The spine is made up of vertebrae, ring-shaped bones that line up in a row to form the spinal canal. Inside the spinal canal is the spinal cord - a bundle of nerve fibers and cells that conduct nerve impulses from the brain to various parts of the body and vice versa. The individual nerves that exit the spinal canal are separated from the spinal cord. In vertebral fractures, bone fragments can injure the spinal cord, leading to partial or complete muscle loss and loss of sensation below the level of the injury. The spinal cord can be damaged at the very moment of the vertebral injury, but also later when moving and carrying the injured person. Injuries occur when direct physical force damages the vertebrae, ligaments or discs of the spine, causing crushing, crushing or rupture of brain tissue, and penetrating brain injuries. Such injuries can also lead to vascular damage leading to ischemia or hematoma causing additional damage. All types of injuries can cause brain edema which further reduces blood flow and oxygenation.

Approximately 5% to 10% of unconscious patients presenting as a result of a fall or motor vehicle accident have a major injury to the cervical spine [1]. A number of findings may further suggest cervical spine injury; these include other associated injuries above the clavicle, diaphragmatic breathing or apnea, flaccid areflexia including a flaccid rectal sphincter, a sensory level as demonstrated by facial gesturing in response to painful stimuli above the clavicles but not below them, and hypotension associated with a normal heart rate and warm extremities (spinal shock). Priapism, although unusual, is further suggestive of spinal injury.

Etiology

Spine injuries are common in the modern urban trauma setting [2]. Although rare, spinal cord injury (1.3% of all trauma patients) carries an extremely high rate of morbidity and mortality. There are about 11,000 new traumatic spinal cord injuries (SCIs) each year. The SCI population in the United States is about 240,000 and the cost of treating them is billions of dollars.

Although surgical techniques have dramatically improved and the ability to get spinal stability and alignment enable earlier rehabilitation of the patients, the neurological recovery and the 10-year survival of this population has not changed significantly over the years.

The etiologies of SCI are:

1. due to high-energy motor vehicle collisions (MVCs); most are thoracic and lumbar

2. high fall injuries; most are in the thoracolumbar zone

3. sports injuries, from diving or other head collisions; most are cervical

4. violence/penetrating trauma

5. other miscellaneous causes

Three other statistical points worth mentioning:

1. Male to female ratio for these injuries is 4:1, without any racial predisposition.

2. In sports accidents–related SCI, 92% resulted in quadriplegia as compared to 54% in MVC-related SCI.

3. The 10-year survival rate of patients beyond 30 years with SCI is about 50%.

Suspicion

All patients with significant blunt trauma are assumed to be at risk for cervical spine injury [3]. Inadvertent movement of the neck of a patient with an unstable cervical spine injury can lead to permanent neurologic disability or death. Accordingly, many trauma patients are transported to the ED in a stiff cervical collar and immobilized to a backboard. Though providing protection of the cervical spine, immobilization places the patient at risk for aspiration and ventilatory compromise.

If the patient requires airway management, precious time should not be wasted obtaining a single lateral radiograph of the cervical spine to exclude cervical spine injury. This approach delays definitive airway management and provides a false sense of security, as a single view is inadequate to exclude injury to the cervical spine.

Numerous studies have shown that the proper approach to managing these patients is RSI with in-line immobilization. Paralyzing the patient reduces the risk of patient movement during intubation. A second individual maintaining immobilization of the head and neck in the neutral position throughout the procedure prevents neck hyperextension during laryngoscopy.

Intubation

Cervical spine injuries are often associated with TBI (traumatic brain injury), so it would be good to remember to keep the patient in a cervical collar or inline stabilization up to the point of intubation. During intubation the collar can be removed while maintaining in-line cervical stabilization (usually by a specific individual not involved in the intubation) to prevent cervical spine movement [4]. Once the endotracheal tube has been confirmed and secured, a rigid cervical collar should be put back in place.

Rapid sequence intubation (RSI) with a short-acting paralytic and induction agent is the standard intubation technique for most trauma patients.  In exceptional patients, severe facial injuries may preclude oral intubation, in which case a surgical cricothyroidotomy should be performed to assure airway security.

