Trauma Medular - Cervical Trauma Columna

OCTOBER 2021 | VOLUME 23 | ISSUE 10
Emergency Medicine Practice Evidence-Based Education • Practical Application
CLINICAL CHALLENGES:
• What are the latest
recommendations on spinal
immobilization?
• What are the best practices for
managing airway and breathing
in spine-injured patients?
• Which decision tools will help
determine imaging choice?
Authors
Geoffrey Jara-Almonte, MD
Assistant Residency Director, Department of
Emergency Medicine, NYC Health + Hospitals/
Elmhurst Hospital Center, Icahn School of
Medicine at Mount Sinai, New York, NY
Chandni Pawar, MD
Mount Sinai Hospital Emergency Department,
New York, NY
Peer Reviewers
Emergency Department
Michael Abraham, MD, MS, FAAEM Management of
Adjunct Assistant Professor of Emergency
Medicine, Department of Emergency Medicine,
University of Maryland Medical Center,
Cervical Spine Injuries
Baltimore, MD n Abstract
Jared Ham, MD The majority of the nearly 18,000 new cases of spinal cord injury
Department of Emergency Medicine, in the United States each year involve the cervical spine. Although
Department of Neurology and Neurocritical the morbidity, mortality, and healthcare costs associated with
Care, University of Cincinnati Medical Center,
Cincinnati, OH
these injuries is very high, quality evidence to guide emergency
management is limited. Recent changes to guidelines have called
into question decades of practice, including prehospital spinal
Prior to beginning this activity, see “CME immobilization protocols, timing of surgery, and pharmacotherapy.
Information” on page 26.
A systematic approach to the diagnosis and management of the
spine-injured patient is outlined in this review, with a focus on
recent updates and management of emergent complications.
For online access, scan with your

smartphone camera or QR code reader app:
This issue is eligible for 4 Trauma CME credits. See page 26. EBMEDICINE.NET
Case Presentations
EMS calls to alert you that they have 24-year-old man with head trauma, and they are 15 minutes out…
CASE 1
• EMS says the man was found down on the street.

• He has head trauma and a GCS score of 7, but his vital signs are normal.
• You anticipate that this patient will need intubation. The EMS crew asks whether they should intubate in
the field and whether he requires spinal immobilization...
A 64-year-old man walks into the ED complaining of left-sided neck pain after he was in a head-on
motor vehicle crash several hours ago…
• A resident is examining the patient, who said he was a restrained driver in the MVC, and the airbags
CASE 2
did not deploy. He was ambulatory at the scene, and refused to go to the ED at that time, but now
complains of left-sided neck pain.
• On exam, he has left-sided paraspinal tenderness to palpation over the cervical and lumbar spinal area
without step-offs or deformity. No neurological deficits are noted on exam.
• The resident asks you whether the patient should be placed in a hard collar and whether imaging is
appropriate…
A trauma is called overhead: a young woman was thrown from a horse onto her head and back…
• You run to the trauma bay where the young woman has been brought in by EMS. The trauma resident is
evaluating her ABCs.
• You see that the patient is awake, has a GCS score of 15, and is answering questions appropriately, but
CASE 3
she appears uncomfortable.

• Her blood pressure on the monitor is 80/48 mm Hg. As the resident finishes the primary survey, you
note that the patient is unable to lift her lower extremities on command. Her grip strength is weak, and
she has gross loss of sensation in the bilateral upper extremities.
• You wonder whether this is a head or a spine injury, and how best to treat her hypotension. Should she
receive corticosteroids?
n Introduction comprehensively reviewed to provide the best avail-

able evidence for clinical decision-making in caring
Whether working in a dedicated trauma center or
for the patients with spine injuries. Acute care of the
not, emergency clinicians will encounter patients with
critically ill patient with SCI will also be reviewed,
a concern for potential spinal injury. These can be
including airway management, safe and appropriate
challenging cases, given that presentations can range
patient transfer, and time to surgical intervention.
from subtle findings to complete paresis. Failure to
recognize and treat the unstable spine injury has
profound consequences for the patient and can
n Critical Appraisal of the Literature
provoke some degree of anxiety for all emergency PubMed was searched for the term spinal cord
clinicians, given that as many as 9% of spinal injuries injuries. Results were limited to clinical trials and
may be missed initially.1 meta-analyses from 2011 to 2021. This returned
This issue of Emergency Medicine Practice fo- 1238 results, which were reviewed for relevance to
cuses primarily on injuries of the cervical spine, as it is emergency management and stabilization of spinal
the most common site of neurologic compromise and injuries. The Cochrane Database of Systematic Reviews
is associated with the most significant morbidity and was searched for the term spinal cord injuries, which
mortality. References will be made, as appropriate, to returned 51 results. Websites of relevant professional
thoracolumbar injures and general principles of care societies were searched for practice guidelines.
of the spine-injured patient. Citation searching of selected articles was performed
In the last decade, there have been important to identify additional resources.
updates involving spinal cord injury (SCI) prehospital Of the recent studies related to acute
care, diagnostics, and medical management. New management, clinical questions addressed included
guidelines have been published by professional bod- optimal methods of endotracheal intubation,
ies, including the American Association of Neurologi- acute hemodynamic management, and timing of
cal Surgeons and Congress of Neurological Surgeons decompressive surgery. The Cochrane database
(AANS/CNS) and AO Spine. The literature has been was also queried for the term spinal injuries, which
OCTOBER 2021 • www.ebmedicine.net 2 ©2021 EB MEDICINE

returned 1 relevant systematic review and meta- involving only the anterior column tend to be stable;
analysis on the effectiveness of corticosteroids in however, an unstable injury can be presumed if mul-
the treatment of acute SCI. Three additional reviews tiple columns are injured, or in some cases of isolated
were excluded because they were inconclusive, due posterior column disruption. See Figure 3 and Table
to absence of randomized controlled trials. There 1 (page 5) for spinal cord anatomy and injuries. See
is a large body of literature addressing several Tables 2 and 3 (pages 6 and 7) for examples of un-
important clinical questions, reflecting a long history stable and stable spinal fractures.
of experience with SCI. However, the evidentiary Many attempts have been made to systemati-
base for practice is weak, with few large randomized cally classify and describe injury patterns in order to
controlled trials. Most published guidelines can offer facilitate understanding of prognosis, treatment, and
only weak guidance on most recommendations. communication between clinicians and clinical re-
searchers.7,9,11,12 None has yet achieved widespread
n Epidemiology and Pathophysiology acceptance, though the recently described AO Spine
Epidemiology (https://aospine.aofoundation.org) upper cervical
In the United States, SCI has an annual incidence of injury classification system shows good interrater
approximately 17,900 new cases, with 78% of patients reliability.13-15 The AO Spine upper cervical injury
being male.2 Sixty percent of these patients suffer classification system pocket card and poster can be
cervical spinal injury with complete or incomplete downloaded here: https://aospine.aofoundation.
tetraplegia; these patients have the most significant org/clinical-library-and-tools/ao-spine-classification-
reduction in life expectancy compared to paraplegic systems
patients. The United States has a significantly higher SCI may occur without spinal fracture; several
rate of SCI than other industrialized nations.3,4 important syndromes are described and outlined
Black Americans are disproportionately affected, in Table 1, page 5. The most clinically important of
accounting for 22% to 24% of new injuries, despite these is acute traumatic central cord syndrome, which
being only 13% of the United States population.2 may be caused by hyperextension, resulting in buck-
The estimated lifetime cost for treatment of a ling of the ligamentum flavum and compression of
single patient with SCI in the United States is be- the cord.16 It is typically associated with pre-existing
tween $1.6 and $4.8 million.2 Over the past 30 years, spinal stenosis in elderly patients undergoing rela-
the demographics of SCI have shifted, reflecting the tively low-energy trauma. Acute bone injury or ma-
aging of the national population; the average age lalignment is generally absent. Patients present with
of injury has increased from 29 to 43 years; in those incomplete quadriparesis; the upper extremities are
aged 65 to 74 years, the incidence increased from 84 involved more frequently than the lower extremities.
cases per million to 131 cases per million.5
Motor vehicle crashes and falls account for
the majority of spinal cord injuries.2 Interpersonal
Figure 1. Causes and Demographics of
violence (primarily gunshot wounds) and athletic Spinal Cord Injury in the United States
injuries account for a smaller but important minority
of injuries, as these patients tend to be younger.5
SCI due to falls increased from about 20% of cases in
1997 to 40% of cases in 2012.5 (See Figure 1.)
Anatomy
The spine consists of bony and ligamentous structures
that house the spinal cord and associated nerves;
damage to any of these components can have im-
portant functional outcomes. Critical to assessing the
significance of a bone injury is the concept of spinal
stability, which was first proposed by Nicoll in 1949.
Unstable fractures are those in which bone deformity
is likely to increase and may lead to development or
worsening of spinal cord compromise.6
The rostral-most components of the spine—C1,
C2, and the C2-C3 junction—have a unique anatomy
and patterns of injury. From the third cervical verte-
bra and caudally, the spine may be conceptualized
Source: National Spinal Cord Injury Statistical Center, Facts and Figures
as consisting of 2 or 3 functional columns.7-10 (See at a Glance. Birmingham, AL: University of Alabama at Birmingham,
Figure 2, page 4.) Traumatic injury may disrupt the 2021. Available at: https://www.nscisc.uab.edu/Public/Facts%20and%20
integrity of structures in 1 or more columns.6,8 Injuries Figures%20-%202021.pdf
GROUP SUBSCRIPTIONS: groups@ebmedicine.net 3 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.

