Evaluation and acute management of cervical spinal column injuries in adults
- Amy Kaji, MD, PhD
Amy Kaji, MD, PhD
- Associate Professor of Emergency Medicine
- David Geffen School of Medicine at UCLA
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
- Section Editor
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editors
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
- Susanna I Lee, MD, PhD
Susanna I Lee, MD, PhD
- Deputy Editor — Radiology
- Associate Professor of Radiology
- Harvard Medical School
- Massachusetts General Hospital
This topic review discusses the evaluation and initial management of injuries to the cervical spinal column in adults, including the appropriate use of imaging studies. The importance of early recognition and appropriate management of such injuries is underscored by their association with spinal cord injury.
Descriptions of the range of spinal column fractures and other injuries, the management of spinal cord injuries, and spinal trauma in children are discussed separately. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs" and "Acute traumatic spinal cord injury" and "Anatomy and localization of spinal cord disorders" and "Evaluation of cervical spine injuries in children and adolescents" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete".)
EPIDEMIOLOGY AND ANATOMY
The epidemiology and clinically important anatomy related to cervical spine injuries are discussed separately. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Epidemiology' and "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Anatomy'.)
MECHANISMS, CLASSIFICATION SCHEMES, AND TYPES OF INJURY
Common mechanisms of injury, classification schemes, and important types of cervical spinal column injuries are discussed separately. (See "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Mechanisms of injury' and "Spinal column injuries in adults: Definitions, mechanisms, and radiographs", section on 'Cervical spinal column injury'.)
Prehospital management — General prehospital management of trauma is discussed separately; subjects of particular importance to spinal injury are described below. (See "Prehospital care of the adult trauma patient".)
- Oteir AO, Smith K, Stoelwinder JU, et al. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury 2015; 46:528.
- Rhee P, Kuncir EJ, Johnson L, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma 2006; 61:1166.
- Salim A, Martin M, Sangthong B, et al. Near-hanging injuries: a 10-year experience. Injury 2006; 37:435.
- Hanna SJ. A study of 13 cases of near-hanging presenting to an Accident and Emergency Department. Injury 2004; 35:253.
- Ham W, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg 2014; 76:1131.
- www.facs.org/trauma/publications/helmet.pdf www.facs.org/trauma/publications/helmet.pdf (Accessed on February 15, 2008).
- Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology 2006; 104:1293.
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
- Ollerton JE, Parr MJ, Harrison K, et al. Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review. Emerg Med J 2006; 23:3.
- Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med 2007; 50:236.
- Tator, CH. Management of associated spine injures in head injured patients. In: Neurotrauma, Narayan, RK, Wilberger, JE, Poulishock, JT (Eds), McGraw-Hill, New York 1996.
- Hackl W, Hausberger K, Sailer R, et al. Prevalence of cervical spine injuries in patients with facial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92:370.
- Williams J, Jehle D, Cottington E, Shufflebarger C. Head, facial, and clavicular trauma as a predictor of cervical-spine injury. Ann Emerg Med 1992; 21:719.
- Holly LT, Kelly DF, Counelis GJ, et al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J Neurosurg 2002; 96:285.
- Maroon JC, Abla AA. Classification of acute spinal cord injury, neurological evaluation, and neurosurgical considerations. Crit Care Clin 1987; 3:655.
- Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
- Porter JM, Ursic CM. Digital rectal examination for trauma: does every patient need one? Am Surg 2001; 67:438.
- Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.
- Guldner GT, Brzenski AB. The sensitivity and specificity of the digital rectal examination for detecting spinal cord injury in adult patients with blunt trauma. Am J Emerg Med 2006; 24:113.
- Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343:94.
- Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998; 32:461.
- Rose MK, Rosal LM, Gonzalez RP, et al. Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth. J Trauma 2012; 73:498.
- Panacek EA, Mower WR, Holmes JF, et al. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury. Ann Emerg Med 2001; 38:22.
- Goode T, Young A, Wilson SP, et al. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? Am Surg 2014; 80:182.
- Denver D, Shetty A, Unwin D. Falls and Implementation of NEXUS in the Elderly (The FINE Study). J Emerg Med 2015; 49:294.
- Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001; 286:1841.
- Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003; 349:2510.
- Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med 2009; 54:663.
- Stiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ 2009; 339:b4146.
- Yealy DM, Auble TE. Choosing between clinical prediction rules. N Engl J Med 2003; 349:2553.
- Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma 2005; 59:1121.
- Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007; 62:1427.
- Greenbaum J, Walters N, Levy PD. An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med 2009; 36:64.