The important principles to remember are to avoid hypoxia, hypercarbia, and hypotension, because these factors can significantly increase the morbidity and mortality of the head-injured patient.

Initial View

Unfortunately, on the initial lateral view of the cervical spine, only the first five or six cervical vertebral bodies are typically identified [1]. This must not be interpreted by the physician as a normal study. In fact, an initial view of the cervical spine in the injured patient that demonstrates only the more proximal vertebrae can be an explaining this is that injuries to the distal cervical cord leave the shoulder elevators unopposed; involuntary elevation of the shoulders in these patients thereby obscures radiographic demonstration of the more distal cervical vertebrae. Thus, the only acceptable initial study of the cervical spine is a lateral view in which all cervical vertebrae, including C7 and the C7-T1 interface, are well visualized. To this end, the x-ray technician frequently requires the assistance of the emergency department staff. Most often, if gentle but firm downward traction on the arms is applied, a satisfactory view may be obtained. If a second view is unacceptable, the swimmer’s view should be obtained and will demonstrate the most distal vertebrae. When the initial portable lateral view is normal, an anteroposterior, lateral, and open-mouth odontoid view of the cervical spine should be obtained in stable patients; if this is normal, immobilization of the neck may be discontinued and further evaluation of the patient’s injuries undertaken. When immediate surgical intervention for other injuries is not required and the above views of the spine are complete and normal, further radiologic assessment of the skull may proceed. The open-mouth odontoid view will significantly decrease the number of patients in whom the diagnosis of an important cervical injury is missed, and this should routinely be obtained before allowing unrestricted movement of the patient.

If any doubt exists after these initial studies as to the possibility of a significant cervical injury, or if a potentially unstable or significant cervical injury is demonstrated, immediate neurosurgical or orthopaedic consultation should be obtained. Computed tomography (CT) is another imaging modality that can be used; often, in the headand neck-injured patient, it is time-saving to scan rapidly through the head and neck. Recent studies have demonstrated there may be benefits of methylprednisolone in patients with acute spinal cord injuries; when this diagnosis is highly probable based on physical examination, patients presenting within 8 hours of injury may benefit from an initial intravenous bolus of 30 mg/kg, followed by 5.4 mg/kg/h for 24 hours. Patients treated in this manner may demonstrate improved neurologic status subsequent to the injury; patients presenting after 8 hours should be discussed with a neurosurgical or orthopaedic specialist. During this time, the patient should remain immobilized on a spine board to which the head has been secured utilizing a rigid or semirigid cervical collar (not a soft collar).

Orbital Injury

Thirty percent of all facial fractures involve the orbit, of which the majority affect the orbital floor, also referred to as a ‘blowout’ fracture [5]. The relatively thicker lateral and superior orbital rim provides firm support and protection, creating a weakness in the orbital floor, thus saving the globe from rupture.

Due to the serious nature of the mechanisms that result in orbital injuries, one must first exclude any neurologic injuries, which are prioritised over ocular injuries. Assess the patient in accordance to ATLS (Advanced Trauma Life Support) guidelines including full assessment of the cervical spine. Should there be suspicion of spinal injury, immobilise the patient and image the spine to exclude injury. There has been a move towards CT in most centres, and it provides an opportunity to scan the head, orbits, facial bones and cervical spine concurrently.

After intracranial and cervical spine injuries have been excluded, progress to a detailed ophthalmic assessment. Examination should assess visual acuity and colour vision, which reflect visual prognosis. Further examination should include globe position, eye movement, sensory examination of the supra- and infra-orbital nerve distribution, presence of a relative afferent pupillary defect (RAPD) and careful palpation of the orbital rim to note any step deformity. In open globe injuries with visible penetrating objects, it may be tempting to remove the object; however, avoid this as it may cause the globe to collapse.