Sensation is preserved. Diagnosis may be challeng- toxicity, cellular apoptosis, and infiltration of immune
ing due to the absence of bone injury on computed cells with resultant edema.
tomography (CT), and it generally requires magnetic
resonance imaging (MRI) to demonstrate cord edema. n Differential Diagnosis
Maintaining a high index of suspicion in cases that Spinal injury must be considered in patients with
could present with acute traumatic central cord syn- posttraumatic back pain or new neurological findings.
drome is key to making sure this injury is not missed. A broad differential includes both traumatic and
nontraumatic injuries. (See Table 4, page 8.)
Pathophysiology
SCI may be thought of as occurring in a primary Spinal Fracture
phase and a secondary phase. Primary injury Spinal fractures may occur secondary to high- or
results from the direct mechanical effect of the low-energy trauma. Typically, pain is sudden in
altered anatomy on spinal cord tissue. The 4 main onset, temporally related to the event, and may be
mechanisms of primary injury are: (1) impact plus localized to the midline. The examination may reveal
persistent compression, (2) impact with transient tenderness to palpation or percussion. Ambulation
compression, (3) distraction, and (4) laceration or may be difficult or impossible. Fractures may occur
transection.17,18 In general, the effects of a primary with minimal or no trauma in some populations,
injury cannot be reversed. such as those with osteoporosis, cancer with bone
Secondary injury describes a cascade of events metastases, and ankylosing spondyloarthropathies.
that begins in the seconds following the primary in-
jury, and it may persist for weeks to months, inhibiting Nontraumatic Spinal Compression
recovery or resulting in progressive damage.17,18 The Nontraumatic spinal cord compression should be
occurrence of secondary injury was hypothesized over considered in the setting of new neurologic deficit or
a century ago by Allen, who observed that removal symptoms. Consider spinal epidural hematoma in pa-
of a hematoma from a canine model of SCI improved tients on anticoagulant medications, coagulopathy, or
recovery.19 The mechanisms of secondary injury are recent instrumentation. Typically, hematoma forma-
complex and incompletely understood, but involve tion is secondary to venous disruption and may not
hypoperfusion and hypoxia of the injured tissue, al- present acutely after injury. Neurologic symptoms are
tered vascular permeability, ionic imbalance, excito- specific to the site of hematoma formation, and MRI
Figure 2. The Denis 3-Column Model of Spinal Stability
A1 A2
AF
PLL
SSL
ALL
A3 A4
View A View B View C

View A1 demonstrates a schematic representation of the components of the 3 columns. View A2 highlights the components of the anterior column, A3
the middle column, and A4 the posterior column. View B demonstrates an anterior compression fracture with only anterior column involvement. View C
demonstrates an unstable burst fracture with both anterior and posterior columns violated.
Abbreviations: AF, annulus fibrosis; ALL, anterior longitudinal ligament; PLL, posterior longitudinal ligament; SSL, supraspinous ligament.
Francis Denis. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clinical Orthopaedics and Related Research®.
Volume 189, pages 65-76. https://journals.lww.com/clinorthop/Abstract/1984/10000/Spinal_Instability_as_Defined_by_the_Three_column.8.aspx
©1984, The Association of Bone and Joint Surgeons®.

is required for imaging. With emergent hematoma
evacuation to avoid progression of neurologic injury, Figure 3. Spinal Cord Anatomy and
patients generally have a good prognosis. Function
Other etiologies of nontraumatic SCI include
spinal epidural abscess, compressive tumor, disc Dorsal Columns
Ipsilateral vibration
Corticospinal Tract
herniation, and pathologic fractures. Close attention and proprioception
Ipsilateral motor,
to red flags such as an immunocompromised state or Upper motor neurons
history of cancer or intravenous (IV) drug use will help

identify patients most at risk. Inquire about symptoms
and signs of SCI, such as bowel and bladder dysfunc- Anterior Horn
Lower motor neurons
tion, as well as saddle anesthesia.
Spinocerebellar Tract
Ipsilateral proprioception
Spinothalamic Tract
Contralateral pain
and temperature
www.ebmedicine.net
Table 1. Incomplete Spinal Cord Injuries

Spinal Cord Syndrome Mechanism Neurologic Deficits Location of Injury (in Red)
Anterior cord syndrome • Flexion injury • Bilateral motor, light touch, and
• Vascular/atherosclerotic disease temperature below level of lesion
involving anterior spinal artery
• Disc herniation
• Iatrogenic due to cross-clamping
the aorta
Central cord syndrome • Hyperextension injury in patients • Distal upper extremity motor
with underlying spondylotic function
disease
• Intramedullary tumor
• Syringomyelia
Posterior cord syndrome • Hyperextension injury (rare) • Bilateral loss of light touch,
• Tabes dorsalis proprioception, and vibration
• Subacute combined degeneration
• AIDS myelopathy
• Friedreich ataxia
• Epidural metastasis
• Multiple sclerosis
Brown-Séquard syndrome • Penetrating injury • Ipsilateral motor function,

• Multiple sclerosis proprioception, and vibration
• Contralateral loss of pain and
temperature
Conus medullaris • Burst fractures at L1 • Symmetric involvement • Injury to distal spinal cord between
• Disc herniation • Hyperreflexia T11-L1 vertebrae
• Flexion injury • Perianal anesthesia
• Malignancy • Bowel and bladder dysfunction
Cauda equina syndrome • Disc herniation • Asymmetric involvement • Injury to lumbosacral roots from L2
• Lumbar spinal stenosis • Hyporeflexia vertebrae to sacrum
• Malignancy • Saddle anesthesia
• Flaccid paralysis below level of
injury
• Radicular pain
www.ebmedicine.net

