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Cervical spine injury

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Updated 2024 AOSpine/PSCI, 2024 DAS/AoA, 2024 WSES/EANS, and 2024 WMS guidelines for the evaluation and management of cervical spine injury.

Background

Overview

Definition
Cervical spine injury is a traumatic disruption of the cervical vertebrae, intervertebral discs, or cervical spine ligaments, which can result in spinal cord compression or transection leading to transient or permanent loss of motor, sensory, and autonomic functions.
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Pathophysiology
The pathophysiology of cervical spine injury involves the initial mechanical trauma, which can cause spinal cord compression, transection, or both. This is followed by a secondary injury phase characterized by spinal cord ischemia, edema, and hemorrhage. The extent of the injury depends on the severity of the trauma and the level of the spinal cord affected.
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Epidemiology
The annual incidence of traumatic cervical spine injury in Western populations is reported at 4-17 per 100,000 person-years. Spinal cord injuries in the US are reported to represent 3% of hospital trauma admissions.
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Risk factors
Risk factors for cervical spine injury include high-energy trauma, such as motor vehicle accidents and falls from height, as well as certain medical conditions, such as rheumatoid arthritis and ankylosing spondylitis. Other risk factors include violence, alcohol use, diving, and sports-related injuries.
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Disease course
The clinical course of cervical spine injury can vary widely. Initial presentation often includes neck pain, stiffness, and tenderness, along with neurological deficits such as weakness or numbness in the limbs. In severe cases, the condition can progress to quadriplegia, respiratory failure, and autonomic dysfunction. Patients can also have associated injuries, such as head trauma, atlanto-occipital dissociation, occipital condyle fracture, anterior subluxation, facet joint dislocation, spinal epidural hematoma, and vertebral artery injury.
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Prognosis and risk of recurrence
The prognosis of cervical spine injury is generally poor for complete spinal cord injuries. During the initial hospital stay, over 50% of patients with spinal cord injury develop multisystem complications. The 30-day mortality rate is reported to be 9.4%. Early surgical intervention can help decrease the instantaneous death risk, especially in early surgery.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of cervical spine injury are prepared by our editorial team based on guidelines from the AO Spine Foundation (AOSpine/PSCI 2024), the European Hip Society (EHS/EAU/ISTH/EACTAIC/EACTS/AATS/ESTS/EBCOG/EKS/ESAIC/NATA/SRLF/EURAPS 2024), the Royal College of Emergency Medicine (RCEM/NACCS/AoA/DAS/ICS/BSOA 2024), the Wilderness Medical Society (WMS 2024), the World Society of Emergency Surgery (WSES 2024), the World Society ...
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Classification and risk stratification

Classification: as per AANS/CNS 2013 guidelines, use the Subaxial Injury Classification and Severity Scale for the classification of spinal cord injury.
A
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Subaxial Injury Classification and Severity Scale (SLICS)
Morphology
No abnormality
Compression
Burst
Distraction (such as facet perch, hyperextension)
Rotation/translation (such as facet dislocation, unstable teardrop or advance-stage flexion compression injury)
Disco-ligamentous complex
Intact
Indeterminate (such as isolated interspinous widening, MRI signal changes only)
Disrupted (such as widening of the disk space, facet perch or dislocation, kyphotic deformity)
Neurological status
Intact
Root injury
Complete cord injury
Incomplete cord injury
Root injury with continuous cord compression in setting of neuro deficit
Complete cord injury with continuous cord compression in setting of neuro deficit
Incomplete cord injury with continuous cord compression in setting of neuro deficit
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  • Severity assessment

Diagnostic investigations

Cervical imaging, CT: as per ACR 2019 guidelines, do not obtain imaging in patients aged ≥ 16 years and < 65 years with suspected acute blunt cervical spine trauma if imaging is not indicated by NEXUS or Canadian C-Spine Rule clinical criteria and the patient meets low-risk criteria.
D
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NEXUS criteria for cervical spine imaging
Focal neurologic deficit
Midline spinal tenderness
Altered mental status
Intoxication
Distracting injury present
Risk of cervical spine fracture or dislocation is low. Imaging not required.
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  • Cervical imaging (radiography)

  • Cervical imaging (MRI)

  • Thoracolumbar imaging

  • Evaluation for arterial injury

  • Evaluation for DVT

Respiratory support

Airway management, pre-oxygenation and facemask ventilation: as per AoA/BSOA/DAS/ICS/NACCS/RCEM 2024 guidelines, ensure multidisciplinary planning, preparation, and optimization of human factors before airway management in patients with suspected or confirmed cervical spine injury.
B
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  • Airway management (supraglottic airway devices)