The Seidel test is useful in the traumatic setting, especially to establish any occult open globe injuries. The test is conducted by instilling fluorescein onto the ocular surface. Using a cobaltblue light from a slit lamp, the aim is to see whether there is any aqueous humour leakage washing the fluorescein away – a waterfall appearance on a background of green fluorescein. In such cases, the test is considered positive and a sign of open globe injury. A negative Seidel test with a soft globe (malformed eye, collapsed cornea, intra-ocular pressure <10>

Pregnancy

Spinal cord injury (SCI) affects approximately 11 000 Americans each year and is associated with signifi cant loss of physical and personal independence [6]. Since 20 – 30% of these patients are women at an average age between 16 and 45 years at the time of injury, consideration must be given to their reproductive potential. While amenorrhea occurs in a majority of women following SCI, 90% return to normal menstrual cycles within 12 months of their injury. While 30% of these women will choose to use either temporary or permanent contraceptive methods secondary to the concern of possible pregnancy complications, many look forward to a rewarding life as a mother following their acute injury. A generalist obstetrician or subspecialist in maternal - fetal medicine may become involved as part of the team working to stabilize the pregnant patient in the critical first hours after an acute spinal cord injury, or managing the pregnancy, labor, and delivery of a patient years later when the sequelae of chronic spinal cord damage are present. Competent care in either setting requires the physician to be knowledgeable about the common and predictable complications specific to the acute and chronic forms of SCI.

A number of physiologic changes that occur in the pregnant patient can complicate intubation. There is significant capillary engorgement of the mucosa throughout the respiratory tract leading to swelling of the nasal and oral pharynx, larynx, and trachea, all of which can increase the challenge of intubating a patient involved in an acute spinal cord injury. Additionally, pregnant patients have a decreased functional residual capacity, thus decreasing their oxygen reserves. The initiation of tracheal protective procedures such as jaw - thrust, bag - valve - mask ventilation, and cricoid pressure, while necessary, can inadvertently cause movement of the cervical spine and subsequent damage if meticulous stabilization is not practiced.

Immobilization

Any patient with blunt force injury to the head should be suspected of having cervical spine injury until proven otherwise [7]. Penetrating injuries to the torso and extremities not associated with blunt force are rarely associated with cervical spine injury. Cervical spine injury is associated with 5% of all blunt force injuries to the head; the greater the force, the greater the incidence of associated injury. Immobilization of the cervical spine during transport of a patient with potential injuries must include an appropriately sized and fitted cervical collar, head blocks, and a long, rigid spine board to which the patient is secured. Immobilize the cervical spine during evaluation by manual stabilization and logrolling the patient.

The presence of a head injury is the strongest independent risk factor for injury of the cervical spine [8]. Suspect injury and immobilize the cervical spine in all patients with a GCS of <15>

The concern for damage to the cervical spine has been well publicized, so many bystanders are reluctant to perform even the simplest airway maneuvers for fear of litigation [9]. Secondary cervical injury is that which occurs after the initial insult but is caused not only by further movement but also hypoxia. Attention should be paid at all times to consideration of a potential cervical spine injury, but the priority in management is adequate airway care, which may on occasion override absolute immobilization of the neck. If cervical movement is required to open an obstructed airway, then this must be the minimum movement possible to allow airway clearance. The head should be held immobilized by one member of the rescue team with one hand on either side of the head and ideally supported on a hard surface. It should be remembered that the person holding the head will be unable to perform other tasks and therefore should not be the most experienced team member. A semi-rigid cervical collar should be applied, although this does not provide complete immobilization and may worsen intracranial pressure. Additional support from blocks and tape will also be needed at the earliest opportunity, although they may not provide complete support. A useful technique during resuscitation of the supine trauma patient is to support the head between the knees of a kneeling rescuer, thus freeing the rescuer’s hands. Occasionally a patient in very critical condition may warrant minimal cervical spine protection in the first few moments of a rapid extrication. In this case, immobilization must be applied at the earliest opportunity.

Children

In children, the aims of head injury management are much the same as for adults – preventing secondary brain injury [10]. Hypoglycaemia may be a feature and requires prompt treatment. The cerebral perfusion pressure must be adequate and body temperature kept normal. Cervical spine injuries are rare but if present are often high and may be devastating. When immobilizing a child on a spinal board it may be necessary to pad the shoulders to obtain neutral alignment of the head and neck if not using a paediatric board. Adult long leg vacuum or box splints provide ideal immobilization devices for infants and small toddlers. Combative children are difficult to manage. They must not be forcibly restrained but should receive manual immobilization of the head and neck along with reassurance and adequate analgesia. Parental involvement may help.

