h1 class=”calibre8″>23 Nonoperative Management and Treatment of Cervical Spine Injuries

Jacob Hoffman and Mark L. Prasarn

Keywords: nonoperative treatment, cervical spine, trauma, ligamentous injury, immobilization, spinal stabilization, decompression

23.1 Introduction

Cervical spine trauma encompasses a broad range of injuries ranging from mild ligamentous injury to fracture-dislocations with catastrophic spinal cord injury. Nonoperative modalities have remained essential in the initial and, oftentimes, definitive care for most injuries. The majority of cervical spine fractures and stable ligamentous injuries can be treated with nonoperative means while avoiding the inherent risks of surgical intervention. After appropriate examination, diagnosis, and patient discussion, a good functional outcome without long-term disability can be anticipated with nonoperative management in most cases.

Beginning at the scene of the trauma through the definitive intervention, nonoperative treatment modalities are used in all cases. Patients should be immobilized, quickly evaluated, and treated definitively (if indicated). Strict adherence to proper immobilization techniques are followed to minimize motion of the injured cervical spine and prevent catastrophic neurological injury. All injuries should be assumed to be unstable until proven otherwise.

Definitive treatment goals are the same for nonoperative management as for operative intervention. These include (1) preservation of neurological function, (2) improvement in neurological deficit if already present, (3) reduction of spinal deformity and maintenance of acceptable alignment, (4) minimization of loss of spinal mobility, (5) achievement of a healed and stable spinal column, and (6) prevention of long-term pain and disability.

23.2 At the Scene

In acute trauma cases, Advanced Trauma Life Support (ATLS) protocol mandates life-threatening injuries take priority in treatment. Compromise to airway, respiration, and circulation should be promptly addressed. The greatest risk of spinal cord injury occurs at the time of high-energy impact. However, neurological deficits can develop at any point during the initial treatment period. Up to 25% of spinal cord injuries occur after a patient has been assumed under medical care. ¹ It is paramount that first responders work quickly to immobilize the cervical spine to prevent neurological decline.

The care of spine trauma patients at the scene has dramatically improved over the past several decades; extraction, immobilization, and transport of trauma patients in adherence with ATLS protocols for resuscitation have been credited. ATLS protocol instructs medical personnel to assume that spinal injury has occurred in all trauma patients. At the scene, the patient should be placed immediately into a cervical collar, head immobilization device, and spine backboard.

In athletes with suspected cervical spine injuries, health care providers are presented with unique challenges that are not present within the general population. Equipment worn for personal protection is an obstacle for medical personnel to gain access to the airway, neck, and chest. In 2015, the National Athletic Trainers Association updated their executive summary of acute spinal injury treatment. ² In their recommendations, equipment can be removed by the highest-level trained personnel prior to transfer to the hospital, if this is deemed appropriate. It is also an option to leave everything but the facemask in place until arrival at the emergency room. The injured athlete should then be placed into a rigid cervical stabilization device and placed onto a spinal backboard.

23.3 At the Hospital

The patient should arrive in the emergency department on a backboard with a cervical collar in place. In the face of global instability, motion can still occur in spite of all attempts at rigid collar immobilization. The patient should be moved on and off the backboard as few times as possible until the stability of the spine can be adequately assessed. For most injuries, the collar provides an increased level of stability, although it does not provide complete immobilization. ³ With complete ligamentous disruption, the collar has minimal effect on providing restriction to cervical movement. Manual stabilization of the spine is much more significant in restricting motion. ⁴

During the primary and secondary surveys, clinicians must maintain a high index of suspicion for cervical spine injury. Any trauma patient with head or maxillofacial injuries should be presumed to have a cervical spine injury. Common causes of missed cervical spine injuries include the polytrauma patient, altered mental status due to intoxication or traumatic brain injury, or a noncontiguous spinal injury. ^5,6 Many patients with cervical spine trauma require rapid sequence intubation due to other significant injuries. Often intubation and placing the patient on mechanical ventilation occurs prior to the secondary survey and imaging. In a study comparing four various intubation techniques, use of the Lightwand (Aaron Medical, St. Petersburgh, FL) showed the least amount of cervical motion while the commonly used Macintosh blade showed the greatest. ⁷ Using a technique that produces less motion may lessen the risk of secondary neurological injury during airway management.

