Axial load injuries occur when vertical compression

forces shatter the ring-like structure of a cervical vertebra,

resulting in an outward burst of bony fragments. These

injuries require disruption of all 3 columns and are

clinically unstable. Burst fractures of Cl (Jefferson frac ­

ture) are relatively common and highly unstable.

Table 86-1 . Sta bil ity of cervica l spine injuries.

Flexion

Anterior subluxation (hyperflexion sprain) (stable)*

Bilateral interfacetal dislocation (unstable)

Simple wedge (compression) fracture (usually stable)

Spinous process avulsion (clay-shoveler's) fracture (stable)

Flexion teardrop fracture (unstable)

Flexion-rotation

Uni lateral interfacetal dislocation (stable)

Pillar fracture

Fracture of lateral mass (can be unstable)

Vertical compression

jefferson burst fracture of atlas (potentially unstable)

Burst (bursting, dispersion, axial-loading) fracture (unstable)

Hyperextension

Hyperextension dislocation (unstable)

Avulsion fracture of anterior arch of atlas (stable)

Extension teardrop fracture (unstable)

Fracture of posterior arch of atlas (stable)

Laminar fracture (usually stable)

Traumatic spondylol isthesis (hangman's fracture) (unstable)

Lateral flexion

Uncinate process fracture (usually stable)

Injuries caused by diverse or poorly understood mechanisms

Occipital condyle fractures (can be unstable)

Occipitoatlantal dissociation (highly unstable)

Dens fractures (type II and Ill are unstable)

''Usual occurrence. Overall stabil ity is dependent on integ rity of

the other ligamentous structures.

Reprinted with permission from Baron B), McSherry KJ, Larson, J r.

JL, Scalea TM. Chapter 2SS. Spine and Spinal Cord Trauma. In:

Tintinalli JE, Stapczynski JS, Cline OM, Ma OJ, Cydulka RK, Meckler

G O, eds. Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York: McGraw-Hill, 201 1.

Any significant trauma to the spinal cord generally

occurs at the time of the initial injury. Although individual

injuries will frequently exhibit unique neurologic findings,

several classic syndromes have been described. The central

cord syndrome occurs with hyperextension mechanisms,

typically in elderly patients with severe spinal stenosis. It

presents with motor weakness that is more pronounced in

the upper extremities as compared with the lower. The

anterior cord syndrome occurs with hyperflexion mechanisms and results in motor and sensory loss below the level

of injury with preservation of position and vibratory sense

(located in the posterior columns). The Brown-Sequard

syndrome most commonly stems from a penetrating

injury that hemisects the cord. Classic findings include the

ipsilateral loss of motor function and position and

CHAPTER 86

vibratory sensation combined with the contralateral loss of

pain and temperature sensation distal to the lesion.

Spinal cord injury without radiologic abnormality

(SCIWORA) is seen in pediatric patients and should be

considered in all patients with neurologic findings despite

negative initial plain film or computed tomography (CT)

imaging. Magnetic resonance imaging (MRI) may reveal

significant pathology, including ligamentous injury, intracordal edema, and hemorrhage.

CLINICAL PRESENTATION

� History

Try to determine the exact mechanism of injury, as this may

help predict the overall severity of pathology ( Table 86-2).

Inquire about the presence of neck pain and any neurologic

complaints, including weakness, paresthesias, and the loss

of bowel or bladder function. Review the patient's past

medical history for relevant comorbid conditions, including rheumatoid arthritis, ankylosing spondylitis, or c ervical

degenerative joint disease.

Table 86-2. Patients at high risk for cervical spine injury.

Injury mechanism

Primary clinical

assessment

High speed (>35 mph or 56 kph combined

impact) motor vehicle crash

Motor vehicle crash with death of an occupant

Pedestrian struck by moving vehicle

Fall from height >10 ft or 3m

Significant or serious closed head injury*

Neurologic symptoms or signs referable to

the cervical spine

Pelvic or multiple extremity injuries

Additional information Intracranial hemorrhage seen on CT

,

.