Bilateral facet dislocations occur when a greater force of flexion also mechanically unstable
Type III causes soft tissue disruption to continue anteriorly to the annulus the superior articular facet
odontoid fibrosis of the intervertebral disk and anterior longitudinal liga-
ment, resulting in extreme instability. The forward movement of Flexion-Rotation. Rot
fracture the spine causes the inferior articulating facets of the upper ver- unstable injury visualized b
Table 2. Unstable Spinal Fractures tebra to pass upward and over the superior facets of the lower
vertebra (Fig. 36.10), resulting in anterior displacement of the
graphs (Fig. 36.13) or a com
the x-ray image reveals sym
spine above the level of injury. lateral magnified lateral ma
Fracture Type, Mechanism, and Illustration Imaging A unilateral facet disloc
Complications Shear Injury. Trauma to the head directed in an anteropos- rotation. The rotational com
terior (AP) direction may result in fracture of the odontoid one of the facet joints, wh
Type: C1 burst fracture Lateral masses of above the transverse ligaments (type I) or, more com- flexion and rotation cause th
process
C1 splayedmonly,
outwardat the base of the odontoid process where it attaches to C2 with the superior facet rid
(Jefferson fracture) (type II; Fig. 36.11). Slight angulation of the force may result in inferior facet and coming to
Mechanism: Axial loading (red leaders) and noof the fracture into the body of C2 (type III; Fig. 36.12). In this position, the disloc
extension
Complications: longer articulate
Type I with
odontoid fractures are usually stable because they are an locked in place, making CH APTER 36th
to the odontoid tip. However, if traction forces posterior ligament complex
• Transverse ligament rupture pillars of C2avulsion
(blue injuryBilateral facet dislocations occur when a greater force of flexion also mechanically unstable because they can e
injure the apical
causesand alar disruption
soft tissue ligaments, the fracture
to continue may
anteriorly to thebe the superiorAny
unstable.
annulus cervical
articular fracture
facet of the atlas. o
• Vertebral artery injury leaders) Type II odontoid fractures
fibrosis of are, by
the intervertebral diskdefinition, unstable liga-
and anterior longitudinal and are however torticollis may also
ment, resulting
often complicated in extreme instability.
by nonunion. Type IIITheodontoid
forward movement
fracturesof areFlexion-Rotation.
as a muscleRotary spasm. atlantoaxial
It may
the spine causes the inferior articulating facets of the upper ver- unstable injury visualized best on open-mou
tebra to pass upward and over the superior facets of the lower graphs (Fig. 36.13) or a computed tomograph
vertebra (Fig. 36.10), resulting in anterior displacement of the the x-ray image reveals symmetric basilar sku
spine above the level of injury. lateral magnified lateral mass confirms a C1-C
A unilateral facet dislocation is caused b
Shear Injury. Trauma to the head directed in an anteropos- rotation. The rotational component of this in
Multiple fractures in terior (AP) direction may result in fracture of the odontoid one of the facet joints, which acts as a fulc
process above the transverse ligaments (type I) or, more com- flexion and rotation cause the contralateral fac
B ring of C1 monly, at the base of the odontoid process where it attaches to C2
(type II; Fig. 36.11). Slight angulation of the force may result in
with the superior facet riding forward and
inferior facet and coming to rest within the inte
extension of the fracture into the body of C2 (type III; Fig. 36.12). In this position, the dislocated articular m
Type I odontoid fractures are usually stable because they are an locked in place, making this a stable injur
avulsion injury to the odontoid tip. However, if traction forces posterior ligament complex is disrupted.
injure the apical and alar ligaments, the fracture may be unstable. Any cervical fracture or dislocation ma
Type II odontoid fractures are, by definition, unstable and are however torticollis may also be caused by a b
often complicated by nonunion. Type III odontoid fractures are as a muscle spasm. It may be difficult to d
Type: Bilateral cervical facet

dislocation
Fracture of C2 extending
Mechanism: Flexion injury
diagonally
Facets ofinto
C6body of to
lie anterior Facets of C
C2 (type III)of(red
those leader)
C7 with severe to those of
Complications: subluxation
with subluxation of C6 on C7
• Vertebral artery injury
severe cord
• Spinal cord injury
contusion (blue leader) 352 PART II Trauma | SECTION ONE General Concepts and System Injuries
B Type III
odontoid
fracture
Fig. 36.10. A, B, Bilateral facet dislocation. Facets of C6 lie anterior to those of C
luxation of C6 on C7.
B
Fig. 36.10. A, B, Bilateral facet dislocation. Facets of C6 lie anterior to those of C7, with severe sub-
luxation of C6 on C7. F
Type: C2 dens fracture type II
(typ
(odontoid fracture) Fracture at base of odontoid process A
B Fracture at base of
Mechanism: Flexion injury (type II odontoid fracture) odontoid process
(type II odontoid fractu
Complications:
D
• Type II: transverse ligament Fracture of C2 extending
diagonally into body of
C2 (type III) (red leader)
rupture with
severe cord
contusion (blue leader)
B
B
Fig. 36.11. A, B, Odontoid fracture with lateral displacement. Mechanism—flexion; stability—unstable.
C The tip of the odontoid process is laterally displaced in this lateral flexion injury.
Fig. 36.11. A, B, Odontoid fracture with lateral displacement. Mechanism—flexion
D
Type: C2 dens fracture type III The tip of the odontoid process is laterally displaced in this lateral flexion injury.
Downloaded for Anonymous User (n/a) at Icahn School of Medicine at Mount Sinai from ClinicalKey.com by Elsevier on August
(odontoid fracture) 25, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
Mechanism: Flexion injury Downloaded for Anonymous User (n/a) at Icahn School of Medicine at Mount Sinai from ClinicalKey.com
25, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. Al
Complications:
• Type III: extension into
vertebral body
F
Fig. 36.12. A–F, Odontoid fracture, type CHA

III. PTER 36 Spinal Injuries 353
Type: Atlantoaxial dislocation Asymmetry in

Mechanism: Flexion in patients relation of lateral Downloaded for Anonymous User (n/a) at Icahn School of Medicine at Mount Sinai from ClinicalKey.com by Elsevier on August
25, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
predisposed to ligament laxity, masses of C1

eg, Down syndrome, rheumatoid to odontoid
arthritis, ankylosing spondylitis; process
rare without predisposing
condition
Complications:
• Spinal cord compression
• Chronic spinal deformity
Asymmetry in
relation of lateral
Reprinted from Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th edition. Ron Walls, Robert Hockberger, Marianne Gausche-Hill,
masses of C1 eds.
to
odontoid process
Spinal Injuries. Amy H. Kaji, Robert S. Hockberger.
Fig. 36.12. A–F, Odontoid fracture, type III. Pages 345-371. Copyright 2018, with permission from Elsevier.
d for Anonymous User (n/a) at Icahn School of Medicine at Mount Sinai from ClinicalKey.com by Elsevier on August B
021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved. Fig. 36.13. A, B, Rotatory subluxation of C1 on C2. Mechanism—rotation; stability—unstable. There is
marked asymmetry in the relationship of the lateral masses of C1 to the odontoid process. Rotation causes
Visceral Injuries Muscle Spasm
Retroperitoneal injuries and renal injuries may present Isolated neck and back pain can be concerning for
with posttraumatic back pain. Typically, this will be SCI, and a history of trauma should always be sought.
lateralizing to some degree and not associated with Consider risk factors and inciting events when deter-
other neurologic signs or symptoms. The examination mining a diagnostic and treatment plan. Difficulty in
may reveal signs of hemorrhagic shock. maintaining posture, stiffness, and unremitting pain
Vascular Injury
Vascular injury can be secondary to trauma, as in the Table 3. Stable Spinal Fractures
case of blunt cerebrovascular injury. This may present
Fractures Mechanism
as stroke, vertebrobasilar insufficiency, headache, or
• Clay-shoveler’s fracture Flexion
neck pain. Primary spinal infarction is a rare cause of • Dens fracture type I
SCI and may be seen in aortic catastrophes and severe • Transverse process fracture
hypotension, as well as etiologies typical of cerebral • Wedge fracture
infarction (emboli, atherosclerosis, hypercoagulability, • Unilateral facet dislocation Extension
and vasculitis). This results in anterior cord syndrome, • Vertebral body burst fracture Vertical compression
which consists of loss of bilateral motor, pain, and • Isolated articular pillar and
temperature sensation, with maintenance of vibration vertebral body fracture
and proprioception below the level of injury.
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Table 2. Unstable Spinal Fractures (Continued from page 6)

