Approach to blunt traumatic cervical spine injuries: Clinical sciences

Blunt traumatic cervical spine injury is an injury to the bone, discs, muscle, ligaments or spinal cord of the c-spine. It commonly occurs from flexion-extension injuries from motor vehicle collisions, and compression injuries from falls or contact sports. The cervical spine is particularly vulnerable to these mechanisms of injury because of its mobility and exposure.

Anatomically, the c-spine is made of 7 vertebrae starting from C1, or atlas, which attaches to the base of the skull to C7, also known as the vertebra prominens, located at the base of the neck connecting to the thoracic spine. C1 and C2 are often referred to as cranio-cervical spine, while C3 to C7 are known as the subaxial c-spine. Any injury to the cervical spine can result in deficits below the level of injury.

Alright, your first step when evaluating a patient with a blunt cervical spine injury is to perform a primary survey by assessing their ABCDE. First, stabilize their spine with a rigid c-collar and lay the patient on a flat board for spine immobilization. If a c-collar is not available, manually stabilize the neck to prevent movement of the spine and potentially to prevent further damage of the spinal cord.

Then you can move on to the rest of the ABCDEs. Evaluate and secure the airway as soon as possible. The big concern here is the injury of the phrenic nerve, which originates at C3 through C5 spinal nerve roots. Any injury at this level or above prevents breathing due to diaphragm paralysis.

Now, when intubating these patients, you need to be very careful. When the cervical spine is injured, you cannot tilt the head and lift the chin to intubate. Use a jaw thrust instead! Keep in mind that patients with phrenic nerve injury might need a surgical airway like tracheostomy and mechanical ventilation.

Next, check for breathing and ensure adequate ventilation by providing supplemental oxygen. Then, obtain two large bore IVs or an intraosseous line and start fluid resuscitation while continuously monitoring vital signs. Then, assess disability, or neurologic status, by calculating the patient’s GCS. Lastly, expose the patient by removing all clothing and bandages to ensure no injuries are missed. After examining the patient, make sure to place a warm blanket over them to avoid hypothermia.

Once you’ve completed the primary survey and stabilized the patient, you can move on to the secondary survey. Which includes history and physical exam. Also, order adjunctive tests like trauma labs which include type and screen, CBC, CMP, lactate, pregnancy test, urinalysis, and urine toxicology screen.

Finally, obtain imaging, meaning plain lateral neck x-ray or CT of the cervical spine. Even though x-ray is no longer recommended due to low sensitivity, it is still done in some places, especially if the CT is unavailable.

History usually reveals a similar mechanism of injury in most cervical spine injuries, including flexion-extension injury, direct hit to the head with an object, or high impact injury due to a fall from a high height. As for the physical exam, you will typically find neck tenderness at the level of injury, bruising, neck spasm, and sometimes neurologic deficits like quadriplegia or loss of rectal tone.

Here’s a clinical pearl! When dealing with patients with altered mental status, especially if they are under the influence of substances, you can’t really rule out cervical spine injuries.

Instead, you should act like they have c-spine injury, so keep the c-collar on and lay the patient on a flat board. However, if there is a concern for vomiting, bleeding, or aspiration, they should be log-rolled to the side, suctioned, and possibly intubated.

Okay, let’s begin our discussion at the top of the cervical spine starting with atlanto-occipital dislocation. This is a highly unstable, life-threatening injury as the dislocation allows the skull to move independently from the spinal column causing a severe damage to the brainstem.

On exam, you can expect to find signs of neurogenic shock and quadriplegia. Because this injury is high, the patient will have no diaphragm motion, so they need to be intubated. The imaging of C1 and C2 will likely reveal a dislocation or dissociation of the atlas, or C1, from the occiput confirming your diagnosis of atlanto-occipital dislocation.

Here’s another clinical pearl! Neurogenic shock occurs from spinal cord injury above T6 leading to loss of peripheral vasomotor tone. It presents as hypotension that is unresponsive to fluids; and bradycardia from the loss of sympathetic innervation to the heart.