Cervical Spine Injury: Prehospital, Emergency Room, and Acute Management

The entire spinal column is at risk; 15% of fractures are multiple and involve different spinal segments. The cervical spine can be partially immobilized by a hard cervical collar, but the efficacy of a collar is limited unless used with a hard, full-length backboard. A wide variety of hard cervical collars are available; superiority of one over another has not been shown. Immobilizing the cervical spine is accomplished by simultaneous control of head and trunk motion. This is most reliably accomplished by combining a hard cervical collar with a full-length backboard. Bolsters (or, alternatively, sandbags) on either side of the neck, secured by straps (or tape) across the head, maximally limits movement of the neck, whereas strapping the rest of the body to the backboard prevents truncal movement. This appears to provide the most safe and effective method of spine immobilization for transport.

Airway protection is paramount. If intubation is necessary, in-line cervical traction with efforts to minimize cervical extension should be undertaken, if at all possible. Immobilization precautions must be taken until spinal injury can be excluded or more definitive spine treatment initiated. It is important, however, to remove the backboard as soon as possible, keeping the patient on a firm padded surface while maintaining spinal alignment. In an insensate patient with spinal cord injury (SCI), skin breakdown, leading to decubitus ulcers, can begin within 2 hours of lying on a hard backboard. When transfers are necessary, the technique of logrolling should be employed in an attempt to maintain spinal alignment.

In certain patients with preexisting spinal deformities, providing care in the position of greatest comfort for the patient may take precedence over maximum spinal stabilization.

EMERGENCY ROOM AND ACUTE MANAGEMENT

Initially, it is important to follow advanced trauma life support (ATLS) evaluation and resuscitation protocols, determine the degree and extent of neurologic loss, and prevent any further loss of function. This is accomplished by ensuring an adequate airway and oxygenation, establishing and maintaining a systolic blood pressure greater than 90 mm Hg, serial complete neurologic examinations, radiographic identification of the degree and extent of spinal column injury, spinal realignment, and ensuring acute stabilization.

The most widely used neurologic examination protocol is that of the American Spinal Injury Association (ASIA). Sensory examination includes testing of all sensory modalities across the 28 dermatomes from C2 to S5. The major muscle groups are tested in the arms and legs and graded from 0 (no movement) to 5 (normal active movement against full resistance). The neurologic findings direct the radiographic assessment.

Plain spine radiographs have for the most part been supplanted by computed tomography (CT) scanning with reconstruction. Even if the CT findings are “normal,” magnetic resonance imaging (MRI) is always indicated in the presence of SCI to look for traumatic herniated disks, intraspinal hematomas, or significant ligamentous injury.

There continues to be controversy over the pharmacologic treatment of SCI. The National Acute Spinal Cord Injury Studies (NASCIS) demonstrated statistically significant improved neurologic recovery if methylprednisolone was administered within 8 hours of injury. However, the functional significance of this recovery has been questioned, and meta-analysis of published data fails to confirm any benefit of this approach. If methylprednisolone is to be used, the loading dose is 30 mg/kg, with a maintenance dose of 5.4 mg/kg/hr for 24 hours.

It is important to be vigilant for the presence of neurogenic shock and provide appropriate treatment. With mid-level to high-level cervical SCI, there is loss of sympathetic function and associated loss of vascular tone. This can result in significant pooling of blood in the lower extremities and associated hypotension. Volume resuscitation is ineffective in this setting, and pressors must be utilized early. Because SCI patients may also have multiple injuries, the distinction between hypovolemic and neurogenic shock must be recognized. In hypovolemic shock, there is tachycardia, cold clammy skin, altered mental status, and low urine output. In neurogenic shock, there is bradycardia, warm dry skin, normal mental status, and normal urinary output.

Once the SCI patient has been stabilized, the specific treatment required for the spinal injury is determined. Certain injuries may be treated with traction and bracing, whereas others require surgical intervention.

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