unnecessary radiation. It is estimated that each year in the United States
approximately 800,000 patients undergo cervical spine radiography at a cost of
$180 million. [63] Using selective criteria for the performance of
cervical spine radiography can decrease the need for cervical radiographs by
one third [63] for a savings of $60 million a year. [64]
In addition, selective radiography could also reduce by one third the 3760
excess thyroid cancers predicted in the 800,000 trauma patients irradiated each
year. [64]
Indications for
Imaging the Cervical Spine
Reports of "asymptomatic" or "occult" cervical
spine injuries, [16] [86] and their potential
catastrophic outcome if undetected, have led many physicians to obtain cervical
spine radiographs on all victims of blunt trauma. After careful review of these
cases, many authors question the existence of the acute, "asymptomatic"
cervical spine fracture. [49] [101] [115]
Reports of "occult" cervical spine fracture confirm the danger of
relying on the history and physical examination in the patient who has altered
mental status, intoxication, or other distracting injuries. [115]
There are three groups of trauma patients who should undergo radiographic
evaluation of the cervical spine: patients who present with neurologic deficit
consistent with a cord lesion; patients with altered sensorium from head injury
or intoxication; and patients complaining of neck pain or tenderness. [67]
The EP should also have a low threshold for obtaining cervical spine
radiographs in trauma patients with painful, distracting injuries or
preexisting spinal disorders such as ankylosing spondylitis, rheumatoid
arthritis, or psoriatic spondyloarthopathy. [7] [70] [92]
[103] [112]
Several small prospective studies have identified criteria that
can be useful in limiting the performance of cervical spine radiographs. [63]
[79] [102] [105] [120] Cervical
spine radiographs may not be indicated in the patient with intact mental
status, a normal neurologic examination, no neck pain or tenderness, and no
distracting injuries. [35] [63] [71] [79]
[102] [109] [115] [120] [133]
According to the current ATLS manual, cervical spine radiographs might not be
indicated if, in addition to the above criteria, the patient has no pain with
side-to-side movement and flexion and extension. [29] Although these
clinical criteria may be employed into everyday emergency practice to screen
patients for cervical radiographs, there has been no adequate study performed
to assess the validity and reliability of the criteria. Interrater reliability
of these clinical criteria was evaluated in a study by Mahadevan et al. [82]
They found substantial reliability for the overall application of these risk
criteria for cervical spine injury, but individual criteria were slightly less
reliable. A large, multicenter, prospective study is currently underway to
evaluate these clinical criteria used as a preliminary screen for cervical
spine injury. [64] Preliminary data from this study found the
low-risk criteria do not identify all patients with cervical spine injury but
have 100% sensitivity and 100% negative predictive value for injuries that require
intervention. [62]
Cervical Spine
Injuries in Head and Face Trauma
The American College of Surgeons Committee on Trauma cautions to
"assume a cervical spine injury in any patient with multisystem trauma,
especially with an altered level of consciousness or a blunt injury above the
clavicle." [28] The committee recommends that a lateral
cervical spine x-ray be obtained on every patient sustaining an injury above
the clavicle. [27] Others also consider the presence of head or face
injuries to be an indication for cervical spine radiography. [10] [108]
The rate of cervical spine injury in facial trauma series varies from 0% to 4%.
[73] Bayles et al [8] reviewed 1382 cases of mandibular
fractures and found cervical spine injuries to be rare. They concluded that
history and physical examination, without radiographic studies, are sufficient
to evaluate the alert, cooperative patient with blunt, low-velocity mandibular
trauma and no other complicating features. Two other reports [9] [88]
confirmed the low incidence (1.04% and 1.8%) of cervical spine injuries in
patients with facial trauma. In both reports, however, the authors recommend
maintaining a high index of suspicion for cervical spine injury because CT or
flexion-extension views were required after the initial screening radiographs
were negative. Of note, in the report by Merritt and Williams [88] a
single lateral cervical spine radiograph served as the initial screening
radiographic examination. Hills and Deane [60] reviewed a series of
8285 blunt trauma victims and found that facial injuries were not associated
with cervical spine injuries; however, they found a much greater risk of
cervical spine injury in victims with clinically significant head injury. Three
recent retrospective studies concluded that patients with gunshot wounds
limited to the head do not have cervical spine injuries and do not require
immobilization. [22] [72] [74] Immobilization
of the patient with an injury above the clavicle is prudent until a physician
is able to evaluate the patient fully for possible cervical spine injury and
determine the need for radiographs.