,The definition of sign ificant or serious head injury is subjective,

but may include intracranial hemorrhage, parenchymal contusion,

skull fracture, or persistent altered level of consciousness or

unconsciousness.

Reprinted with permission from Ba ron BJ, McSherry KJ, Larson, Jr.

J L, Sca lea TM. Chapter 255 . Spine and Spinal Cord Trauma. In:

Tintinalli J E, Stapczynski JS, Cline OM, Ma OJ, Cydulka RK, Meckler

G O, eds. Tintina/lis Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York: McGraw-Hill, 201 1.

� Physical Examination

As with all trauma patients, perform an initial primary

survey and address all emergent life-threatening conditions.

Immobilize all patients with any suspicion for cervical

spine injury by applying a hard cervical collar. Visually

inspect the spine for any signs of trauma, including

abrasions, ecchymoses, open wounds, and deformity,

and carefully palpate for any focal tenderness or bony stepoffs. Keep in mind that the presence of alterations in men ­

tal status (eg, intoxication of head injury) or distracting

injuries ( eg, significant extremity fractures) may render the

physical exam unreliable. Perform a thorough neurologic

exam, including an assessment of strength, sensation

(including light touch and proprioception), deep tendon

reflexes, and rectal tone. The bulbocavernosus reflex can

be used to differentiate between complete and incomplete

SCI. With a gloved finger in the rectum, gently squeeze the

glans penis or the clitoris with your opposite hand. The

involuntary contraction of the anal sphincter indicates a

positive reflex and rules out a complete SCI.

DIAGNOSTIC STUDIES

� Laboratory

There are no laboratory tests specific for the diagnosis and

management of cervical spine injury.

� Imaging

A standard 3-view series of the cervical spine

(anteroposterior [AP] , lateral, and odontoid views) has

been the historical standard to rule out cervical spine

injury. Recent evidence has questioned the sensitivity of

these films, and most patients with a moderate to high

likelihood of cervical spine injury warrant noninfused CT

imaging (sensitivity for bony injury >95%). Plain films are

generally adequate for pediatric patients and young

otherwise healthy adults with a very low pretest probability

for injury. The entire cervical spine extending from the

occiput to the top of Tl must be visualized to consider the

imaging adequate when reviewing plain films (Table 86-3

and Figures 86-2 through 86-7). MRI is the study of choice

in all patients with neurological deficits and those with

presumed unstable ligamentous injuries.

Table 86-3. Key to interpretation of cervical spine radiographs.

Radiograph

lateral (Figure 86-2)

AP

Open mouth (odontoid)

Alignment

Anterior middle and posterior arcs,

posterior laminar line and predental

space (Figures 86-3 and 86-4)

Spinous processes should be in a

straight line (Figure 86-6)

lateral margins of C1 should align with

lateral margins of C2 (Figure 86-7)

Bones

Vertebrae and spinous process

uniformity and height

Interspinous process distance

should be equal (Figure 86-6)

Space on each side of odontoid

should be equal. Inspect

odontoid for fractures

Cartilage

Intervertebral disk

space and height

Soft Tissue

Prevertebra I soft tissue

width (Figure 86-5)

CERVICAL SPINE I NJURI ES

Spinous

process

Facet joint

Figure 86-2. Normal lateral C-spine. Reprinted with

permission from Bail itz J, Bokhari F, Sca letta TA, et al.

Emergent Management of Trauma. 3rd ed. New York:

McGraw-Hill Education, 201 1.

Anterior

Posterior

contour

line

A. Figure 86-3. Normal alignment of lateral C-spine.

The anterior and posterior vertebral bodies should line

up to with in 1 mm. The spinolaminar line can be

traced through the base of the spinous process of each

vertebra. Repri nted with permission from Bail itz J,

Bokhari F, Sca letta TA, et al. Emergent Management of

Trauma. 3rd ed. New York: McGraw-Hill Education,

201 1.