Approach
Diagnostic workup of patients following acute cervical spine trauma can reveal a range of injuries ranging from potentially life-threatening, highly unstable bony and ligamentous injuries through to minor soft-tissue sprains (whiplash). Treatment is highly dependent on the exact symptomatic and radiographic presentation, and can range from emergency surgical decompression and/or fixation, to rigid immobilization in a halo or semi-rigid immobilization in a collar, to physical therapy and analgesia.
Pain management is an urgent priority in the care of patients with acute spinal cord injury (SCI). Various types of pain from nociceptive somatic and visceral to neuropathic pain can be experienced due to spinal column injury, or from destruction of soft tissues, expansile hematoma and other local host tissue inflammatory response. Following C-spine clearance, the majority of patients with acute cervical spine trauma can be successfully managed with range-of-motion exercise and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Many patients' symptoms will resolve after a few days to a week of NSAID therapy. Those patients who do not improve rapidly, however, should be treated algorithmically, as described below, without delay.
Immediate management
All trauma patients should be evaluated based on the principles of Advanced Trauma Life Support®, independent of whether a spinal cord fracture or SCI is suspected or confirmed.[14] Any patient with acute neck pain following trauma and an altered neurological status should be considered at risk of acute cervical spine injury until a complete assessment is performed.
The primary survey should focus on hemorrhage control, airway, breathing, circulation, disability, and exposure; the <C>ABCDE approach.[26] Cervical and thoracolumbar spinal motion restriction should be maintained throughout this phase, until the spine is further evaluated during the secondary survey.[14] The primary goal during the "disability" evaluation, after assessing the Glasgow Coma Scale (GCS) score and pupillary response, is to identify any lateralizing signs by conducting a rapid assessment of motor function and reflexes in the extremities.[14] The secondary survey aims to obtain a full and detailed history and physical examination after completion of the primary survey, and the patient is deemed to be stable and have no life-threatening injuries.[14] After using appropriate clinical decision rules and assessing risk for spinal cord fracture or SCI during the primary and secondary survey, patients at risk for spinal trauma should be further evaluated with dedicated imaging studies.[14] See Diagnosis approach.
The patient's management thereafter will be determined by the findings on examination and imaging, and the injury will be managed either as an uncomplicated neck injury or a complicated injury requiring emergency neurosurgical intervention. Potentially emergent cervical injuries include fracture, dislocation, disk herniation, and other injury patterns associated with a higher probability of either sustained or potential neurological injury.
Uncomplicated neck injury
Uncomplicated cervical spine injuries typically do not involve neurological symptoms. These injuries most often resolve spontaneously or with a minimum of conservative therapy (physical modalities such as physical therapy, range-of-motion exercise, and NSAIDs), typically within 3 months.[14] Improvement with conservative care should be reevaluated after 4 weeks. Short-term (1-2 weeks) opioid analgesics may be helpful for patients with moderate- to high-intensity pain.[14] Patients can be treated with tramadol, hydrocodone or oxycodone plus acetaminophen. The treating physician should consider imaging any patient with pain out of keeping with the mechanism of injury, with, for example, CT scans and flexion-extension x-rays of the cervical spine.
Restoration of normal motion to the spine is of great importance, so cervical collars are largely counterproductive and typically contraindicated, as is bed rest. Exercise to tolerance is important for supportive therapy. Referral for physical therapy should be considered. Physical modalities include home ROM exercises to tolerance (should not cause pain). The patient should be reevaluated for progress from physical therapy after 4 weeks. Conditioning exercises are contraindicated until pain levels drop. If the patient is unable to participate in active rehabilitation due to pain, a consultation with a neurologist or other pain specialist is warranted.