- Watanabe M, Sakai D, Yamamoto Y, et al. Upper cervical spine injuries: age-specific clinical features. J Orthop Sci 2010; 15:485.
- Govender S, Vlok GJ, Fisher-Jeffes N, Du Preez CP. Traumatic dislocation of the atlanto-occipital joint. J Bone Joint Surg Br 2003; 85:875.
- West OC, Anbari MM, Pilgram TK, Wilson AJ. Acute cervical spine trauma: diagnostic performance of single-view versus three-view radiographic screening. Radiology 1997; 204:819.
- Crim JR, Moore K, Brodke D. Clearance of the cervical spine in multitrauma patients: the role of advanced imaging. Semin Ultrasound CT MR 2001; 22:283.
- Petri R, Gimbel R. Evaluation of the patient with spinal trauma and back pain: an evidence based approach. Emerg Med Clin North Am 1999; 17:25.
- Freemyer B, Knopp R, Piche J, et al. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med 1989; 18:818.
- Offerman SR, Holmes JF, Katzberg RX, Richards JR. Utility of supine oblique radiographs in detecting cervical spine injury. J Emerg Med 2006; 30:189.
- Mower WR, Hoffman JR, Pollack CV Jr, et al. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med 2001; 38:1.
- Kaups KL, Davis JW, Parks SN. Routinely repeated computed tomography after blunt head trauma: does it benefit patients? J Trauma 2004; 56:475.
- Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.
- Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma 2005; 59:1121.
- Widder S, Doig C, Burrowes P, et al. Prospective evaluation of computed tomographic scanning for the spinal clearance of obtunded trauma patients: preliminary results. J Trauma 2004; 56:1179.
- Ajani AE, Cooper DJ, Scheinkestel CD, et al. Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation. Anaesth Intensive Care 1998; 26:487.
- Mejaddam AY, Kaafarani HM, Ramly EP, et al. The clinical significance of isolated loss of lordosis on cervical spine computed tomography in blunt trauma patients: a prospective evaluation of 1,007 patients. Am J Surg 2015; 210:822.
- Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma 2009; 67:651.
- Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 2005; 58:902.
- Plumb JO, Morris CG. Clinical review: Spinal imaging for the adult obtunded blunt trauma patient: update from 2004. Intensive Care Med 2012; 38:752.
- Inaba K, Byerly S, Bush LD, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial. J Trauma Acute Care Surg 2016; 81:1122.
- Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999; 212:117.
- Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. AJR Am J Roentgenol 2000; 174:713.
- Daffner RH. Cervical radiography for trauma patients: a time-effective technique? AJR Am J Roentgenol 2000; 175:1309.
- Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. AJR Am J Roentgenol 2001; 177:677.
- Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg 2005; 140:762.
- Adelgais KM, Grossman DC, Langer SG, Mann FA. Use of helical computed tomography for imaging the pediatric cervical spine. Acad Emerg Med 2004; 11:228.
- Rybicki F, Nawfel RD, Judy PF, et al. Skin and thyroid dosimetry in cervical spine screening: two methods for evaluation and a comparison between a helical CT and radiographic trauma series. AJR Am J Roentgenol 2002; 179:933.
- Holmes JF, Mirvis SE, Panacek EA, et al. Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries. J Trauma 2002; 53:524.
- Cohen WA, Giauque AP, Hallam DK, et al. Evidence-based approach to use of MR imaging in acute spinal trauma. Eur J Radiol 2003; 48:49.
- Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003; 55:811.
- Biffl WL, Moore EE, Offner PJ, Burch JM. Blunt carotid and vertebral arterial injuries. World J Surg 2001; 25:1036.
- Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg 2007; 246:632.
- Cooper DJ, Ackland HM. Clearing the cervical spine in unconscious head injured patients - the evidence. Crit Care Resusc 2005; 7:181.
- Kothari P, Freeman B, Grevitt M, Kerslake R. Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg Br 2000; 82:1034.
- Kato H, Kimura A, Sasaki R, et al. Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan. J Trauma 2008; 65:373.
- Kasimatis GB, Panagiotopoulos E, Megas P, et al. The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies. J Trauma 2008; 65:86.
- Tewari MK, Gifti DS, Singh P, et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol 2005; 63:204.
- Boese CK, Lechler P. Spinal cord injury without radiologic abnormalities in adults: a systematic review. J Trauma Acute Care Surg 2013; 75:320.
- Hendey GW, Wolfson AB, Mower WR, et al. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma 2002; 53:1.
- Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol Neurosurg 2008; 110:429.