Initial Radiographic
Examination
The American College of Radiology Musculoskeletal Task Force
developed appropriateness criteria for obtaining imaging studies on patients
with potential cervical spine trauma. [3] The appropriateness rating
for each radiologic examination was developed for each of six patient groups,
or variants. The initial imaging study recommended in this and other reports is
a series of the AP, lateral, and open-mouth radiographs. [71] [81]
[115] [126] The cross-table lateral view by itself is not
adequate to exclude cervical spine injury. [81] [126]
Exclusion of the AP view was not thought to be appropriate, [3] even
though a small study by Holliman et al [65] concluded that the AP
view did not provide additional information that was not already present on the
lateral or open-mouth views. The necessity of routinely obtaining oblique views
remains controversial. [71] Freemeyer et al [45] compared
five-view and three-view cervical spine series in the evaluation of patients
with cervical trauma. There were no fractures or dislocations detected on the
five-view series that were not detected or suspected on the three-view series.
In certain cases, the authors did not that the supine oblique views allowed
more specific diagnosis of injuries. Turetsky et al [119] advocate
the routine addition of the oblique views to detect fractures not seen on the
standard three-view series. Kaneriya et al [69] found that performing
oblique views improved visualization of the C7-T1 region and significantly
decreased the use of CT scanning of this region as an adjunct to the three-view
series. Including the cost of adjunctive CT scanning for poorly visualized
C7-T1 region, the average cost per completely imaged cervical spine in this
study was $92 for five-view series and $116.28 when oblique views were not
obtained. In summary, cervical oblique views should be used selectively after
the three-view series has been evaluated, to assist in visualization of the
cervicothoracic junction [13]
[115] or
poorly visualized areas of the posterior column. [115]
X-ray Interpretation
The EP must be able to identify injuries on the initial three-view
cervical spine series. Obvious fractures are easily identified; however, a
systematic approach to reading plain radiographs must be employed to avoid
missing less obvious or additional injuries. The lateral cervical spine
radiograph should not be considered adequate unless all seven cervical
vertebrae and the superior aspect of T1 are visualized. If the C7-T1 region
cannot be visualized, performing a pulled lateral view [104] (slow,
steady pulling of the patient's hands toward the feet), swimmer's view, or
supine oblique views can allow for visualization of this critical area of the
spine. If not seen on these views, a CT scan of the C7-T1 region should be
considered.
Next, the physician should follow the ABCs [129] of
reading the lateral view. The Alignment
of the cervical spine lordotic curves and posterior cervical line should be
assessed. Next, the Bones of the
spine should be assessed for contour, height, deformity, and fracture. The Cartilage or disk spaces should be
assessed for anterior or posterior widening or loss of height. Soft tissue spaces assessed should
include the prevertebral space at C3 and C6, the distance between spinous
processes at each level, and the predental space. Abnormal prevertebral soft
tissue swelling is a commonly used indirect indicator of potential spinal
injury. Measurements of greater than 5 mm at C3 [29] and greater
than 22 mm at C6 [32] are considered abnormal; however, several
authors have found these measurements to be inaccurate and insensitive indicators
of injury. [32] [59] [89] [117] In
addition, the presence of an endotracheal or nasogastric tube can affect the
measurement of this space as well as the respiratory phase of the patient
during x-ray. [121] The predental space should not exceed 3 mm in an
adult. [61] Other findings on the lateral view that can indicate
injury are: vertebral malalignment > 3 mm (dislocation); AP spinal canal
space < 13 mm (spinal cord compression); angulation of intervertebral space
> 11°, and vertebral body anterior height < 3 mm posterior height
(compression fracture). [29]
The open- (or closed-) mouth odontoid view of the atlas and axis
should be reviewed carefully for fractures or malalignment of the odontoid with
the lateral masses of C1. [61] The AP view should be assessed for
alignment of the spinous processes and symmetry of the vertebral bodies. The
reported sensitivity of the standard three-view series (i.e., lateral, AP and
open-mouth odontoid views) in identifying cervical spine injuries is 92% [29] to 99%. [81]
Indications for obtaining flexion-extension views of the cervical
spine are not well defined. These additional views be indicated in symptomatic
patients with a normal three-view series in whom there is suspicion of ligamentous
injury. [3] This imaging study should be performed only in patients
who are awake, alert, and cooperative enough to stop neck movement should pain
occur. [78] All neck movement should be made voluntarily by the
patient, and it is recommended these films be done under the direct supervision
of a knowledgeable physician. [29] Flexion-extension views on
patients with fractures identified on the initial radiographic series can be
useful in demonstrating instability. In this circumstance, however, it is recommended
that the neurosurgical consultant, not the EP, perform the study. [78]
Flexion-extension views can be falsely negative secondary to pain or spasm.