Patients may have no diagnosis beyond neck strain; however, their condition may be complicated by comorbidities or other injuries sustained simultaneously. Most common are other musculoskeletal symptoms including: lower back pain, upper-extremity joint pain, and temporomandibular joint pain, each of which are associated with a traffic crash mechanism of rear-impact collision with whole-body accelerations. Headache with no other neurological symptoms can be associated with the following: closed head injury, irritation of the greater occipital nerve, cervical facet injury (C2-4 most typically), or cervical muscle tension. Patients with symptoms of closed head injury should be monitored for difficulty with activities of daily living, work activities, and relationships. If complaints persist for >2 months, patients should be referred for neuropsychological evaluation. A head strike or loss of consciousness is not required for a diagnosis of a closed head injury or mild traumatic brain injury (mTBI). Symptoms can be exacerbated and possibly caused by pain, opioid analgesic use, and psychological trauma related to a crash. Symptoms can also be exacerbated by issues related to the potential for compensation (although all physical and psychological problems must be ruled out first before suspecting this). Most mTBIs resolve spontaneously within a few months of the trauma, but some will persist.
Neck injuries with high probability of neurological injury following initial assessment
Potentially urgent cervical injuries include fracture, dislocation, disk herniation, and other bony injury patterns associated with a higher probability of either sustained or impending neurological injury. The patient's neck should be immobilized pending urgent evaluation and diagnosis by history, clinical evidence of upper motor neuron lesion, and CT scan or MRI. A rigid backboard should be used for transport only and every effort may be made to remove the board as soon as possible.[26] The neurological evaluations should be followed by classification according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), which was proposed by the American Spinal Injury Association (ASIA). ASIA: International standards for neurological classification of SCI (ISNCSCI) worksheet Opens in new window
These patients may present similarly to those with uncomplicated neck injuries, but will typically have signs or symptoms of myelopathy or radiculopathy. The ongoing management of these patients may require medication, therapeutic modalities, and supportive care, depending on the fracture type and patient factors, including age.[14] Occipital condyle fractures without neural compression or cranio-cervical misalignment can be managed successfully with a rigid or semi-rigid cervical orthosis.[14][60]
If there is a rapid onset of paresis and a potential delay in specialist consultation, treatment with intravenous methylprednisolone should be considered. High-dose methylprednisolone has been shown to be the only efficacious pharmacologic option when administered within 8 hours of injury in the context of acute SCI.[61][62] Although studies have identified a subgroup of patients who demonstrated better motor scores after receiving methylprednisolone within 8 hours of injury compared with placebo, side effects included infection, gastrointestinal bleeding, hyperglycemia and death.[61] The American College of Surgeons state that the use of methylprednisolone within 8 hours following SCI cannot be definitively recommended.[14] Where is it used, there is variability in the decision to administer methylprednisolone and which specific protocol to use.[14][63] In the context of the controversial role of corticosteroids in SCI, the use of methylprednisolone should be considered on an individual basis. It remains an option for patients presenting within 8 hours of nonpenetrating SCI in the young, nondiabetic, and immunocompetent patient population. If there is a penetrating SCI, then methylprednisolone should not be administered.[14] Furthermore, the infusion of methylprednisolone should not exceed the 24-hour period given the increased risk of adverse events such as pneumonia and sepsis.[62] Therefore, it is important that medical comorbidities are taken into account prior to initiating treatment. For example, the risks of administration may outweigh the benefits in a patient with diabetes mellitus and a complete thoracic SCI. Blood glucose levels must be carefully monitored during the course of methylprednisolone therapy, and hyperglycemia aggressively managed with an insulin infusion.
If specialist consultation within the institution is not available, prompt phone consultation with a suitable specialist (neurosurgeon or spine-trained orthopedic surgeon) is required. The important information to relay in this consultation is a complete history, physical examination (including neurological examination), and results of any imaging tests. The treating physician should ask about:
The use of methylprednisolone
Reversal of anticoagulation (should the patient be taking such medications)
The requirement for emergency transport to a specialized center.