Distracting injuries in the polytrauma patient can often mask the presence of a significant spine injury. Trauma patients with facial trauma or closed head injuries should raise suspicion for associated cervical trauma. Meticulous examination of the spine must always be performed including inspecting the patient’s cervical posture. Any gross malalignment in angulation or rotation might suggest dislocation or subluxation. The physician should palpate the posterior cervical spine noting for step-offs between spinous processes or pain out of proportion in the awake patient. A meticulous neurological examination of the patient is performed during the secondary survey. The exam is carefully documented according to American Spinal Injury Association (ASIA) guidelines. Throughout the hospitalization, the patient should undergo serial examinations. If possible, the examinations should be performed by members of the same team of providers who are familiar with the patient’s previous exam. In spinal shock, distal motor function cannot be fully assessed until the bulbocavernosus reflex returns.

Once the patient has been deemed hemodynamically stable to receive a computed tomography (CT) scan, a coordinated effort should be made to move the patient off the backboard. A full trauma scan including imaging of the brain, face, spine, chest, abdomen, and pelvis should be obtained in one trip to the scanner, with one movement off and on the triage bed. The entire axis of the spine should be carefully reviewed for noncontiguous fractures. In blunt trauma and in the presence of a spine fracture, there is a 19% incidence of noncontinuous spine injuries. ⁵

The risk of decubitus ulceration is directly proportional to the length of time on a backboard—8 hours on a backboard is associated with a 100% likelihood of a decubitus ulcer. ⁸ The patient should be moved from the board as soon as possible. Appropriate spine immobilization must be continued while removing the patient from a spinal board.

Contrary to all available evidence suggesting that the log roll is an ineffective and potentially dangerous technique for spine immobilization, it is still universally used. In fact, studies conducted prior to 2004 showed dramatic and unacceptable motion with a log roll. ⁸ Recently, many studies have reevaluated this controversial practice. Compared with any other method of transfer, the log roll maneuver has been shown to cause more segmental motion at the level of the unstable, injured segment. ^{3,9,10,11,12,13,14,15,16,17} Lift and slide techniques are superior as they tend to create less motion at the injured segment. ¹³

23.4 Imaging Studies

All traumatically injured patients with suspected spinal injuries should have the entire spinal axis imaged and carefully reviewed. In the absence of a facet dislocation and in the presence of significant spine injury, the appropriateness of a magnetic resonance imaging (MRI) scan must be determined. The spinal motion needed to transfer the patient on and off the MRI table must be kept in mind when deciding on the necessity of this imaging modality. The strongest argument for an MRI is a suspected neurological deficit that is not explained by the injury seen on a CT scan. The other indication for MRI is to evaluate the posterior ligamentous complex which is felt to be critical for stability of the spinal column. If the patient has an unstable injury which requires surgery (and has been identified clinically or by other imaging studies), it is not necessary to obtain an MRI just to assess the dorsal ligamentous complex.

Specific injury mechanisms and fracture patterns should prompt the treating team to search for commonly associated nonspinal injuries. In many instances, the definitive treatment of cervical spine fractures may be delayed due to the life-threatening condition present in these acutely injured patients. In addition, the mechanism of injury is useful for identifying patients at risk for other injuries, and clinicians must not become solely preoccupied with cervical pathology. In a retrospective review of 492 cervical spine CT scans with spinal traumatic pathology, 60% of patients had injury to an additional anatomic region or organ system. ⁵

23.5 Closed Reduction of the Cervical Spine

After appropriate imaging and medical stabilization has occurred, patients with cervical facet subluxations or dislocations or burst-type fractures may undergo closed reduction with the use of skeletal skull traction. The reduction achieved by this means allows for realignment and stabilization in the acute phase of treatment. Contraindications to skeletal skull traction include distractive cervical injuries, patients with certain skull fractures, and stable fracture patterns. ^18,19

When a closed reduction of a dislocated segment is needed, it should be performed expediently in the awake and alert patient. Serial neurological examinations should be performed during any reduction maneuvers. If the patient is obtunded or intoxicated and reliable neurological examinations are impossible, then an emergent MRI should be obtained prior to attempting reduction to rule out significant disc herniation. ²⁰ Closed reduction provides a rapid means of reducing cervical spine deformity, indirectly decompressing the neural elements and providing stability. It has been shown to be safe and can dramatically improve neurological status if performed within the first few hours following the injury. In an animal model, it was shown that decompression within 3 hours showed better and quicker neurological recovery. ²¹ A small series of patients with no cord function who received reduction in an emergent manner immediately began to recover. ²² Therefore, a closed reduction should be performed as early as possible in the stable patient who is able to give a reliable neurological exam. In the medically compromised patient, the priority is to achieve hemodynamic stability prior to performing urgent reduction or obtaining an MRI.

There remains controversy surrounding MRI in patients with acute cervical spine dislocations, prior to reduction. Advocates of a prereduction MRI consider the potential for displacement of an unrecognized disc herniation or other space-occupying lesion an undue risk for the patient. Eismont et al reported on a series of six patients who roentgenographically demonstrated herniation of an intervertebral disc with marked protrusion of disc material into the spinal canal following subluxation or dislocation of a cervical facet. For the first patient in this series, no myelogram or CT scan was performed, and the patient awoke with complete quadriplegia following dorsal open reduction and internal fixation under general anesthesia. Following a myelogram and ventral decompression surgery, the cause was identified as an extruded intervertebral disc. The authors recommended obtaining an MRI in all patients prior to attempting closed reduction and definitive surgery. ^23,24,25 Several other cases with neurological deficits after open reduction under general anesthesia have been reported. ^23,25 There have also been reports of progression of neurological deficits during traction while the patient was awake, which later resolved. ²⁶ Some surgeons recommend decompression and open reduction should there be a disc herniation on imaging.

A prereduction MRI may result in a large number of patients undergoing surgical decompression, open reduction, and stabilization prior to manipulative reduction in the emergency department. Some have advocated performing immediate closed reduction in the patient who is awake and can reliably participate in serial neurological examinations. In a study of 11 patients who underwent MRI before and after awake closed reduction, Vaccaro et al reported that no patients had neurological decline during reduction despite a prevalence of disc herniation prior (18%) and after (56%) manipulation. ²⁰ Darsaut et al attempted to determine the effect of disc herniation during closed reduction in a series of 17 patients who had a cervical dislocation that was reduced under MRI monitoring. They demonstrated that this technique could be used successfully as a research tool. ²⁷

A commonly used algorithm is based on the patient’s neurological status. If the patient is unable to participate reliably in the physical examination, then an MRI is obtained as expeditiously as possible. The principal disadvantage of obtaining an MRI is the loss of potentially vital time to neural canal decompression. It has been shown that neurological recovery after injury is directly related to the duration of external compression on the spinal cord. ²⁸ If the patient has a significant spinal cord injury, the risk is that the cord will remain compressed for a longer period of time. If the patient has an ASIA A, B, or C injury and is able to cooperate with the reduction and serial neurological examinations, strong consideration should be given to an immediate, rapid reduction. In this situation, the MRI would be obtained after reduction. In the setting of an obtunded patient without an accurate exam, an emergent MRI should be obtained prior to attempting any reduction maneuver. Should there be a herniated disc present, an anterior decompression is recommended prior to reduction and stabilization. ▶ Fig. 23.1 reviews the decision tree regarding patients with acute subaxial cervical subluxations and dislocations.

23.6 Reduction Techniques

As early as the 4th century BC, reduction maneuvers have been attempted to correct spinal deformity. ²⁹ The goal of reduction is to reestablish the anatomic alignment of the cervical spinal axis in a graded, controlled manner. Restoration of alignment indirectly decompresses the canal and if completed rapidly, may prevent progression of neurological injury. Gardner–Wells tongs are applied with the pins placed 1 cm above the pinna of the ear just below the equator of the head. By placing the pins at this site, the distractive force of the Gardner–Wells tongs will parallel the longitudinal axis of the cervical spine. A flexion moment can be obtained with a posterior placement of pins while anterior placement causes an extension moment. Pins are tightened to 3.6 kg of pressure. While tightening, a precalibrated indicator on the pin protrudes a measured amount once the correct torque is obtained.

It is recommended that the initial applied weight be no more than 4.5 kg. Using more weight can be catastrophic if the patient has unrecognized ligamentous instability. After every application of increased weight, a neurological examination and lateral radiograph should be obtained. The radiographs should be scrutinized to ensure that a distraction-type injury is not present that might be worsened by the traction. Additional weight should be added incrementally until reduction is obtained. Once reduction is achieved, the weight should be decreased to the minimum amount needed to maintain the reduction. Routine examinations are continued and definitive stabilization can occur once medically appropriate. Pulmonary and skin issues can be addressed with use of a kinetic treatment bed until surgery. If reduction cannot be obtained, then an MRI should be obtained and the patient should be taken for urgent open reduction in the operating theatre.