Therefore, if one is concerned, one should immobilize the patient in a
semirigid collar and repeating the flexion-extension views in 1 [38]
to 3 weeks. [29]
Adjunct Imaging
Studies
Indications for CT scanning of the cervical spine in trauma
include an inadequate plain film survey, suspicious plain film findings,
fracture/displacement demonstrated on plain films, and a high clinical
suspicion of injury despite a normal plain film survey. [13] [61]
CT is particularly useful in visualizing the occiput to C2 level in patients
whose plain films suggest injury at that level [3] [38]
or in whom an open-mouth odontoid is not feasible. [11] It is also
frequently used to visualize the lower cervical spine (C7-T1) in patients whose
plain films are inadequate. [69] [116] CT scanning is
limited in visualizing horizontally oriented fractures and demonstrating sagittal
displacement or subluxation of vertebral bodies. [61] Nunez and Quencer [91] have
found helical CT scanning to be an effective screening tool for cervical
fractures in the high-risk, multiply injured trauma patient undergoing CT
scanning of other body regions. In the lower-risk patient, they use helical CT
as an adjunct to plain films for suspicious or poorly visualized segments of
the cervical spine. Helical CT scanning is able to overcome the limitations of
earlier generation scanners with two- and three-dimensional reconstruction.
Magnetic resonance imaging (MRI) is considered the imaging
procedure of choice in the patient with neurologic signs or symptoms whose
plain films are normal. [3] CT myelography should be considered if
MRI is not available or if the patient is unable to tolerate MRI. [3]
MRI differentiates cord hematoma from edema and demonstrates disk and soft
tissue (e.g., muscle and ligament) injuries, subtle osseous fractures, and
chronic changes in the cord. [31] [77] Distinguishing
cord edema from hematoma has a prognostic significance. The presence of
hemorrhage and an increasing length of cord injury on MRI correlates with poor
neurologic outcome. [43] Patients with edema recover, whereas those
with hemorrhage fare worse. [61] In addition, MRI (conventional or
magnetic resonance angiography) is a noninvasive technique that can display
occlusion or injuries to the vascular structures of the neck. [51] [77]
[98] [109] Limitations to MRI include its availability,
magnetic resonance-incompatible life support and monitoring equipment, and
cervical traction devices. Magnetic resonance-compatible life support and
monitoring equipment has been developed. Other standard contraindications
(e.g., presence of pacemaker, noncompatible aneurysm clips, and metallic
foreign bodies) may preclude its use, however.
CLASSIFICATION OF CERVICAL SPINE INJURIES
A classification system is useful in communicating between
physicians, in formulating a prognosis, and in planning therapeutic
interventions. [42]
Cervical spine injuries have been variably classified according to
mechanism of injury, stability, and morphology of injury. Table 5 (Table Not
Available) [61] combines mechanism of injury with stability. Injury
results from a single or combined mechanism of axial loading, flexion,
extension, rotation, lateral bending, and distraction. [29]
According to Finkelstein and Anderson, [42] an all-encompassing
classification system of injuries to the upper cervical spine would be
difficult to develop because of the complex anatomy. They favor the
classification system developed by the Orthopedic Trauma Association. [94]
Stability is difficult to predict, however, White and Punjabi [127]
have developed a checklist to assist in the determination of subaxial
stability. Given the variability in the classification systems and difficulty
in the clinical assessment of stability, it might be most prudent for the EP to
consider all but the most stable cervical spine injuries (e.g., isolated
spinous process fracture) as potentially unstable until evaluated by a
neurosurgical or orthopedic consultant.
TYPES OF CERVICAL SPINE INJURIES
Upper Cervical Spine
Injuries
Atlanto-occipital
Dislocation
Atlanto-occipital dislocation (AOD) is typically a fatal injury
secondary to severe neurologic injury to the brainstem. Atlanto-occipital dissociation is a general term for functional
instability at the occipitocervical junction and manifests as subluxation or
dislocation at the atlanto-occipital joint, the atlantoaxial joint, or both. [33]
Henry et al [58] reviewed the literature and found reports of 38
survivors of AOD. This injury usually results from severe hyperextension with
distraction [90] but can also occur with lateral flexion and
hyperflexion. [58] Three types of AOD have been described. [118]
In type I, the commonest type of AOD, the cranium moves anterior with respect
to the atlas. Type II, commonest in children, is a longitudinal distraction of
the occiput from the atlas. In type III, the cranium is displaced posteriorly
with respect to the atlas. Despite being a severe, often fatal injury,
radiographic findings in AOD are often subtle. Several authors have evaluated
measurements of the occipitocervical junction to assist in the detection of
AOD. Additional radiographic studies, such as CT scanning or MRI, may be
needed. Management of AOD follows the ABCDEs of trauma resuscitation, with the
airway and breathing taking priority as the cervical spine is immobilized.