Timing for surgical decompression has been a topic of controversy within the spine community. AOSpine 2017 guidelines concluded that early decompression (≤24 hours after injury) for adult patients presenting with SCI irrespective of level should be offered, although the quality of evidence for the recommendation was low.[64] In a meta-analysis, patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury, as measured by an improvement in total motor scores, light touch scores, and pinprick scores. Patients who had early decompression also had better ASIA Impairment Scale (AIS) grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery.[65]
Trauma in the arthritic spine
Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are associated with unique fracture patterns and management paradigms after spinal trauma. AS is a seronegative enthesopathy occurring more commonly in men, with onset typically before ages 40 years. Imaging demonstrates a "bamboo spine" with multilevel bridging syndesmophytes and squaring of the vertebral bodies. Hyperextension-distraction fractures resulting from minor trauma can produce severe SCI requiring urgent decompression and long-segment instrumented fusions. Key to early management is immobilization of patients in their own natural position to prevent further injury, followed by urgent surgical consultation.
DISH manifests in the spine as bony bridges fusing the anterolateral aspects of 4 or more vertebral bodies along the anterolateral ligament. Fractures may occur adjacent to a fused segment or within the fused segment involving a vertebral body. A retrospective review of 112 patients with AS- or DISH-related fractures found that the most common mechanism (39%) was ground-level falls; 8% also had 2 or more noncontiguous segments involved, highlighting the importance of ruling out concomitant injuries.[66]
Trauma in the aging spine
Unique challenges exist in managing spine trauma in the older adults (>65 years old). Central cord syndrome (CCS) is the most common subtype of incomplete traumatic SCI. It is defined by cruciate weakness (upper extremities worse than lower extremities) and a variable pattern of sensory loss and bowel/bladder dysfunction. While most commonly seen in older adults with pre-existing cervical canal stenosis and hyperextension injuries, CCS may also occur in other populations with acute fractures and disc herniations.
Historically, the role of early surgical decompression in CCS has been unclear given the substantial spontaneous recovery commonly seen with this subtype.[67] The Spine Trauma Study Group found that, at 12-month follow-up of an observational dataset, early decompression (<24 hours after injury) was associated with an increased likelihood of improvement in AIS grade (OR=2.8) compared with late surgery, and that those in the early surgery group experienced a 6.3 point improvement in total motor score. Early surgical intervention is further supported in the 2017 AOSpine guidelines.[64]
Patients with fractures and CCS should be definitively treated through internal and/or external immobilization in consultation with a surgical service. For less severe deficits (AIS grade D), an initial conservative approach with close clinical follow-up is appropriate, reserving the option to surgically decompress depending on the extent and temporality of recovery.[68]
The most common cervical spine fractures in older adults are odontoid fractures, which are often caused by low-energy falls. Divergent views exist regarding operative versus nonoperative (e.g., rigid collar, halo) treatment.
Type I (tip of the dens) fractures are rare and typically treated with a collar after ruling out associated transverse atlantal ligament (TAL) injuries or atlantooccipital dislocation. Type III fractures may be treated with either a halo vest (TAL intact, not significantly displaced and stable in a halo) or surgery (anterior odontoid screw or posterior fusion). Type II fractures are the most common type and are treated similarly to type III fractures with a halo or surgery; however, halo vests are associated with substantial morbidity and mortality in older adult patients.
A study of geriatric patients with type II odontoid fractures treated surgically (n=101) or nonsurgically (n=58) found greater treatment failure with older age (OR=1.08/year), initial nonsurgical treatment (OR=3.09), male sex (OR=4.33), and baseline neurological system comorbidity (OR=4.13).[69] As a result, upfront surgical intervention is now considered a reasonable approach in older adults who would otherwise be treated in a halo. If the surgical risk is too high, a rigid collar and close clinical and radiographic follow-up may be a reasonable approach to achieve a fibrous nonunion across the fracture site while sparing the morbidity of a halo.
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