Fracture Type, Mechanism, and Illustration Imaging C H A P TE R 36 Spinal Inj
348 PART II Trauma | SECTION ONE General Concepts and System Injuries
Complications
Type: Atlanto-occipital dislocation
Mechanism: Flexion and rupture Anterior translation of
of transverse ligament occiput relative to atlas
Complications: CHAPTER 36
Thoracic fracture with
• Often immediately fatal anterior subluxation
Type II odontoid and compression of
spinal cord posteriorly
fracture
A
B
Fig. 36.16. A, B, MRI scan showing fracture-dislocation
B of the thoracic spine.
Fig. 36.3. A, B, Odontoid fracture with anterior dislocation. Mechanism—flexion with
Type: C2 pedicle fracture stability— unstable.
(hangman’s fracture) TABLE 36.1

Mechanism: Extension Classification of Spinal Injuries Basion (mm)
Complications: MECHANISM OF SPINAL INJURY STABILITY (mm)
• C2 anterior subluxation FLEXION Tip of

Wedge fracture Stable dens
• C2/C3 disc rupture Fracture of bilateral
Fracture of
bilateral pedicle
Flexion teardrop fracture Extremely unstable
• Disruption of posterior pedicles of C2 Clay shoveler’s fracture
Fig. 36.6. A, Lateral view of a Stable
wedge fracture of C5 with angulation. Mechanism—flexion; stability—
of C2
longitudinal ligament Subluxation

mechanically stable. B, Note the anterior wedging of the C4 vertebral body and angulation of C4 on C5.
Potentially unstable
• Spinal cord injury (rare) Bilateral facet dislocation Always unstable
Fig. 36.4. The basion-axial interval (BA
Atlanto-occipital dislocation Unstable are normally less than 12 mm.
Anterior atlantoaxial dislocation with or Unstable
without fracture
Fig. 36.17. A, B, CT scan of posterior neural arch fracture of C1. Mechanism—extension; stability—
Odontoid fracture withThe
unstable. lateral displacement
fracture Unstable
line is well visualized.
Type: Teardrop fracture fracture
Mechanism: Flexion Fracture of transverse process Stable
Vertical Compression. Vertical compression inju
FLEXION-ROTATION
Complications: B are capable o
in the cervical and lumbar regions, which
Unilateral facet dislocation Stable ening at the time of impact.
BasionWhen forces are applied fr
• Spinal cord injury Rotary atlantoaxial
Fracture dislocation Unstable
Odontoid
(skull) or below (pelvis or feet), Aone or more verte
endplates may fracture.
AnteriorThe nucleus pulposus of the inte
• Rupture of both anterior and through posterior
EXTENSION
neural arch
process
disk is forced into theofvertebral
arch atlas body, which is shattered
Flex
resulting in a burst fracture (Fig. 36.19). Sagittal CT c
posterior longitudinal ligaments Posterior neural arch fracture (C1) Unstable lateral radiograph will demonstrate a comminuted verte
• Anterior cord syndrome Flexion teardrop fracture Hangman’s fracture (C2) Unstable and there will typically be greater than 40% compress
anterior vertebral body, which helps differentiate it
Extension
Fig. 36.18. teardropfracture.
Hangman’s fracture Mechanism—extension; Usually stable insimple
stability— flexion;
wedge fracture. Coronal CT cuts and a frontal r
unstable. Fracture lines extending through the pedicles ofunstable in extension
C2 are well demonstrate a characteristic vertical fracture of the
visualized. Retropharyngeal soft tissue swelling is apparent. body. This is a stable fracture because all the ligamen
Posterior atlantoaxial dislocation, with or Unstable Fig. 36.5. The Po
without fracture
VERTICAL COMPRESSION
Bursting fracture of vertebral body Stable

Jefferson fracture (C1) Extremely unstable
Isolated fracturesFig.
of articular
36.7. A,pillar and view ofStable
B, Lateral a teardrop fracture. Mechanism—flexion; stability—unstable. The frac-
vertebral body tured fragment off the C5 body resembles a teardrop.
Reprinted from Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th edition. Ron Walls, Robert Hockberger,
Downloaded Marianne Gausche-Hill,
for Anonymous User (n/a) eds.
at Icahn School of Medicine at Mount Sinai from ClinicalKey.com by Els
25, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All right
Spinal Injuries. Amy H. Kaji, Robert S. Hockberger. Pages 345-371. Copyright 2018, with permission from Elsevier.

may warrant further investigation. Muscle pain and Immobilization
spasm can be managed symptomatically, while keep- Clinical experience has shown that patients with SCI
ing in mind that it may be concomitant with SCI. or vertebral fractures may develop delayed neu-
rological decompensation following the initial in-
sult.23-25,27,28 Cadaver studies have shown that bodily
n Prehospital Care movement may cause pathologic motion at unstable
The routine application of spinal immobilization in spinal segments, decrease the space available for the
prehospital trauma care has been advocated and spinal cord, and potentially result in cord impinge-
credited with a decrease in the number of patients ar- ment or injury. Together, these 2 observations led to
riving with complete spinal injuries.20-22 Nonetheless, the hypothesis that patient movement (either volun-
in the past decade, growing uncertainty regarding tary or due to transport) resulted in observed cases of
the causal relationship between spinal immobilization delayed neurologic decompensation and that it could
and improved outcomes and increased recognition of be prevented by utilizing specialized appliances to
the risks of immobilization have resulted in updated immobilize the patient’s spine during prehospital
prehospital spinal care paradigms. transport.29 This premise has been supported primar-
ily by cadaver and kinematic studies.
Recognition Clinical data linking spinal immobilization
Early recognition of the trauma patient who is at risk directly with improved patient outcomes or patient
for spinal injury is critical. Historically, a large percent- movement with neurologic decompensation are
age of fractures were missed, and missed spinal injury either lacking or of low quality. In 1998, Hauswald
is associated with an increased rate of neurological performed a retrospective study comparing a
deterioration.23-25 Recognition of this relationship led cohort of patients in Malaysia treated without
clinicians to advocate that all trauma patients with a prehospital immobilization to a cohort of American
possible mechanism of spinal injury be treated as if patients who were immobilized. The Malaysian
they had an unstable spine, until proven otherwise.21 cohort had a lower rate of neurological injury.27 A
This became a core principle in the evolution of pre- structured literature review from 2015 identified 12
hospital systems in the 1960s and 1970s.26 Anecdotal studies describing 41 cases of delayed neurological
reports of a reduction in the number of patients ar- injury. In the majority of cases, the timing of
riving with complete spinal lesions over this time has decompensation was surmised, based on a change
been held up as evidence of the effectiveness of this in examination between different providers and
approach.22 However, these data are of poor quality locations, without an acute decline witnessed.28
and are unable to establish causality.20 The majority of cases in which the decline was
directly attributed to movement came from a low-
quality source of evidence with a very high risk
of bias.25 A 2016 systematic review of selective
Table 4. Differential Diagnosis of Spinal prehospital immobilization protocols identified 7
Injury studies containing 76 patients who had a spinal
Traumatic Injuries
injury but were not immobilized; 72 suffered no
• Spinal fracture delayed neurologic deterioration, 4 had no follow-
• Ligamentous injury up data.30
• Neurogenic shock Multiple harms of immobilization have been
• Cord syndrome noted. A meta-analysis found the risk for pressure
l
Anterior cord syndrome
l
Central cord syndrome
ulcers associated with immobilization to be 6.8% to
l
Brown-Séquard syndrome 38%.31 Multiple systematic reviews have identified
• Referred pain additional risks, including respiratory compromise,
l
Retroperitoneal injury increased intracranial pressure, and masking of
Rib fractures additional pathology.32,33 Case reports of iatrogenic
l
• Spinal cord injury without radiographic abnormality (SCIWORA)