- Gupta SK, Rajeev K, Khosla VK, et al. Spinal cord injury without radiographic abnormality in adults. Spinal Cord 1999; 37:726.
- Ackland HM, Cameron PA, Varma DK, et al. Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med 2011; 58:521.
- Menaker J, Philp A, Boswell S, Scalea TM. Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet? J Trauma 2008; 64:898.
- Schoenfeld AJ, Bono CM, McGuire KJ, et al. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma 2010; 68:109.
- Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal? Radiology 2005; 237:106.
- Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J Neurosurg 2011; 115:541.
- Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 78:430.
- Stassen NA, Williams VA, Gestring ML, et al. Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient. J Trauma 2006; 60:171.
- Badhiwala JH, Lai CK, Alhazzani W, et al. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med 2015; 162:429.
- Kirschner J, Seupaul RA. Does computed tomography rule out clinically significant cervical spine injuries in obtunded or intubated blunt trauma patients? [corrected]. Ann Emerg Med 2012; 60:737.
- Malhotra A, Wu X, Kalra VB, et al. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol 2016.
- Dunham CM, Brocker BP, Collier BD, Gemmel DJ. Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit. Crit Care 2008; 12:R89.
- Como JJ, Thompson MA, Anderson JS, et al. Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma? J Trauma 2007; 63:544.
- Lukins TR, Ferch R, Balogh ZJ, Hansen MA. Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm. ANZ J Surg 2015; 85:917.
- Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am 2006; 44:1.
- Griffiths HJ, Wagner J, Anglen J, et al. The use of forced flexion/extension views in the obtunded trauma patient. Skeletal Radiol 2002; 31:587.
- Freedman I, van Gelderen D, Cooper DJ, et al. Cervical spine assessment in the unconscious trauma patient: a major trauma service's experience with passive flexion-extension radiography. J Trauma 2005; 58:1183.
- Goodnight TJ, Helmer SD, Dort JM, et al. A comparison of flexion and extension radiographs with computed tomography of the cervical spine in blunt trauma. Am Surg 2008; 74:855.
- Padayachee L, Cooper DJ, Irons S, et al. Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion-extension fluoroscopy versus computed tomography with three-dimensional reconstruction. J Trauma 2006; 60:341.
- Harrison JL, Ostlere SJ. Diagnosing purely ligamentous injuries of the cervical spine in the unconscious trauma patient. Br J Radiol 2004; 77:276.
- Sliker CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. Radiology 2005; 234:733.
- Khan SN, Erickson G, Sena MJ, Gupta MC. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma 2011; 25:51.
- Pollack CV Jr, Hendey GW, Martin DR, et al. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann Emerg Med 2001; 38:8.
- Wang JC, Hatch JD, Sandhu HS, Delamarter RB. Cervical flexion and extension radiographs in acutely injured patients. Clin Orthop Relat Res 1999; :111.
- Insko EK, Gracias VH, Gupta R, et al. Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J Trauma 2002; 53:426.
- Botte MJ, Byrne TP, Abrams RA, Garfin SR. Halo Skeletal Fixation: Techniques of Application and Prevention of Complications. J Am Acad Orthop Surg 1996; 4:44.
- Bradley LH, Paullus WC, Howe J, Litofsky NS. Isolated transverse process fractures: spine service management not needed. J Trauma 2008; 65:832.
- Homnick A, Lavery R, Nicastro O, et al. Isolated thoracolumbar transverse process fractures: call physical therapy, not spine. J Trauma 2007; 63:1292.
- EPIDEMIOLOGY AND ANATOMY
- MECHANISMS, CLASSIFICATION SCHEMES, AND TYPES OF INJURY
- INITIAL MANAGEMENT
- Prehospital management
- - Spinal immobilization
- - Helmet removal
- Emergency department (ED) management
- - Airway management
- - Spinal and neurogenic shock
- - Secondary survey
- Management of spinal cord injury
- RADIOGRAPHIC EVALUATION OF CERVICAL SPINAL COLUMN INJURY
- Overview of imaging
- Imaging of patients not at high risk
- - Clinical decision rules for obtaining radiographs
- Canadian C-spine rule
- NEXUS versus Canadian C-spine rule
- - Plain radiographs versus CT
- - Interpretation of plain radiographs
- Imaging of patients at higher risk
- - CT for cervical spinal column injury
- - MRI for cervical spinal column injury
- Evaluation for ligamentous injury and SCIWORA
- - Epidemiology
- - Approach to imaging
- - Flexion-extension radiographs
- DEFINITIVE MANAGEMENT AND DISPOSITION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS