Approach to blunt traumatic cervical spine injuries: Clinical sciences

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Introduction0:00–1:09

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 seven vertebrae starting from C one or ATLAS which attaches to the base of the skull to C seven, also known as the vertebra prominence located at the base of the neck connecting to the thoracic spine.
C one and C two are often referred to as cranial cervical spine. While C three to C seven are known as the subaxial C spine.
Any injury to the cervical spine can result in deficits below the level of injury. All right.

Primary Survey1:09–3:09

Your first step when evaluating a patient with a blunt cervical spine injury is to perform a primary survey by assessing their ABCD E first stabilized their spine with a rigid sea collar and lay the patient on a flat board for spine immobilization.
If AC 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 ABCD ES evaluate and secure the airway as soon as possible.
The big concern here is the injury of the phrenic nerve which originates at C three through C five 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 patients 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.

Secondary Survey3:09–4:56

Also order adjunctive tests like trauma labs which include type and screen CBCC MP, 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's 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 a 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's concern for vomiting, bleeding or aspiration, they should be log rolled to the side, suctioned and possibly intubated.
Ok. Let's begin our discussion at the top of the cervical spine, starting with Atlanto occipital dislocation.

Atlanto-occipital dislocation4:56–6:27

This is a highly unstable life threatening injury as the dislocation allows the skull to move independently from the spine 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 C one and C two will likely reveal a dislocation or dissociation of the Atlas or C one from the occiput, confirming your diagnosis of atlanto-occipital dislocation.
Here's another clinical pearl neurogenic shock occurs from spinal cord injury above T six, 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.
This is different from spinal shock, which refers to loss of spinal cord function after a cord injury and presents as flaccid paralysis, loss of reflexes, sensory deficits and urinary retention or bowel incontinence.
All right, let's move on to our next injury. The most common C one fracture known as Jefferson or C one burst fracture.

Jefferson C1 fracture6:27–7:17

This type of fracture occurs from heavy axial loading. So patients often present after being hit on the top of the head by heavy fallen objects or from landing head first from a shallow dive or a fall.
As a reminder, the C one vertebra has a unique thin shaped ring with two lateral bony masses. Instead of a prominent posterior vertebral body.
Imaging will reveal a fracture of the C one vertebral rings with displacement of the lateral vertebral masses. With these findings diagnose A Jefferson C one fracture.

Hangman C2 fracture7:17–7:52

Next, let's talk about hangman fracture or C two bilateral pedicle fractures. Next to the usual mechanism of injury.
This type of fracture can occur from hanging by the neck as the name suggests physical exam might additionally reveal radiculopathy and myelopathy on imaging.
You can expect to find a fracture along the part of the vertebral ring or it connects to the C two pedicles. With these findings, you can diagnose ac two fracture.

Odontoid C2 fracture7:52–8:51

All right, let's talk about another injury of the C two spine. The odontoid fracture, the odontoid process or dens is a bony pedicle of C two that projects upward into C one, allowing the lateral rotation of the head around the fixed spinal column fracture at the base of the odontoid process is very serious because it tends to be an unstable fracture with a high likelihood of extending into the vertebral body of C two and compromising the spinal cord or worse the brainstem on exam.
You can expect to find neck pain worse with movement. The imaging will typically show a fracture of the odontoid process with some associated traumatic prevertebral soft tissue swelling.
If you see this, think of odontoid C two fracture. Ok.

Subaxial fracture and dislocation8:51–10:27

Let's keep moving down the cervical spine to subaxial fractures and dislocations depending on the location and extent of injuries.
Along C three to C seven. You may notice focal neurologic deficits on exam as well as signs of a cord syndrome indicating associated spinal cord injury.
On imaging. You might see a fracture or dislocation of the cervical spine below C three.
In this case, diagnose a subaxial C spine fracture or dislocation. Here's a high yield fact, there are three main types of incomplete spinal cord syndromes.
Central cord syndrome is the most common type and occurs after a hyperextension injury. Patients with central cord syndrome have motor and sensory deficits that are more prominent in the upper extremities than lower extremities.
On the other hand, anterior cord syndrome results from an injury of the anterior two thirds of the spinal cord. This type of injury presents as muscle weakness and bilateral loss of pain and temperature sensation.
Lastly, in Brown Sicard syndrome, also known as a lateral hemisection of the cord patients often experience ipsilateral muscle weakness, loss of proprioception and vibration, as well as contralateral loss of pain and temperature sensation.
Ok. We have now reached our final type of injury, ligamentous spinal cord injury without radiographic abnormalities, also known as SCAA.

Ligamentous SCIWORA10:27–11:57

Additional physical exam findings here include focal neurologic deficits like upper extremity, paresthesia or motor weakness.
The imaging is usually unremarkable. However, as there are signs of spinal cord injury, you should consider scala in scopa.
The damage to the spinal cord doesn't come from fractures but from hyper extension of the spine, soft tissue edema or vascular injury, which is why X ray and CT seem normal.
Your next step is to order an MRI of the C spine which provides the best visualization of the spinal ligaments. A disruption to subaxial spinal cord ligaments on the MRI supports the diagnosis of sclera.
Ok. Let's wrap up with a high yield fact, even if you think your patient doesn't have a cervical spine fracture or spinal cord injury.
Don't be quick to remove their sea collar to clear the patient. For CCA removal, they must be neurologically asymptomatic with normal physical exam, awake not under the influence of any substances and with negative imaging.

Review11:57–12:49

All right, as a quick recap, blunt cervical spine injuries most commonly occur from motor vehicle collisions fall from heights and contact sports as with any trauma patient.
Your first step is to perform a primary survey and ensure cervical spine immobilization then perform a secondary survey with adjunctive tests including x rays and CT of the cervical spine.
In general, cervical spine injuries are categorized anatomically by the location of the injury. The main types include atlantooccipital dislocation, Jefferson or C one burst fracture.
Hangman's fracture. C two odontoid fracture, subaxial spine fractures and ligamentous scala.