• Vascular injury
spinal injury resulting from attempts to immobilize
• Muscle strain patients with ankylosing spondylitis in a neutral
position suggest this is a high-risk procedure.28,34
Nontraumatic Injuries
• Spinal cord compression
• Spinal epidural hematoma Summary Recommendations
• Spinal stenosis Multiple evidence-based guidelines support selective
• Tumor immobilization and allowing for the use of alternative
• Infection methods instead of the traditional rigid cervical collar,
• Spinal fracture (pathologic)
backboard, and foam blocks.22,35-37 (See Table 5,
• Muscle spasm
page 9.) Spinal immobilization is not recommended
www.ebmedicine.net for patients with isolated penetrating trauma, as it

offers little benefit and delays time to recognition of n Emergency Department Evaluation
injuries and provision of care.22,38 The presence of a spinal injury, or the possibility
For patients with known or suspected spinal of spinal injury, can generally be ascertained with
injury, efforts should be made to reduce spinal move- a focused history and physical examination. The
ment during transport, evaluation, and treatment. presentation may be variable. Complete spinal
This may be accomplished with or without the use of cord injuries may be readily apparent, though in
specialized appliances, including long or short spinal patients with altered mental status or intoxication, a
boards, sandbags, foam blocks, or cervical collars. No high index of suspicion will need to be maintained
high-quality evidence exists to support the routine throughout the evaluation. (See Table 6, page 10.)
use of any of these instruments, and they may be
considered treatment options. The best methods to History
reduce spinal movement will be determined by physi- The history begins with handoff from EMS, if
cian experience and judgment, resource availability, available. Details such as the height of a fall, the
and individual patient characteristics. speed of travel of a motor vehicle, or the type of
impact may influence the clinical risk assessment
Table 5. Guidelines for Prehospital Spinal Immobilization22,35-37

Guideline Key Recommendations Evidence Base/Methodology
American Association of • Triage by trained EMS personnel to decide who requires immobilization • Single-specialty author group
Neurological Surgeons/ (Level II) • Single-database systematic review
Congress of Neurological • Do not immobilize patients who are awake, alert, and without: pain or • Study quality assessed using Modified
Surgeons 2013 – tenderness, abnormal neurological examination, and distracting injury North American Spine Society criteria
Theodore et al 201322 (Level II) for literature assessment
• Immobilize patients, when indicated, on long backboard with foam blocks, • Strength of recommendations: Level I
straps, and rigid cervical collar (Level III, downgraded from “guideline” in (standard), Level II (guideline), Level
prior revision) III (option)
• Do not perform spinal immobilization in penetrating trauma (Level III)
American College of • Conceptualize the goal of spinal immobilization as “spinal motion • Consensus statement by American
Surgeons Committee restriction” (SMR), as it is impossible to eliminate all movement College of Emergency Physicians,
on Trauma, American • Backboards, scoop stretcher, vacuum splint, and ambulance cot are all American College of Surgeons
College of Emergency acceptable as long as head, neck, and torso are kept in line Committee on Trauma, National
Physicians, and National • Rigid cervical collar is mandatory when SMR is applied Association of EMS Physicians
Association of EMS • Indications for providing SMR in blunt trauma are: • No structured literature review or
Physicians consensus l
Glasgow coma scale score <15 or intoxication assessment
statement – Fischer et al l
Midline neck or back pain or tenderness • No grading of recommendations
201837 l
Focal neurological sign or symptom
l
Distracting injury
Norwegian guidelines – • Patients with spinal injury should have spinal stabilization (Strong) • Multidisciplinary author group
Kornhall et al 201736 • A minimal handling strategy should be followed (Strong) • Multidatabase systematic review
• Spinal stabilization should not delay life-saving interventions (Good • Study quality assessed using
Clinical Practice) GRADE methodology
• Victims of isolated penetrating trauma should not be immobilized (Strong) • Recommendations rated as Strong or
• Triaging tools based on clinical findings should be implemented (Strong) Conditional based on balance of
• Cervical stabilization may be achieved with manual in-line stabilization, harms/benefits
foam blocks, or a rigid collar or combination (Conditional) • Good Clinical Practice for “obviously
• Transfer from ground to stretcher should be performed with a scoop rational” recommendations with
stretcher (Conditional) heterogenous literature
• Patients with a potential spinal injury should be transported on a vacuum
mattress or ambulance stretcher (Conditional)
• Hard-surface stretcher systems should be used for transports of shorter
duration only (Conditional)
Danish guidelines – • Adult trauma patients should not undergo spinal stabilization with a rigid • Multidisciplinary author group
Maschmann et al 201935 cervical collar (Weak) • Multidatabase systematic review
• Adult trauma patients should not undergo spinal stabilization on a hard • Study quality assessed using
backboard unless unstable, where other spinal stabilization measures GRADE methodology
would be more time-consuming (Weak) • Recommendations rated as Strong,
• Recommend immobilization with vacuum mattress for stable patients with Weak, or Good Clinical Practice
midline spinal pain or focal deficit (Weak) based on balance of harms/benefits
• Isolated penetrating injury should not undergo spinal stabilization (Strong)
Abbreviations: EMS, emergency medical services; GRADE, Grading of Recommendations Assessment, Development, And Evaluation.
www.ebmedicine.net