If the patient has a sudden decline in neurological status during a closed reduction attempt, it may be due to a variety of causes such as displacement of herniated disc, hemorrhage or edema within the parenchyma of the neural elements, vascular injury to the spinal cord, and/or hemorrhage into the epidural, subdural, or subarachnoid spaces. Caution should be used in patients with ossified posterior longitudinal ligaments (OPLL), as a segment of the OPLL may displace and cause increased stenosis after reduction. ²⁶ If an alert, cooperative patient experiences a decline in neurological status during attempted closed reduction, immediate reversal of the reduction maneuver sequence must be performed. The patient should be reexamined and then an emergent MRI should be performed. The patient can be taken to the operation theatre for decompression, reduction, and stabilization if a space-occupying lesion is identified and is causing cord compression. ^6,26

Gardner–Wells tongs are used due to the high pull-out strength of the construct when steel pins are used. ³⁰ If using weights over 25 kg, MRI-compatible tongs with titanium pins are insufficient. Weights of over 60 kg have been used safely for closed reduction when stainless steel pins are used. ²⁶ The use of a halo may be considered since it provides four titanium pins to distribute the forces over more pins. The major disadvantage of stainless steel pins is their MRI incompatibility. A potential reason stainless steel pins may fail is due to an underlying skull fracture. ³⁰ Potential complications with the use of skeletal skull traction include cranial perforation, dislodgement, pin site infection, propagation of an unrecognized skull fracture, or superficial temporal artery laceration. ^19,31,32,33 Complications with prolonged immobilization can also occur including cervical pressure ulcers, pneumonia, and venous thromboembolic events. ¹⁹ The patient should be taken expediently for definitive stabilization as physiological status allows to avoid these complications (▶ Fig. 23.2).

23.7 Definitive Treatment

The majority of cervical spine injuries should be treated nonoperatively. When making the decision for nonoperative management, surgeons must survey the entire clinical picture. Surgical intervention may be indicated in the setting of progressive neurological deficit or any injury deemed to be unstable. As it is thought that the posterior ligamentous complex is the key to stability, ligamentous injuries in those who are skeletally mature require spinal fusion to maintain stability. The presence of a neurological injury is not an absolute indication for surgery.

The remaining spectrum of cervical spinal injuries can initially be treated with nonoperative management. A variety of closed treatment options can be used including bedrest, long-term skeletal traction, halo apparatus, external orthosis, or casting. Many significant fractures can be treated with an initial period of bedrest in a kinetic treatment bed followed by bracing and mobilization once early healing has been achieved. The absence of significant pain should be the clinical indicator of the patient’s readiness to be cleared from the kinetic treatment bed and mobilized. Upright films in the external orthosis should be obtained to confirm that the spinal column is stable under physiological loads.

23.8 Timing of Surgical Intervention

Debate continues over the appropriate timing of traction or surgery in cases of acute spinal cord injury. Although early surgical intervention has been shown to prevent complications associated with prolonged bedrest, there has not been great historical evidence that it will improve neurological function. ^34,35,36,37 Complete cord injuries and neurologically intact patients are very likely to remain neurologically unchanged with appropriate surgical or nonoperative care. Incomplete lesions typically improve with either surgical or nonsurgical care. Late surgery with decompression of the cervical spinal canal in incomplete cord injuries has been shown to improve neurological function even several years following the traumatic event. ³⁸ In the acute setting, there has been sparse evidence supporting early surgery, although the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated that those undergoing cervical decompression within 24 hours showed a 2.8 times greater likelihood of a 2 grade AIS improvement as compared to those having late decompression. ³⁹

23.9 Upper Cervical Injuries

Upper cervical fractures or discoligamentous injuries can be potentially devastating with high mortality rates and poor long-term functional outcomes. With the aging population, there has been an increase in upper cervical fractures and ligamentous injuries. Low-energy falls coupled with poor bone quality due to osteopenia can lead to significant C1 and C2 fractures. Elderly patients with neurological deficits have poor survival rates compared to younger cohorts. ⁴⁰

Ligamentous injury to the craniocervical junction can lead to occipitocervical dissociation. Occipitocervical injuries are associated with high-energy trauma and are often found postmortem. ⁴¹ Atlanto-occipital dislocations can oftentimes be difficult to diagnose. However, early, routine use of CT scans has improved diagnosis. ⁴² When encountering this injury, the treating physician must be vigilant about making the diagnosis to ensure the patient’s survival and prevent catastrophic neurological deterioration. At the scene, these patients should be carefully immobilized on a backboard with a rigid collar. For additional stabilization, the head is secured with sandbags and tape. At the earliest possible moment after initial work-up, a halo vest is applied until definitive surgical stabilization is performed. Any form of traction for type II injuries (axial distraction) can be catastrophic and is strictly contraindicated. If diagnosis is made early, these injuries can be successfully treated with dorsal occipital cervical fusion with at least 3 months of halo vest immobilization. ^42,43,44 However, there still remains a paucity of literature, mostly including case reports, on which dislocations can be treated nonoperatively. ⁴⁵