Cervical spine injury is relatively uncommon in children, but keep the whole spine immobilized until history, examination X-rays exclude injury [11]. Injuries in children tend to involve upper (C1–3 level), rather than lower cervical spine. Remember that rotatory subluxation may cause signifi cant cervical spine injury without fracture: the clue is combination of injury, neck pain and torticollis. Interpretation of cervical spine X-rays in younger children is frequently complicated by pseudo-subluxation of C2 on C3 and of C3 on C4. If in doubt, continue immobilization and obtain an expert opinion.

The paediatric spine is inherently more elastic so momentary intersegmental displacement may endanger the cord without disrupting bones or ligaments. This can result in spinal cord injury without radiological abnormality (SCIWORA). Usually there are objective signs of injury, but these can be delayed. Therefore, if children present with transient neurological symptoms after neck injury, make sure you assess them carefully. Exclusion of significant injury requires an alert child with normal spinal and neurological examination with no painful distracting injuries and normal radiology (rarely the case for the seriously injured child).

Airway

The establishment of an adequate airway has the highest priority in the primary survey [12]. Oxygen by high-flow nasal cannula (10-12 L/min), 100% nonrebreather mask, or bagmask ventilation with pulse oximetry should be started if not already in place. Maneuvers used in the trauma patient to establish an airway must consider a possible cervical spine injury. Any patient with multisystem trauma, especially those with an altered level of consciousness or blunt trauma above the clavicles, should be assumed to have a cervical spine injury. The rapid assessment for signs of airway obstruction should include inspection for foreign bodies and facial, jaw, or tracheal/laryngeal fractures that may result in acute loss of airway patency. Techniques that can be used to establish a patent airway while protecting the cervical spine include the chin lift or jaw thrust maneuvers.

Patients who can communicate verbally without difficulty are unlikely to have an impaired airway. Repeated assessment of airway patency is always prudent. Those patients with severe head injury, altered level of consciousness, or Glasgow Coma Scale (GCS) score 8 or less usually require placement of a definitive airway. Orotracheal or nasotracheal intubation can be attempted with cervical spine precautions if a second person maintains axial immobilization of the head to prevent destabilization of the spine. If ventilatory failure occurs and an adequate airway cannot be obtained readily by orotracheal or nasotracheal intubation, surgical cricothyroidotomy should be performed as rapidly as possible.

CT

Radiographic plain films of the chest and pelvis are required in all major injuries [12]. Lateral C-spine films have been supplanted by formal CT scanning of the neck in patients with suspicion of or mechanism for cervical spine injury. Bedside focused assessment with sonography for trauma (FAST) is the preferred triage method for determining the presence of hemoperitoneum in blunt trauma patients or cardiac tamponade in blunt and penetrating trauma patients. The presence of hemoperitoneum in an unstable patient on FAST may be an indication for exploratory laparotomy. Presence of hemoperitoneum in a stable patient or a negative FAST in a patient with abdominal pain is indication for further evaluation with abdominal CT scan.

Patients who have an abnormal chest radiograph with a mechanism for blunt aortic injury should undergo further screening with either helical chest CT done at the time of abdominal imaging or with aortography, if necessary. Cervical spine CT scans should be obtained for patients who are unconscious, have pain in the cervical region, have neurologic deficits, or have painful or distracting injuries. CT scanning of the head should be performed in all patients with loss of consciousness or more serious neurologic impairment. Radiographs of the long bones and noncervical spine can usually be deferred until the more critical injuries of the thorax and abdomen have been delineated and stabilized.

The main signs of a spinal cord are inconspicuous, with the neurological function above the injury being normal and below the level absent or markedly reduced. Specific manifestations depend on the exact level of injury and whether the injury is complete or partial. Spinal cord injury, like other fractures and sprains, is typically painful, and patients more preoccupied with other painful injuries or whose level of consciousness has been altered by intoxication or head injury do not have to complain of pain. Bone injuries include fractures and sprains. Fractures can affect the body, surfaces, pedicles, and spinous and transverse extensions. Dislocations typically affect surfaces. Subluxation is a rupture of a ligament without bone injury. In the neck area, posterior fractures and dislocations can damage the vertebral arteries, causing a stroke-like syndrome.