Immobilization with a halo-vest followed by occipitocervical surgical fixation
is the usual treatment. [42]
Fractures
of the Atlas
Fractures of the atlas usually are the result of compressive
forces resulting from motor vehicle collisions, falls, or diving into shallow
water. It is estimated that fractures of the atlas account for 3% to 13% of all
cervical spine fractures, [54] and nearly 40% are associated with a
fracture of the axis (C-2). [29] Accompanying neurologic injury is
uncommon. [90] These fractures usually are visualized on initial
plain film radiographs. There are three common patterns of atlas fractures. [90]
Posterior arch fractures are commonest. The Jefferson,
or burst, fracture results from
disruption of both the anterior and posterior rings of C-1 with displacement of
the lateral masses. Lateral mass displacement exceeding 7 to 8 mm suggests
instability at C1-C2. Fractures of the lateral masses, which compose the third
fracture pattern, are relatively uncommon. Fractures of the posterior arch and
lateral masses are usually stable and treated with a Philadelphia-style collar.
[90] Stable Jefferson fractures can be treated with external
immobilization, whereas unstable fractures might require operative fixation.
The EP should treat fractures of the atlas as potentially unstable until a
neurosurgeon or orthopedic surgeon has evaluated the patient.
Atlantoaxial
Ligamentous Injuries
There are several terms used to describe ligamentous injuries to
the atlantoaxial complex. These injuries occur secondary to flexion or
extension forces that could be combined with rotation. Thus, terms such as atlantoaxial subluxation, atlantoaxial
rotatory (rotary) subluxation or dislocation,
and rotary (rotatory) fixation are
used to describe injuries involving the transverse or alar ligaments. The transverse
ligament prevents anterior movement of the atlas on the axis, and the alar
ligaments prevent excessive rotation. The radiographic finding of an increase
in the predental space is due to injury of the transverse ligament. Tears of
the transverse ligament result in a widened predental space known as atlantoaxial subluxation. Rotary
subluxation combines atlantoaxial subluxation with C2 being abnormally rotated
with respect to C1. [106] Atlantoaxial rotatory dislocation or
rotary (rotatory) fixation occurs more commonly in children and is seen
following trauma, an upper respiratory infection, or with rheumatoid arthritis.
[29] There is a rotational dislocation of the articular surfaces of
C1 on C2 owing to alar ligament injury.
The open-mouth odontoid view demonstrates an abnormal relationship
between the atlas and axis that does not change upon rotation of the head. [106]
Emergency treatment of atlantoaxial ligamentous injuries should include collar
immobilization and emergency neurosurgical or orthopedic consultation.
Fractures
of the Dens
Acute fractures of the axis (C2) represent 18% of all cervical
fractures, and nearly 60% of these involve the dens. [29] Fractures
of the dens are high-energy injuries sustained in falls or motor vehicle
collisions. Neurologic injury occurs in approximately 25% of these fractures. [90]
Three types of odontoid fractures have been described by Anderson and DeAlonzo.
[4] Type I fractures are uncommon (2%-3% of odontoid fractures) and
are considered relatively stable injuries that can be managed with external
immobilization. [83] Type II fractures are the commonest accounting
for 60% of odontoid fractures. [83] These fractures occur through
the base of the dens near the attachment of ligaments; therefore, most type II
fractures are displaced and unstable. Management of type II fractures is
controversial. High rates (30% to 60%) of nonunion using external
immobilization have led some to advocate surgical fixation as the primary
treatment. [83] Type III fractures are fractures into the body of
the axis and are usually stable. [42] Fracture reduction using
skeletal traction with light weight is followed by immobilization with a
halo-vest. Nonunion is treated with surgical fixation. Kokkino et al [75]
and Castillo et al [21] have reported cases of vertical fractures of
the dens. These injuries do not fit into the above classification scheme and
are best visualized using conventional tomography or CT scanning with sagittal
reformations. Treatment of stable (i.e., transverse ligament not involved),
isolated vertical fractures is with external immobilization.