Fractures of the occipital condyle and C1 are often treated nonoperatively. In 1988, Anderson and Montessano proposed the most widely used classification system of occipital condyle fractures based on fracture morphology. ⁴⁶ Type I fractures are nondisplaced, comminuted variants. Type II fractures involved a basilar skull fracture with extension into the occipital condyle. Type III fractures are produced from a rotational force causing an alar ligament tensional avulsion. Tuli et al ⁴⁷ proposed an additional classification system based on stability. Isolated type I fractures are considered stable and can be treated without immobilization. Type IIA fractures are stable fractures without ligamentous disruption and require a rigid collar. Demonstration of significant instability on imaging or ligamentous disruption on MRI (Type IIB) invokes the need for surgical stabilization. Good outcomes have been shown with initial management of occipital condyle fractures treated with nonoperative modalities even in cases of neurological injury. ^48,49,50

An axial force transmitted through the cranium onto the atlas causes a compressive force leading to a burst or Jefferson fracture of C1. Most fractures are considered stable and are treated in a cervical collar. ⁵¹ Unstable atlas ring fractures (> 7 mm overhang of the sum total of the lateral masses) indicate ligamentous disruption of the transverse ligament and typically require surgical stabilization. ⁵²

Odontoid fractures are the most common C2 fractures. They are classified based on the anatomic location and degree of displacement of the fracture. Many can be treated with a rigid orthosis or halo vest. Anderson and D’Alonzo ⁵³ type I avulsion injuries are rare and can be treated with either a soft or rigid collar. Fractures through the body of the atlas (type III) typically heal uneventfully and have a good prognosis without surgery. Transverse type II fractures through the waist of the odontoid have much controversy regarding their treatment due to a high associated nonunion rate. A dorsally displaced odontoid fracture is more likely to be treated with surgery. ^{54,55,56,57,58} Polin reported on a series of 36 patients with type II odontoid fractures treated with a rigid collar versus a halo. They showed no difference in outcomes when either modality was used. ⁵⁸ Previous studies have shown nonunion rates ranging from 54 to 75% when treated in either a halo vest or a rigid collar. ^59,60,61,62 A posteriorly displaced fracture in patients > 65 years old is at high risk of nonunion. ^60,63 Elderly patients treated in a halo vest have a high morbidity and mortality rate. ⁶⁴ The clinical relevance of nonunion in elderly patient continues to be debated. Some authors report that these can be followed and may not require surgical intervention. In a series of persistent nonunions, no progression of atlantoaxial instability or neurological deterioration, including myelopathic symptoms during the follow-up period, was noted. ⁵⁹ Contrary to this, Kepler et al showed a 17% incidence of new neurological deficits in a similar cohort. ⁶⁵ Definitive treatment is individually based and involves shared decision-making by the patient and family.

Transverse ligament ruptures can be managed in an orthosis or halo if a bony avulsion occurs. ^66,67 Nonoperative management avoids the significant loss of motion following a C1–C2 arthrodesis. If there is a complete ligamentous disruption, Dickman et al demonstrated a 100% failure to heal. These injuries often result in a significant incidence of neurological injury, and there is frequent association with other upper cervical injuries. Atlantoaxial arthrodesis is indicated in complete ligamentous disruption without bony avulsion in either neurologically compromised or intact patients. ⁶⁸

The vast majority of other axis injuries can be stabilized with an orthosis or a halo vest. Most C2 body fractures are considered stable and can be treated with a collar. ⁶⁹ Traumatic spondylolisthesis of the axis most commonly occurs secondary to a hyperextension and axial load mechanism. Neurological deficit rarely occurs. The exception is for the atypical fracture that occurs ventral to the dorsal vertebral body cortex. ⁷⁰ These atypical fractures may require surgery to prevent neurological decline. Severe hangman’s fractures with instability through the C2–C3 disc space require surgery. Most other axis injuries can be managed successfully nonoperatively. ^{52,69,70,71,72,73,74} In a retrospective review of 41 patients with hangman’s fractures, 11 (27%) patients were treated with a cervical collar, 27 (66%) were treated in a halo, and 3 (7%) were treated with surgical intervention. Of the surgical patients, one had an atypical fracture that failed halo immobilization and the two others had associated cervical fractures. All patients achieved union at 4 to 6 week follow-up (▶ Fig. 23.3). ⁷⁵

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