and decision to risk-stratify a patient based upon way obstruction occurred in 5% of the patients.44 The
validated clinical decision rules.39 Information onset of airway obstruction may be delayed by hours
regarding potential or witnessed neurological deficits or days, suggesting a need for ongoing evalua-
should be sought, and specific attention paid to tion outside of the acute resuscitative period.44 The
the best motor function observed by paramedics. presence of stridor, hoarseness, or muffled voice in a
It is helpful to document the presence and type of patient with a high cervical spine injury should raise
prehospital spinal immobilization applied. concern for developing airway obstruction; consider
The patient history should elucidate specific early intubation, as the procedure may become more
symptoms of spinal injury, including pain to the neck difficult or impossible with increasing mass effect.43
or back, paresthesias, numbness, or weakness of the
extremities. Details regarding the mechanism of injury Breathing
should be sought from the patient. A review of the Respiratory complications are the most significant
patient’s past medical and surgical history should be cause of morbidity and mortality following SCI. With
attuned to conditions that may confer an increased cervical injuries, there is an immediate and transient
risk of spinal injury such as prior spinal surgeries, an- decrease in vital capacity and negative inspiratory
kylosing spondylitis, osteoporosis, or chronic cortico- force that recovers after several days to weeks.47-50
steroid use.40,41 Neuromuscular weakness can lead to hypoventilation,
hypercarbia, impaired clearance of secretions, and
Physical Examination frank hypoxemia. Careful attention to work of breath-
Airway ing and continuous assessments of pulse oximetry
Cervical spine trauma is frequently associated with are recommended.49 Systemic hypoxemia must be
additional cranial injuries that may lead to loss of pro- avoided, as this may exacerbate secondary neuro-
tective airway reflexes.42 Mechanical airway obstruc- logical injury. The efficacy of ventilation should be
tion may also occur as a direct complication of cervi- assessed; some authors advocate routine monitoring
cal spine injury due to prevertebral hematoma and/ of end-tidal CO2 and ongoing assessment of pulmo-
or severe alterations in anatomy.43-46 In a case series nary function tests, though no trials are available to
of 343 patients with isolated atlantoaxial fractures, air- support this practice.51,52
Circulation
Table 6. Immediate Life Threats in Spinal SCI may precipitate neurogenic shock due to inter-
Cord Injury ruption of the sympathetic fibers exiting from the T1-
Element of Immediate Life Treatment and Monitoring
T4 levels, with resulting loss of vasomotor tone and
Primary Threat cardiac output. The incidence of neurogenic shock
Survey has been reported to be as high as 43% in patients
Airway Airway obstruction • Perform early intubation with cervical and high thoracic SCI, but there is no
due to hematoma if patient is developing single agreed-upon definition of the condition.53,54
signs of obstruction During the resuscitation of a multiply injured patient,
• Maintain close clinical
monitoring of airway
it may be clinically difficult or impossible to determine
patency the exact etiology of shock; the dogma has been to
Breathing Respiratory • Consider early intubation treat shock in trauma as hemorrhagic until proven
insufficiency or in high cervical injuries otherwise, as inappropriate vasopressor use in the
failure due to • Maintain continuous setting of hemorrhage may worsen outcomes.55
neuromuscular monitoring of peripheral
weakness oxygen saturation
Disability
• Consider frequent blood
gas monitoring A rapid neurological examination conducted during
• Consider use of the initial resuscitative phase assesses the level of
continuous end-tidal consciousness and motor function of the upper and
capnography and/or lower extremities. A reasonable practice may be to
serial measurements of
test flexion of the fingers (C8) of both upper extremi-
pulmonary function
ties and plantarflexion (S1) in both lower extremities,
Circulation Systemic • Rapidly differentiate from
hypotension due other causes of shock,
along with sensation to light touch. A more thorough
to neurogenic ensure euvolemia, and examination can be conducted on secondary survey.
shock initiate vasopressor early
• Perform continuous blood Exposure
pressure monitoring
Quickly expose the patient to evaluate for occult
• Consider placement of
arterial catheter
injuries. Minimize motion during the process by cut-
ting the patient’s clothes rather than attempting to
www.ebmedicine.net remove them intact.

Secondary Survey n Diagnostic Studies
During the secondary survey, the patient should Decision Rules in Imaging
be rolled over, and the back surveyed for signs of The decision to image the cervical spine can be reli-
trauma. The spine should be palpated for signs ably supported by validated clinical decision tools
of injury, including step-offs or spinal tenderness. from the National Emergency X-Radiography Utiliza-
Routine performance of a digital rectal examination tion Study (NEXUS) and a 2001 prospective cohort
has been recommended to evaluate for rectal tone; study in Canada over 4 years, known as the Canadian
however, 2 retrospective cohort studies demonstrated C-Spine Rule (CCR).39,60 (See Table 7 and Figure 4.)
that it had poor sensitivity (8%-50%) for the diagnosis These clinical decision rules aim to reduce unnecessary
of spinal injuries.56,57 cervical spine imaging while optimizing sensitivity for
detection of injury. The NEXUS criteria explicitly iden-
Neurological Assessment tify low-risk patient presentations, whereas the CCR
A reliable and repeatable assessment of neurological considers patient factors, mechanism of injury, and
function following spinal injury is critical to providing dynamic testing to identify low-risk patients. A system-
clear communication between clinicians, monitoring atic review of 15 validation studies as well as 1 study
for clinically significant deterioration, and providing directly comparing the performance of the 2 rules on
some degree of prognostic value to patients and their the same patient cohort demonstrated the increased
families.58 The American Spinal Injury Association (ASIA) sensitivity of CCR over NEXUS.61,62 Reported specifici-
international standards are the most widely used tool for ties of the rules vary widely and may reflect differing
grading spinal injuries. (See Appendix, page 18.) The real-world interpretation. (See Table 8, page 12.)
ASIA standards have excellent interrater reliability and When risk-stratifying the thoracolumbar spine,
are recommended by evidence-based guidelines. physical examination alone is insufficient to rule out
To determine the level of impairment, begin significant pathology.63 A proposed clinical decision
by assessing the sensory level on each side by rule for thoracolumbar fracture was published in
determining the caudal-most dermatome in which 2015. In a multicenter prospective study of 3065
both light touch and pinprick sensation are intact.
Next, determine the motor level by determining
the caudal-most muscle group in which strength is Figure 4. The Canadian C-Spine Rule39
at least 3/5. Next, determine whether the injury is
incomplete by assessing for sacral sparing. Ask the
patient to voluntarily contract the anus and assess for High-risk factors? NO Low-risk factors?
pinprick and light touch sensation in the S4 and S5
dermatomes as well as sensation to pressure on the YES NO YES
lateral rectal wall. Presence of any sensation indicates
an incomplete injury. In patients with complete injury
or in whom only partial sacral sparing is present Imaging indicated
(isolated motor or sensory), assess for zones of partial
Able to actively
preservation. A zone of partial preservation is any
rotate neck 45°
level caudal to the sensory or motor level that remains NO bilaterally?
innervated (sensation intact or motor score of ≥3) for
that domain in which there is no sacral sparing; the Imaging not indicated YES
presence of zones of partial preservation is one of the
strongest predictors of recovery in clinically complete
High-Risk Factors Low-Risk Factors
lesions.50,59
• Age ≥65 years • Simple rear-end motor vehicle crash
• Dangerous • Sitting position in ED
mechanism • Ambulatory at any time
Table 7. The NEXUS Low-Risk Criteria for • Paresthesias in • Delayed onset of neck pain
Cervical Spine Imaging60 extremities • No midline cervical-spine tenderness
Trauma patients require imaging unless they meet ALL of the Exclusion Criteria
following criteria:
1. No focal neurologic deficit. • Acute paralysis • Pregnancy
2. No posterior midline cervical spine tenderness to palpation. • Age <16 years • Return visit for same injury
3. Patient displays normal level of alertness. • GCS score <15 • Prior vertebral disease,
4. No evidence or suggestion of intoxication. • Grossly abnormal vital signs eg, ankylosing spondylitis,
5. No clinically apparent painful distracting injuries. No injuries • Injury >48 hours rheumatoid arthritis
deemed distracting, on physician discretion. • Penetrating trauma • Prior spinal surgery
Abbreviation: NEXUS, National Emergency X-Radiography Utilization

Study. Abbreviations: ED, emergency department; GCS, Glasgow Coma Scale.

patients, the tool demonstrated a sensitivity of acute central cervical SCI without appreciable spinal
98.9% and negative predictive value of 99.6% for cord edema is predictive of full recovery. Routine
detecting clinically significant injuries.64 Though this preoperative MRI may guide management and has
tool appears promising, it is still pending prospective been associated with a minimal improvement in
validation. (See Figure 5.) functional outcome.69
Plain Films Assessing Ligamentous Stability

