C-Spine Injury

DEFINITION
C-spine injury in trauma patients.
Suspect in any patient with injury above the clavicle.
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INCIDENCE
Up to 15% of pts with blunt polytrauma.
Injuries of head and neck are associated 1/3 of the time.
Presence of head injury confers RR for spinal injury of 8.5.
- and may prevent good examination.

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AETIOLOGY
Trauma.
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BIOLOGICAL BEHAVIOUR

Mechanisms (one or combo)

1.  Axial loading
2.  Flexion
3.  Extension
4.  Rotation
5.  Lateral bending
6.  Distraction

By Anatomical Site
Note
Low incidence of survivorship amongst pts with upper c-spine injury (above C3).
1/3 of upper c-spine injured pts die at the scene.
C2 is a vulnerable bone due to unusual shape and large size - 18% of all c-spine injuries.

Atlanto-occiptal dislocation

Uncommonly seen though account for 19% of fatal c-spine injuries.
Result from severe flexion and distraction.
Most die of branstem destruction or have lower C-spine neuro deficit.
Spinal immobilisation recommended initially.

Atlas # (C1)
5% of c-spine injuries.
40% associated with C2 #s.
Most commonly Jefferson burst # from axial loading.
- ie disruption of ant/post rings of C1 & displacement of lateral masses.
Best seen on open-mouth C1-2 view; can be confirmed by CT.
If pt survives & seen in ED, usually no spinal injury.
Unstable - treat with a collar.
- unilateral #s also occur and more stable, but treat as unstable until seen by ortho/neuro.

C1 Rotary Subluxation
Most often inchildren.
Can occur after trauma, upper resp infx or with RA.
Presents with persistant head rotation.
Seen on open mouth odontoid view - odontoid not equidistent from lateral masses.
Immobilise and refer for specialist treatment.

C2 Odontoid #
- the odontoid projects up, normally in contact w/ ant arch of C1.
60% of C2 #s are odontoid.
Often identified by lat or open mouth but usually need C2 for deliniation.
Type 1: Tip of odontoid, uncommon, stable.
Type 2: Base of dens, most common (NB in <6 yrs, epiphysis here may look like a #).
Type 3: Base of dens and into body of axis.

C2 Posterior Element
Hangman's # - 20% of axis #s.
Extreme extension.
Unstable - external immobilisation.
- variations through lateral masses or pedicles.

C2 Other
20% occur elsewhere in C2.

#s and Dislocations C3-C7
C3# is very uncommon as between vulnerable axis and relative fulcrum at C5-6.
C5 is most common site of #
C5-6 is most common site of subluxation.
- usually vertebral body #s +/- subluxations, articular process subluxation, and #s of laminae, spinous processes, pedicles or lateral masses.
- rarely ligamentous disruption wihout #s or face dislocation.
Neurological injury much higher in facet dislocation.
- 80% of unilateral facet dislocations (30% root injury, 40% incomplete, 30% complete).
- 100% of bilateral locked facets (16% complete, 84% incomplete)

Other pathophysiology
Refer spinal trauma card.
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MANIFESTATIONS

Trauma
Pain / tenderness
Specific to type as above.
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INVESTIGATIONS

XR
How to read a C-spine film

Depends on classification (see spinal trauma)
And specific type of # as above.
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MANAGEMENT
Assume injury until proven otherwise.
Spinal immobilisation aims to avoid displacing potentially unstable spinal injuries.
- before modern trauma management, missing diagnoses of spinal injuries increased risk of permenant neurological sequelae 10 times.

ATLS GUIDELINE

See spinal trauma general management.

1.  Para / quadraplegia

Presumptive evidence for injury.

2.  Awake, alert, sober, no neck pain, neuro normal
Acute #/subluxation extremely unlikely
Remove collar with pt supine.
Palpate
--> if no tenderness have pt move head side-to-side.
--> if no pain c-spine films are not mandatory.