Traumatic
Spondylolisthesis of the Axis
Traumatic spondylolisthesis of the axis occurs in 5% to 10% of all
cervical spine fractures. [42] These injuries involve fractures
through the posterior elements of C2. Neurologic deficits are rare because the
anteroposterior diameter of the spinal canal is greatest at C2 and the
bilateral pedicle fractures allow decompression. [61] The hangman's fracture, so named because of
the similarity in fracture appearance caused by judicial hanging, occurs with
extreme hyperextension. Today, most of these fractures occur in motor vehicle
collisions and diving accidents. [90] There are three basic types of
fractures based on the fracture pattern, mechanism of injury, and resultant
instability. [42] The EP should consider these fractures unstable
injuries and continue external immobilization until neurosurgical or orthopedic
evaluation. Management by nonsurgical means is successful in more than 95% of
cases of traumatic spondylolisthesis. [42]
Other
Injuries of the Atlas and Axis
An avulsion fracture of the anterior arch of the atlas is a rare
injury caused by hyperextension forces. [55] A horizontal fracture
line through the anterior arch of the atlas and prevertebral soft tissue
swelling are seen on the lateral radiograph. In an extension teardrop fracture
of the axis, the intact anterior longitudinal ligament avulses the anterior
inferior corner of the body of the axis. This injury occurs more commonly in
older patients with osteopenia or cervical spondylosis. [55]
Subaxial Cervical
Spine Injuries
Fractures and dislocations of the subaxial cervical spine (C3-C7)
are best categorized according to mechanism of injury. These injuries are often
the result of a combination of flexion, rotation, extension, and vertical
compression forces. C5 is the most commonly fractured cervical vertebra,
whereas C5 on C6 is the commonest site of subluxation. Owing to the small
diameter of the subaxial spinal canal, neurologic injury occurs frequently.
Cervical
Hyperflexion Injuries
Hyperflexion ligamentous injuries to the posterior ligamentous
structures range from mild to severe. The patient with a sprain of this
ligamentous complex has focal tenderness but no neurologic findings. Stability
of the cervical spine is maintained. Severe injuries with complete disruption
of these ligaments result in cervical spine instability and anterior
subluxation. Radiographs appear normal or demonstrate subtle findings such as
focal kyphosis, facet diastasis, or interspinous widening. [42] Treatment
ranges from collar immobilization for mild, stable ligamentous injuries to
posterior cervical fusion for severe, unstable ligamentous injuries.
The wedge or compression fracture results from
hyperflexion forces causing impaction of one vertebra against another. Most of
the force is expended on the anterior vertebral body, resulting in a diminished
height and increased concavity of the anterior border of the vertebral body,
increased density of the vertebral body from bony impaction, and prevertebral
soft tissue swelling. [61] The injury is usually stable without
accompanying neurologic deficit.
The flexion teardrop
fracture is characterized by the presence of a triangular bony fragment at
the anteroinferior aspect of the involved vertebral body accompanied by severe
ligament and intervertebral disk injury. [100] Flexion teardrop
fracture fragments also can be produced by downward displacement of the anterior
edge of the superior endplate. [106] This injury is very unstable
and often is associated with severe neurologic injury. Treatment is reduction
followed by surgical fixation.
Bilateral
facet dislocation is a severe injury characterized by 50% or greater
anterior vertebral body translation. This injury should be considered extremely
unstable, is often accompanied by severe cord injury, and there can be
vertebral artery injury or occlusion. Reduction followed by surgical
stabilization is recommended. [42]
Clay
shoveler's fracture was originally described as an avulsion
fracture of the spinous process of one of the lower cervical vertebrae. Today,
this injury more commonly results from direct trauma to the spinous process,
sudden deceleration in motor vehicle collisions, or forced flexion of the neck.
[61] This
is a stable injury that is not associated with neurologic deficits.
Rotational
Injuries
Unilateral facet dislocation results from combined flexion with
rotation. The dislocated facet is wedged into the intervertebral foramen,
creating a mechanically stable injury. [55] Radiographic findings on
the lateral view include 25% to 50% anterior translation of the vertebral body,
the "bowtie" sign (i.e., visualization of both of the facets at the
level of the injury instead of their normal superimposed position), and
widening of the spinous processes. [5] The frontal view shows
spinous processes above the level of dislocation displaced to the same side as
the dislocated facet; oblique views may show the dislocated facet sitting in
the neuroforamen. Unilateral facet dislocations can occur with or without
associated fractures. The patient may be neurologically intact or demonstrate
nerve root, incomplete cord, or complete cord injuries. [5]
Definitive management depends on the presence of associated fractures. Closed
reduction and halo-vest immobilization can be used for pure unilateral facet
dislocations, whereas reduction with surgical management is used for fracture
dislocations and failures of closed attempts. [42]
Cervical
Hyperextension Injuries
Extension teardrop fractures often involve the axis and lower
cervical (C5 to C7) vertebrae. [61] The fracture fragment results
from avulsion of the anteroinferior aspect of the vertebral body by the intact
anterior longitudinal ligament. With severe force, the intervertebral disk and
posterior ligaments may be involved, leading to an unstable injury. Mechanical
stability may be affected by position of the neck. [61] Extension
teardrop and other hyperextension injuries are associated with variable cord
injuries, including transient neurologic deficits, the central cord syndrome,
and complete quadriplegia. [42] Definitive management depends on
imaging studies and can include reduction, decompression, and fusion.