Three-view plain films (lateral, anteroposterior, The patient with negative CT but persistent, severe
and open-mouth odontoid views) have been midline pain, or signs or symptoms concerning
largely overshadowed by CT due to the superior for neurologic injury represents a challenge. CT is
diagnostic performance of CT. The complete cervical insensitive for ligamentous injury that may cause
spine 3-view series has a wide range of reported instability without bone injury. When clinical concern
sensitivities, from 37% to 64%.65 Plain films are no exists, there are several options: Consider obtaining
longer recommended as a first-line imaging modality dynamic flexion/extension radiographs or an
for adult patients with suspected cervical injury MRI; continue cervical spinal immobilization until
except for instances in which CT is unavailable.65 asymptomatic; or discontinue spinal immobilization
They remain an option for children.66
Computed Tomography
CT is supported as first-line imaging for moderate- Figure 5. Thoracolumbar Imaging Clinical
to high-risk patients with presentations and/or Decision Tool
symptoms concerning for SCI. CT has sensitivity for
spinal injury reported between 90% and 100%.67 In
Alert and evaluable? NO
polytrauma, CT requires less time and is more cost-
effective than multiple-view plain films.65 MRI should
be performed for optimal visualization of the spinal YES
cord, but paravertebral structures can be visualized
on CT as well. Positive physical exam?
• Pain
• Tenderness to YES
Magnetic Resonance Imaging palpation
MRI is the imaging modality of choice when clinical • Deformity
findings are suggestive of SCI, as it may optimize • Neurologic deficit
visualization of the site of a cord lesion and
NO
associated traumatic injuries. Imaging in early injury
is described as “highly dynamic,” emphasizing the
need for temporal context with interpretation.67 Early High-risk mechanism?
MRI, ideally within 3 hours of symptom onset, may • Fall
• Crush injury
identify irreversible damage and assess functional • Motor vehicle crash with YES Imaging indicated
prognosis.68 For example, upper extremity deficits in rollover/ejection
• Unenclosed vehicle crash
• Automobile vs pedestrian
An online tool for the NEXUS NO

Criteria for C-Spine Imaging is
available at: https://www.mdcalc.
com/nexus-criteria-c-spine-imaging Age ≥60 years? YES
An online tool for the Canadian C-Spine Rule NO

is available at: https://www.mdcalc.com/
canadian-c-spine-rule
Imaging not indicated
Table 8. Comparison of NEXUS Criteria Kenji Inaba, Lauren Nosanov, Jay Menaker, et al. Prospective derivation
and Canadian C-Spine Rule62 of a clinical decision rule for thoracolumbar spine evaluation after
blunt trauma: an American Association for the Surgery of Trauma
Decision Rule Sensitivity Specificity Multi-Institutional Trials Group Study. The Journal of Trauma and
Acute Care Surgery. 2015. Volume 78, Issue 3. © 2015 American
NEXUS 0.83-1.00 0.02-0.46 Association for the Surgery of Trauma. https://journals.lww.com/jtrauma/
Canadian C-Spine Rule 0.90-1.00 0.01-0.77 Abstract/2015/03000/Prospective_derivation_of_a_clinical_decision_
rule.2.aspx

on the strength of a negative CT.65 Flexion/extension n Treatment
films have been used to evaluate for ligamentous Supportive Care
stability, but they are frequently nondiagnostic and Airway Management
may be insensitive.70 MRI has good sensitivity for Historically, dogma dictated that the only way to
ligamentous injury, but may be overly sensitive safely intubate a patient with known or suspected spi-
and identify clinically insignificant findings. In a nal injury (including those with head injury) was via a
prospective cohort of 2854 trauma patients, 93 nasotracheal or surgical approach.76,77 This was based
patients with persistent cervical spine pain but on anecdotal reports of neurologic decompensation
without neurologic deficits or traumatic findings on related to intubation and anatomical data suggesting
CT underwent a subsequent MRI; none had clinically that direct laryngoscopy causes pathologic motion
significant findings. This suggests that, in a patient and potential cord impingement at unstable spinal
with a normal CT and normal motor examination, no segments.77-79 With rates of intubation in cervical
further imaging is warranted.71 spine-injured patients as high as 74% to 92%, it is im-
perative that the emergency clinician be familiar with
Assessing for Vascular Injury the safety concerns surrounding intubation.47,80
Blunt cerebrovascular injury may occur with or without In the 1980s and 1990s, the dogma against
spinal injury and is associated with increased risk for orotracheal intubation was challenged by evidence
stroke.72 Digital subtraction angiography remains demonstrating that it could be performed safely
the gold standard for diagnosis, but CT angiography with the aid of cervical stabilization.81-83 Currently,
with a 16-slice or greater scanner has demonstrated a fiberoptic nasotracheal and direct and video-assisted
high sensitivity, and its use as the primary diagnostic orotracheal intubation are all utilized in the operating
modality to identify cerebrovascular injury is endorsed room.84 For patients requiring emergent intubation,
by guidelines.72-74 CT angiography should be an orotracheal approach with rapid sequence
obtained on patients with high-risk cervical spine induction and muscular relaxation performed with
fractures (eg, fractures involving C1-C3, fractures continuous cervical stabilization is generally preferred
extending into the transverse foramen, or in cases and may be accomplished safely.81,82,85-87
of vertebral subluxation), and clinicians should Maintaining manual inline stabilization of the
consider routine CT angiography in all patients with cervical spine during orotracheal intubation is recom-
cervical spine fractures.74 In addition, a screening tool mended despite the fact that it may worsen the laryn-
should be used to identify patients with craniofacial goscopic view, and the anatomic evidence supporting
trauma without spinal injury who are at high risk its efficacy is conflicting.26,88 Nonetheless, decades
for cerebrovascular injury; the modified Denver of clinical experience and multiple case series have
criteria are recommended by multiple practice failed to cast doubt on its efficacy, and the existence
guidelines.72-74 (See Table 9.) Cerebrovascular injury of a few compelling single-case reports linking new
may be managed with antithrombotic therapy and/ neurological injury with orotracheal intubation per-
or endovascular intervention.72,75 Routine screening formed without manual inline stabilization suggests
of asymptomatic patients without high-risk features is that this is a real—if perhaps overstated—risk.45,76,89
not recommended by guidelines, and it may identify The optimal technique for orotracheal
additional injuries, with uncertain benefits.72,74,75 intubation of the spine-injured patient is unknown.
Video laryngoscopy, with either a traditional or
hyperangulated blade, has theoretical advantages
in terms of overcoming the limitations of the glottis
opening associated with cervical stabilization and
Table 9. Modified Denver Screening
decreased cervical spinal motion as compared to
Criteria for Blunt Cerebrovascular direct laryngoscopy, yet 2 studies showed that video
Injury72-74 laryngoscopy does not appear to reduce cervical
Signs and Symptoms Risk Factors spinal motion during the procedure, at least in
destabilized cadaveric cervical spines or healthy live
• Arterial hemorrhage High-energy transfer mechanism with:
subjects.90,91 A 2020 systematic review did find that
• Cervical bruit • LeFort II or III fracture
• Expanding cervical • Cervical spine fracture video laryngoscopy was superior in terms of first-pass
hematoma • Fractures extending into transverse success and time to successful intubation but, overall,
• Focal neurological foramen the rate of secondary neurological injury was low, with
deficit • C1-C3 fractures no difference between direct laryngoscopy, video
• Ischemic stroke on CT • Basilar skull fracture with carotid
laryngoscopy, and fiberoptic approaches.92
canal involvement
• Diffuse axonal injury with GCS = 6 Concerns exist with the use of video
• Near-hanging with anoxic brain injury laryngoscopy in patients with craniofacial trauma,
due to the presence of blood in the airway, but this
Abbreviations: CT, computed tomography; GCS, Glasgow coma scale. does not preclude successful video laryngoscopy.93