3.  Awake, alert, neuro normal, neck pain
Lateral, AP, open-mouth XRs.
- lateral alone has 85% sensitivity, increased to 92% with other views.
- 97% sensitive for unstable injury if good quality and properly interpreted.
--> if normal, remove collar.
--> observed, obtain a lateral flexion XR.
--> if no subluxation, c-spine cleared.
If any level in question,  CT scan (axial at 3mm intervals) through appropriate levels.
10% of pts with a c-spine injury will have another spinal # - and vice-versa.
Flexion extension views may show undetected ligamentous injury
- often such pts have marked paraspinal muscle spasm, do not force the neck painfully (all movement should be voluntary); redo after 2 weeks in a Philadelphia collar.
- contraindications included altered sensorium, subluxation, any neuro deficit.
- done under control and supervision of a knowledgable doctor.
- CT should be done of any suspect areas first.
MRI is preferrable if any neuro deficit is present.
- detects compressive lesions or herniated discs that films can't visualise.
- not in the unstable pt.
- on the basis of specialist advice

4.  Comatosed, decreased LOC, very young
Lateral, AP and open-mouth when possible.
If entire spine viewed and normal, remove after evaluation by a neuro/orthopaedic surgeon.

Tips

* When in doubt, leave collar on.

* Consult neuro/orthopaedic service when spine injury detected or suspected.

* Backboards - remove as soon as possible: >2hrs can leave decubiti.

* Never force the neck - voluntary movements are generally safe.

* In emergencies - clerance of the c-spine is not a priority, but stabilisation of the c-spine through everything else remains a top priority.

What to look for on XR

BMJ REVIEW GUIDELINES

Conscious
Regard spine as stable if ALL of:
1. GCS 15, alert and oriented
2. No intoxicant taken.
3. No serious distracting injuries
4. No signs or syptoms of cervical injury: eg midline tenderness / pain, impaired ROM, neurolgical deficit.
Mobilise under close supervision.

Impaired Consciousness
Spinal injury cannot be exlcluded clinically.
Can either:

1.  Immobilise until consciousness returns
- this has serious complications if prolonged
- removal of immobilisation should be a priority.
- risk of still missing injury clinically perhaps 2%
- appropriate if non-intubated / non-ICU pt, who will not have prolonged immobilisation.

2.  Rely on imaging
Do all of this in any ICU or intubated patient:
- three view cervical (AP, lateral, open mouth if possible)
- must visualise entire C-spine; if 7th jx not seen, get a swimmer's view.
- thoracolumbar AP
- high-res CT (1.5-2mm) craniocervical jx and other suspicious / inadequate areas.

It was traditionally thought ligamentous injuries may be missed with this regiment.
- modern studies show sensitivity >99%.
- probably 99.9% (level 2-3 evidence).
- several large studies support this (BMJ review)
- MRI equally sensitive but unnecessary.
- ideally CT entire C-spine at high-res (no. needed to investigate 8-22 forfurther injury; level 2-3 evidence).

Dynamic XRs (flexion/extension views) are unnecessary
- do not add significantly to sensitivity - already high.
- no. needed to investigate is >500 for 1 further injury.
- false negative (0.33%) near twice as common as true positive.

Myths are widespread:
- >12% of clinicians think XR alone excludes cervical injury (it doesn't).
- >12% of clinicians will clear an unconscious pts c-spine with plain lateral XR (they shouldn't as sensitivity only ~85%).

Complications of Prolonged Immobilisation
Ignored at peril
- 60% orthopaedics specialists think this is of no concern (it certainly is).
Pressure ulceration.
- occurs in 55%, esp after 48 hrs.
- massive morbidity problem if occurs
Elevated ICP
- via venous obstruction
- may worsen brain injury
Difficult airway
- loss of patency
- failed intubation
Difficult CVL access
Mouth access
- poor oral hygeine, risk of septic focus
- difficult enteral nutrition
GI effects
- reflux, aspiration promoted.
Immobility risks
- restricts physio
- risk of DVT



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