Compression
Injuries
The burst fracture of the lower cervical spine is a comminuted
fracture of the vertebral body. The nucleus pulposus is forced into the
vertebral body from severe compressive forces, causing the vertebral body to
shatter outward from within. [61] Radiographs may demonstrate a
comminuted vertebral body on lateral view and a vertical fracture on
anteroposterior view. CT scanning should be obtained and demonstrates the
position of fracture fragments in relationship to the spinal canal. This injury
is usually mechanically stable because all ligaments remain intact. Neurologic
injury depends on the degree of fragment retropulsion into the spinal canal.
Nonsurgical treatment includes reduction with alignment and immobilization.
Surgery is indicated for unstable injuries and inadequate closed reduction and
decompression. [42]
ASSOCIATED INJURIES
Spinal Cord Injuries
A complete spinal cord injury is defined as total loss of
sensory or motor function below a certain level. If any motor or sensory
function remains (e.g., sacral sparing), it is an incomplete injury and the
prognosis for recovery is significantly better. [29] Signs of sacral
sparing include persistent perianal sensation, rectal sphincter tone, or slight
flexor toe movement. [29] [61] The sensory level denotes
the most caudal segment of the spinal cord with normal sensory function on both
sides of the body. The motor level is the lowest key muscle innervation that
maintains a 3/5 (able to move against gravity) muscle.
Spinal
shock is the flaccidity and loss of reflexes seen after a spinal cord
injury. Because it involves complete loss of neurologic function, it can cause
an incomplete spinal cord injury to mimic a complete cord injury. [29]
It is a concussive injury that usually lasts less than 24 hours, and return of
the bulbocavernosus reflex can signal the end of spinal shock. [61] Neurogenic shock refers to the state
produced by loss of vasomotor tone and sympathetic innervation of the heart. [29]
Vasodilatation with pooling of blood results in hypotension. Other
manifestations of hypovolemic shock (e.g., tachycardia and delayed capillary
refill) are not seen.
Incomplete spinal cord injuries are often recognized by certain
patterns of neurologic involvement, with approximately 90% of incomplete spinal
injuries being classified as one of three distinct clinical. [61]
The central cord syndrome, the commonest of the three, usually follows a
hyperextension injury in a patient with cervical canal narrowing secondary to
degenerative arthritis. [29] [61] The ligamentum flavum
is thought to buckle into the cord, injuring the central gray matter and most
central portions of the pyramidal and spinothalamic tracts. [61]
Thus, weakness is disproportionately greater in the upper extremities than the
lower extremities and can be accompanied by variable sensory loss. This injury
can occur with or without cervical spine fracture or dislocation. [29]
The anterior cord syndrome usually results from flexion injuries that result in
cord contusion or is due to protrusion of bony fragments or herniated disks
into the spinal canal. Injury, thrombosis, or laceration of the anterior spinal
artery can also result in anterior cord syndrome. Physical examination findings
include bilateral paralysis and hypalgesia below the level of injury, with
preservation of posterior column functions. This syndrome has the poorest
prognosis of the incomplete injuries. [29] Brown-Se quard syndrome,
or hemisection of the spinal cord, is a rare injury that usually results from
penetrating injuries but can be seen following lateral mass fractures of the
cervical spine. [61]
The syndrome consists of loss of ipsilateral motor and posterior columns
function associated with contralateral sensory loss beginning one to two levels
below the level of injury.
Patients with nonpenetrating spinal cord injury should be treated
with high-dose methylprednisolone within the first 8 hours of injury. Bracken
et al found that patients treated within 8 hours of injury with
methylprednisolone, 30 mg/kg intravenous bolus given over 15 minutes, followed
by a 45-minute pause then a 5.4 mg/kg/hr infusion for 23 hours, showed
significant neurologic improvement at 6 weeks, [119] 6 months, [119]
and 1 year [120] when compared with patients treated with naloxone
or placebo.