  • Airway management (endotracheal intubation)

  • Airway management (cricoid force and external laryngeal manipulation)

  • Airway management (emergency front-of-neck airway access)

Medical management

Setting of care
As per AANS/CNS 2013 guidelines:
Transport patients with acute cervical spine or spinal cord injuries expeditiously and carefully to the nearest medical facility with capacities for definitive treatment, using the most appropriate mode of transportation available.
B
Transport patients with acute cervical spine or spinal cord injuries to specialized acute spinal cord injury treatment centers whenever possible.
B
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  • Hemodynamic management

  • Management of bradycardia

  • Corticosteroids

  • Gangliosides

  • Thromboprophylaxis

Nonpharmacologic interventions

Cervical spine immobilization, indications: as per WMS 2024 guidelines, avoid using the terminology "clearing the spine" in out-of-hospital care unless it is specifically defined in protocols.
D
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  • Cervical spine immobilization (penetrating trauma)

  • Cervical spine immobilization (choice of device)

  • Cervical spine immobilization (normal imaging, awake patients)

  • Cervical spine immobilization (normal imaging, obtunded patients)

  • Nutritional support

Therapeutic procedures

Closed reduction
As per AANS/CNS 2013 guidelines:
Perform early closed reduction of cervical spinal fracture/dislocation injuries with craniocervical traction for the restoration of anatomic alignment of the cervical spine in awake patients.
B
Do not perform closed reduction in patients with an additional rostral injury.
D
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  • Cervical traction

Perioperative care

Perioperative thromboprophylaxis: as per AATS/EACTAIC/EACTS/EAU/EBCOG/EHS/EKS/ESAIC/ESTS/EURAPS/ISTH/NATA/SRLF 2024 guidelines, consider administering pharmacological prophylaxis within 48 hours following trauma or surgery in patients with spinal cord injury.
C
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Surgical interventions

Timing of surgery: as per AOSpine/PSCI 2024 guidelines, offer early surgery as an option in adult patients with acute spinal cord injury, regardless of the level.
B
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  • Open reduction and internal fixation

Specific circumstances

Pediatric patients, evaluation: as per AANS/CNS 2013 guidelines, do not obtain cervical spine imaging in alert pediatric trauma patients aged > 3 years with no neurological deficits, midline cervical tenderness, painful distracting injury, unexplained hypotension, or intoxication.
D
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  • Pediatric patients (management)

  • Patients with spinal cord injury without radiographic abnormality (evaluation)

  • Patients with spinal cord injury without radiographic abnormality (management)

  • Patients with atlanto-occipital dislocation

  • Patients with occipital condyle fracture

  • Patients with isolated C1 fracture (cervical immobilization)

  • Patients with isolated C1 fracture (surgical stabilization)

  • Patients with isolated C2 fracture (evaluation for vertebral artery injury)

  • Patients with isolated C2 fracture (cervical immobilization)

  • Patients with isolated C2 fracture (surgical stabilization)

  • Patients with combined C1-C2 fracture (cervical immobilization)

  • Patients with combined C1-C2 fracture (surgical stabilization)

  • Patients with os odontoideum (diagnosis)

  • Patients with os odontoideum (management)

  • Patients with central cord syndrome

  • Patients with vertebral artery injury

  • Patients with polytrauma (life support)

  • Patients with polytrauma (evaluation)

  • Patients with polytrauma (hemodynamic control)

  • Patients with polytrauma (general principles of management)

  • Patients with polytrauma (blood transfusion)

  • Patients with polytrauma (coagulation management)

  • Patients with polytrauma (thromboprophylaxis)

  • Patients with polytrauma (corticosteroids)

  • Patients with ankylosing spondylitis

Preventative measures

Intraoperative neurophysiologic monitoring
As per AOSpine/PSCI 2024 guidelines:
Identify patients at high risk for intraoperative spinal cord injury and undertake multidisciplinary team discussions for the management of these patients after identification.
B
Obtain intraoperative neurophysiologic monitoring in high-risk patients undergoing spine surgery.
B
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Follow-up and surveillance

Rehabilitation: as per AOSpine 2017 guidelines, consider offering rehabilitation in medically stable patients with acute spinal cord injury able to tolerate required rehabilitation intensity.
C
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