Key Facts

Cervical spine injury is a potentially devastating consequence of trauma. The goal of assessment is to rapidly identify patients who need imaging while safely clearing the C-spine in low-risk patients. Prevention of secondary cord injury through appropriate immobilisation and management is paramount.

Epidemiology

Cervical spine fractures occur in approximately 2-3% of blunt trauma patients. Cervical cord injury occurs in approximately 0.5%. Falls are the most common mechanism in the elderly; RTCs in young adults. C2 is the most commonly fractured vertebra overall. The subaxial C-spine (C5-C7) is the most common level of cord injury.

Aetiology

High-risk mechanisms:

• Road traffic collision >60mph, ejection from vehicle
• Fall from >1 metre or 5 stairs
• Axial loading (diving, rugby)
• Bicycle collision
• Elderly with minor fall (osteoporotic spine)

Specific fracture types:

• C1 (Jefferson fracture): Burst fracture — axial loading
• C2 (Odontoid/dens fracture): Most common C2 fracture; classified by Anderson and D'Alonzo (Type I-III)
• C2 (Hangman's fracture): Bilateral pars interarticularis fracture — hyperextension
• Subaxial fractures: Flexion-distraction, burst, facet dislocations

Pathophysiology

The cervical spine provides structural support and protects the spinal cord. Injury mechanisms include flexion, extension, rotation, compression, and distraction — often combined. Cord injury results from primary mechanical disruption and secondary injury from oedema, ischaemia, and inflammation. The cervical spinal canal is narrowest at C3-C7, making this region vulnerable to cord compression.

Assessment Approach

• Primary survey (ATLS): C-spine immobilisation during airway management

• Canadian C-spine Rules (CCR):

  1. Any high-risk factor? (Age ≥65, dangerous mechanism, paraesthesia in extremities) → CT
  2. Any low-risk factor allowing safe active ROM? (Simple rear-end RTC, sitting in ED, ambulatory, delayed pain onset, no midline tenderness) → assess ROM
  3. Can actively rotate neck 45° left and right? → No imaging needed

• NEXUS Criteria: C-spine can be cleared if ALL 5 criteria met: No midline tenderness, no focal neurological deficit, normal alertness, no intoxication, no painful distracting injury

Neurological Assessment

• Motor and sensory examination of all four limbs
• Anal tone and perianal sensation (sacral sparing)
• Reflexes including bulbocavernosus reflex
• ASIA classification (A-E)

Red Flags

• Midline cervical tenderness with neurological deficit — high suspicion of unstable injury
• Bilateral upper limb weakness > lower limb — central cord syndrome
• Diaphragmatic breathing (paradoxical) — suggests high cervical cord injury (C3-C5 phrenic nerve)
• Priapism — sign of cord injury
• Neurogenic shock (bradycardia + hypotension) — cord injury above T6

Bedside

• Primary survey: ATLS — maintain immobilisation
• Clinical assessment: CCR or NEXUS to determine imaging need
• Neurological examination: Detailed motor, sensory, reflex, anal tone
• ASIA assessment: If neurological deficit present

Bloods

• Standard trauma bloods: FBC, U&Es, coagulation, group and save
• ABG: If respiratory compromise (high cervical injury)

Imaging

• CT C-spine: First-line in trauma — sensitivity >99% for fracture; requested per clinical decision rules
• CT angiography of neck: If fracture involves foramen transversarium (risk of vertebral artery injury)
• MRI C-spine: Indicated for neurological deficit with normal CT, suspected ligamentous injury, or cord compression
• Flexion-extension views: Historical — rarely used acutely now (MRI preferred)

Special Tests

• CT with 3D reconstruction: For complex fractures — surgical planning
• MRI within 24-72 hours: For all patients with neurological deficit
• Formal clearance protocol: For obtunded patients — serial clinical examination ± MRI at 72 hours

Non-pharmacological

• Immobilisation: Scoop stretcher, head blocks with tape/straps; minimise time in rigid collar (pressure sore risk)
• Manual in-line stabilisation (MILS): During airway management — do NOT apply traction
• Log-roll: For examination and repositioning
• Early specialist referral: To spinal surgery for all cervical fractures

Pharmacological

• Analgesia: Paracetamol 1g QDS; opioids cautiously (respiratory depression risk in cord injury)
• Methylprednisolone: NOT routinely recommended (NASCIS trials methodologically flawed; risks outweigh benefits)
• VTE prophylaxis: LMWH once surgical stability confirmed; mechanical prophylaxis from admission
• Vasopressors: Noradrenaline for neurogenic shock (target MAP ≥85 mmHg for 5-7 days)
• Bowel and bladder management: Catheter, laxatives from day 1

Surgical/Interventional

• Surgical fixation: Unstable fractures — anterior or posterior approach depending on injury pattern
• Emergency decompression: For progressive neurological deficit or cord compression on MRI
• Halo vest: External fixation for upper cervical fractures where surgery is not indicated
• Philadelphia collar: Stable fractures during conservative management
• Timing: Early surgery (<24h) increasingly supported for incomplete cord injuries (STASCIS trial)

Referral Criteria

• All cervical fractures — spinal surgery consultation
• Neurological deficit — emergency MRI and spinal surgery
• Unstable fractures — surgical fixation
• Cord injury — specialist spinal cord injury centre transfer when stable
• Obtunded patient with unclear C-spine — protocolised clearance

• Complete cord injury (ASIA A): <5% neurological recovery if still ASIA A at 72h
• Incomplete cord injury: Significant recovery potential — Brown-Séquard best (~90% ambulate), central cord variable
• Odontoid type II fracture: Non-union rate ~40% with collar alone in elderly → surgery often needed
• Jefferson fracture: Generally good prognosis, most treated conservatively
• Bilateral facet dislocation: High rate of complete cord injury (~75%)
• C-spine clearance in alert trauma patient: If CCR negative and full ROM, <0.1% chance of significant injury

Canadian C-Spine Rules Algorithm

Anderson and D'Alonzo Odontoid Fracture Classification

NEXUS Low-Risk Criteria (All 5 Must Be Met to Clear)