Vascular Injuries
Vascular injuries accompanying blunt trauma to the neck are
considered rare. Injuries to the vertebral artery, [51]
vertebrobasilar circulation, [98] cervical part of the internal
carotid, [109] and distal innominate artery [132] have
been reported. Vertebral artery injuries have been reported to occur in 0.9% to
46% of patients with cervical spine fractures. [42] Bone fragments
found within the foramen transversarium are predictive for vertebral artery
injury. [130] A vascular injury should be considered when a
clinically apparent level of neurologic deficit does not correlate with the
known level of spinal injury. [61] Lastly, normal vertebral artery
flow should be demonstrated in the patient with cervical spine trauma and
altered mental status without identifiable head injury. [42]
Diagnosis can be made by conventional MR, MR angiography, or conventional
angiography. [98]
Soft Tissue Injuries
Soft tissue injuries to the neck following motor vehicle
collisions are common. Motor vehicle trauma with a whiplash occurs
approximately 1 million times per year in the United States. [20]
Typically, injury results from sudden acceleration-deceleration trauma. A
common mechanism involves an unaware victim in a stationary vehicle being
struck from behind. Improvements in automobile safety, such as the extended
headrest, were developed to reduce acceleration-deceleration injuries. Other
vehicle safety devices, such as seat belt restraints, are effective in reducing
the frequency of injuries and death; however, cervical strain occurs more
frequently in occupants using shoulder belts than in unrestrained occupants. [66]
Two reported cases of hangman's fracture have resulted from improper (i.e.,
diagonal shoulder belt only) seat-belt use. [100] [131]
Injuries from airbags are increasingly being reported. Maxeiner and Hahn [85]
reported a case of fatal brainstem and high cervical spine injury secondary to
airbag deployment in a front-seat passenger of short stature whose seat was
positioned far forward.
The soft tissue neck injury is termed hyperextension strain, acceleration- deceleration injury, hyperextension/hyperflexion injury, neck strain,
neck sprain, and whiplash. Pain,
both acute and chronic, is the commonest result of any type of
acceleration-deceleration injury. [20] The symptom complex of
protracted pain originates from the rich sensory innervation of cervical
structures and trauma to muscle groups of this
[20]
Patients with acceleration-deceleration often complain of
associated injuries. The EP must carefully examine the patient for evidence of
associated traumatic injuries. Injuries to the temporomandibular joints are
very common. [46] [68] Injuries to the eyes and ears also
can accompany acceleration-deceleration injuries. In addition, patients
commonly report symptoms such as irritability, emotional lability, insomnia,
headache, and deficits in attention, concentration, and memory. [68]
Low back and upper extremity pain can develop. [20]
To some practitioners, the term whiplash has become more of a derogatory term than a medical one,
often implying impending medicolegal litigation. [53] Pathologic
findings have been inconsistent, [52] but several recent articles
have attempted to better define the mechanism of whiplash injuries. [52]
[96] The Quebec Task Force on Whiplash-associated Disorders
attempted to clarify many issues surrounding whiplash injuries, including their
definition, prevention, and treatment. [113] A critical evaluation
of this article by Freeman et al [44] questioned the validity of its
conclusions and recommendations; however, the authors do agree with the Quebec
Task Force that high-quality research into the epidemiology, definition,
treatment, and prognosis of whiplash injuries is needed.
Treatment of patients with acceleration-deceleration neck injuries
is variable. Empiric treatment commonly
includes rest, analgesics, nonsteroidal anti-inflammatory drugs, sedatives,
muscle relaxants, and physiotherapy. Borchgrevnik et al [12] found
that patients who were instructed to return to normal preinjury activities had
a better outcome than those patients who received soft neck-collar
immobilization and sick leave for 14 days. In a small, prospective, randomized,
double-blind study, Pettersson and Toolanen [97] studied the use of
high-dose methylprednisolone (30 mg/kg intravenous bolus followed by 5.4
mg/kg/hr for 23 hours) administered within 8 hours of injury to patients with
acute whiplash. They found a significant difference in presence of disabling
symptoms, total number of sick days, and sick-leave profile favoring the
treated group. Capen [20] recommends use of steroids
(methylprednisolone dose pack or IM corticosteroids) within the first 2 weeks
postinjury. Regardless of the treatment, approximately 20% to 30% of whiplash
victims have symptoms that last beyond 12 months. [20]
INJURED ATHLETE
Whether
as a team physician, spectator, or during a routine ED shift, the EP can
encounter a real or potential cervical spine injury in an athlete. These
high-profile injuries must be handled appropriately to avoid further injury.
Unique management issues that can arise when one is caring for injured athletes
include: on-field evaluation; immobilization techniques; removal of protective
equipment; and return-to-play criteria.
