C-Spine Injury

C-spine injury in trauma patients.
Suspect in any patient with injury above the clavicle.
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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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Mechanisms (one or combo)

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

By Anatomical Site
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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Pain / tenderness
Specific to type as above.
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How to read a C-spine film

Depends on classification (see spinal trauma)
And specific type of # as above.
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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.


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.
--> 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.


* 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


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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