Injuries to the cervical spine can occur in contact sports such as
football, hockey, rugby, wrestling, or boxing, or in other sports (or
recreational activities) in which the head and neck are at risk, such as
gymnastics, diving, or on the trampoline. [84] The commonest sports
associated with vertebral column injury in the United States are football and
wrestling, with C5 being the most commonly injured level. [6]
Neurologic deficit from cervical spine trauma most commonly occurs in football,
wrestling, and gymnastics. [6] Even throwing a Frisbee has resulted
in a quadriplegic injury. [23]
The first step in evaluating the athlete with a potential cervical
spine injury is the on-field assessment. Marks et al [84] developed
an algorithm for the initial evaluation of the injured athlete. The EP who acts
as team physician must ensure that his or her medical team members are prepared
to manage the injured athlete. Preparedness should include ensuring
availability of proper equipment (e.g., spine board, immobilization devices,
and stretcher), rehearsal and review of team member roles, including assigning
a "captain" to direct the efforts of the medical team. [123]
The on-field evaluation should follow the ABCs of trauma resuscitation. The
unconscious athlete should be carefully "log rolled" into a supine
position. The mouthpiece should be removed while the airway, breathing, and
circulation are assessed. Protective equipment (e.g., helmet and shoulder pads
should be left in place until adequate immobilization of the head and neck has
occurred. [123] In the nonbreathing athlete, the face mask must be
rapidly removed, rescue breathing initiated, and the airway secured. Further
resuscitation and rapid transport to a hospital should follow.
Removal of protective equipment must be done in an orderly
fashion. Removal of the helmet must be accompanied by removal of shoulder pads
to maintain the neck in neutral position and not risk secondary cord injury. In
articles by Palumbo et al [95] and Gastel et al, [48]
radiographs of cadavers were used to demonstrate that immobilizing the
neck-injured football player with only the helmet or only the shoulder pads in
place causes significant cervical spine malalignment. Donaldson et al [36]
demonstrated significant cervical spine movements during helmet and shoulder
pad removal in a cadaveric model. They recommend removal of helmet and shoulder
pad equipment be performed in a monitored setting by a team of three to four
members. The American College of Surgeons' Committee on Trauma has developed a
poster on the techniques of helmet removal. [87] Shoulder pads also
must be removed in an orderly manner while the head and neck are stabilized at
the level of the torso. The anterior and axillary straps should be cut first.
Then, the head and thorax should be elevated as a unit as the shoulder pads are
slid from under the athlete. Lastly,
the patient is then lowered back down to the spinal board, and a cervical
collar is applied. [48]
Management of specific cervical spine injuries and
return-to-competition decisions following treatment of these injuries is beyond
the scope of this article. However, is included for reference and might be of
interest to the sports medicine physician. Warren and Bailes [123]
describe three types of athletic spinal injuries. Type I injuries result in
permanent spinal cord injury. A type 2 injury is a transient neurologic deficit
after trauma in persons with normal radiographic studies. Type 3 injuries are
radiographic findings (i.e., fractures, fracture-dislocations, and ligamentous
injuries) without neurologic deficits. An example of a type 2 injury is the burning hands syndrome, a variant of the
central cord syndrome, [123] which is characterized by burning
paresthesias and dysesthesias in both arms or hands and occasionally in the
legs, and by variable weakness. [128] Bony or ligamentous spine
injury is found in approximately 50% of affected patients. [128]
This potentially serious injury must not be confused with the
"burner" or "stinger" injury. This common football injury
is characterized by unilateral burning dysesthesias from the shoulder to hand,
with occasional weakness or numbness in the C5 and C6 distribution. [123]
This peripheral nerve injury is thought to occur secondary to traction on the
brachial plexus or from compression of the nerve root in the neural foramen
following axial compression. [19] The symptoms typically last
minutes but can persist for days to weeks. [19] [123]
Thus, the unilaterality, brevity, and pain-free range of motion in the athlete
can assist in discriminating between a "stinger" and cord injury. [123]
The athlete whose unilateral, upper extremity symptoms completely resolve in
seconds to minutes and who has no neck pain or limitation of neck movement can
safely return to play. [19] The athlete with continued symptoms,
neck pain, incomplete range of motion, or suspicion of neck injury should be
removed from competition and undergo radiologic evaluation. [18] [19]
CONCLUSION
The
EP must be able to manage the patient with potential cervical spine injury
effectively and efficiently. The major management principal for the multiply
injured trauma patient remains cervical spine protection as the ABCDEs of
trauma are evaluated and managed. Preventing additional neurologic injury in
the trauma patient with cervical spine injury is the goal. The EP must have an
understanding of the complex anatomy, types of cervical spine injury, and
associated neurologic, vascular, and soft tissue injuries to manage this
potentially devastating injury positively. Prehospital care, immobilization
techniques, airway management, and recognition and early treatment of cord
injury are some of the challenges the EP faces when managing the patient with
cervical spine injuries. The EP must know the utility and limitations of
different radiographic techniques for evaluating the cervical spine to manage
these patients efficiently. A cost-effective and time-efficient approach must
be used because patients with potential cervical spine injuries are commoner
than those with actual injuries. Future studies into the development and
validation of prehospital protocols for cervical spine immobilization and
utility of low-risk clinical indicators of cervical spine injury could affect
current ED management.
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