Use of the bougie introducer has demonstrated Medical Therapy
improved first-pass success in patients undergoing Though once standard, corticosteroids have fallen
manual inline stabilization.94 An optimal first-line out of favor and are not recommended by the ASNS/
approach to the emergent intubation of the spine- CNS, but are offered as a treatment option by the
injured or immobilized patient may be to utilize video AO Spine association guidelines.69 The best data
laryngoscopy with a standard Macintosh geometry on corticosteroid efficacy are from a prospective
blade and a bougie; this approach allows easy randomized controlled trial where high-dose
conversion between direct and indirect laryngoscopy, methylprednisolone (30 mg/kg IV bolus plus infusion
depending on the airway conditions encountered, of 5.4 mg/kg/hr for 23 hours) was compared to
while maximizing the chances for first-pass success. naloxone and placebo (NASCIS 2). In the subgroup
of patients who received treatment within 8 hours of
Blood Pressure Augmentation injury, there was a small but statistically significant
Systemic hypotension and resulting spinal cord improvement in motor score (4.8 points out of 70).101
hypoperfusion are thought to exacerbate secondary Methodological and data-reporting challenges as
neurological injury. Hypotension (SBP <90 mm Hg) is well as the uncertain clinical significance of this
to be avoided. Multiple case series have suggested improvement make interpretation of these data
that aggressive ICU care involving some combination challenging.102 As well, there were trends to greater
of volume loading, hemodynamic support, and harm in the corticosteroid group. In NASCIS 3,
optimized oxygenation improved outcomes; from a 24-hour versus 48-hour regimen of high-dose
these findings emerged the common practice of corticosteroids was also compared, and there was a
blood pressure augmentation.49 Current guidelines significant increase in pneumonia and sepsis with the
recommend maintaining a mean arterial pressure 48-hour regimen.103
(MAP) in the range of 85 to 90 mm Hg for the first 7 A Cochrane review concluded that 24 hours of
days following injury.49 Other studies have suggested methylprednisolone administered within 8 hours of
that a lower target MAP may be effective if it is injury resulted in a 4-point improvement in the motor
maintained reliably.95 score at 6 months compared with placebo.103 We would
The overall quality of the data supporting this not recommend that the emergency clinician routinely
practice is low, with no randomized controlled trials treat with high-dose corticosteroids; however, they
available to guide therapy.96 A high-quality systematic may be an option if recommended by a consultant.
review on this found the effect of MAP augmentation Corticosteroids are contraindicated in penetrating
was uncertain; some observational studies demonstrated trauma and with concomitant head trauma.
benefit, while the largest and highest-quality studies
available failed to show an effect.96 Adverse events with Surgical Therapy
this practice—most notably, myocardial ischemia and Closed Reduction
dysrhythmias—are frequent.96,97 Closed reduction of cervical dislocations and fracture
More recently, authors have demonstrated dislocations may resolve ongoing spinal cord
that spinal cord perfusion pressure (SCPP) predicts compression. An orthosis is affixed to the calvarium
functional recovery (SCPP = MAP − cerebrospinal via screws, and weight is applied to provide axial
fluid pressure), prompting strategies aimed at the traction to reduce the deformity.104 In case series,
targeting of spinal cord perfusion pressure rather it has proven effective, with 27% to 93% of patients
than rigid MAP goals.96,98 Observational and case- achieving reduction.105 Over-distraction is a potential
controlled studies have shown a trend toward complications. The procedure is safe if performed in
improvement with spinal cord perfusion pressure- awake patients and is recommended if there are no
targeted strategies. injuries rostral to the dislocated segment.105
Overly aggressive volume loading with crystalloid
fluids or blood products may also be deleterious, Decompression
particularly in the patient at risk for respiratory Surgical spinal decompression with or without
embarrassment.99 If the presentation and initial stabilization of bony or ligamentous injuries may be
trauma evaluation suggest that there is low suspicion performed to relieve ongoing cord compression. It
for hemorrhage, then conservative volume loading seems that early decompression (within 24 hours of
with early vasopressor use may be an optimal strategy injury) results in an increased likelihood of clinical
for hemodynamic support. No definitive evidence improvement in cervical but not thoracic SCI.
supports the use of one vasopressor over others; use This is supported by several systematic reviews
of phenylephrine, norepinephrine, and dopamine based on primarily retrospective data as well as
have been reported in the literature.54,100 one prospective cohort study.106-108 Previously,
decompression was prioritized for patients with
incomplete injuries because they were presumed to
have a better chance of functional recovery; however,

in one meta-analysis, it appears that patients with immobilization are typically sufficient to treat patients
complete cervical cord injury seem to benefit most who present early, while surgical reduction and fixation
from early decompressions.109 may be required in delayed presentations.66
Spinal fractures without neurological injury
may be treated with internal stabilization, external SCIWORA
fixation with a halo orthosis, or functional bracing. Spinal cord injury without radiographic abnormality
The decision for treatment modality will depend on (SCIWORA) is a primarily pediatric phenomenon de-
the nature of the fracture, anatomic and functional fined as “objective signs of myelopathy as a result of
stability, and physician experience. trauma,” with no evidence of fracture or ligamentous
instability (excluding MRI findings).113 It is presumed
to result from the laxity of children’s connective tissue,
n Special Populations allowing pathologic vertebral motion and cord injury
Pediatric Patients in the setting of trauma, without resultant bony injury
Pediatric spinal injury represents a unique challenge, or dislocation. Onset of myelopathy may be delayed
given the anatomic and physiologic considerations of by several days. Clinicians must be attuned to a his-
the pediatric spine. tory of transient neurologic symptoms associated with
trauma that might portend recurrent injury.66,113 SCI-
Atlantoaxial Rotatory Fixation WORA is definitionally associated with a stable spine
Atlantoaxial rotatory fixation (AARF) (also known as and is typically managed with short- or medium-term
subluxation) occurs primarily in children, and it has bracing.66 SCIWORA may be thought of as somewhat
been linked to minor trauma, pharyngeal infections, analogous to central cord syndrome in adults, though
and surgery. It occurs when the normal rotation of C1 the latter is generally associated with pre-existing cer-
on C2 becomes fixed.66 The clinical presentation is that vical stenosis and buckling of a calcified ligamentum
of torticollis, with the head turned toward one side and flavum, as opposed to ligamentous laxity.
tilted to the other, with an inability to turn the head
past midline.110 (See Figure 6.) Children with AARF
are generally thought to be well appearing; however, n Controversies and Cutting Edge
in a case-control study, focal neurological complaints Stem Cell Treatment
were reported in 14% of children with AARF versus 6% Advances in pluripotent stem (iPS) cells and their
of children without cervical spine injury.111 Diagnosis use in neuronal regeneration may be a promising
may be suspected based on anteroposterior radio- treatment in SCI. A 2016 review showed the variability
graphs or CT. A dynamic 3-position CT protocol in of stem cell transplantation and its preclinical data.
which images are obtained in the neutral, right-sided, The goal is to improve functional and physiologic
and left-rotated positions appears to have better recovery in SCI safely and reliably; however;
sensitivity for the diagnosis.112 Closed reduction and there is currently no consensus on its clinical use
Figure 6. Atlantoaxial Rotatory Fixation
A B C
View A: The classic "cock-robin" appearance of atlantoaxial rotatory fixation. View B: Dynamic CT image showing left lateral mass of C1 (red arrow) fixed
anterior to left lateral mass of C2 (green arrow) in both rightward (view B) and attempted leftward head rotation (view C).
WA Phillips, RN Hensinger. The management of rotatory atlanto-axial subluxation in children. Journal of Bone & Joint Surgery. Volume 71, Issue 5.
Pages 664-668. © 1989 American Orthopaedic Association. https://journals.lww.com/jbjsjournal/Abstract/1989/71050/The_management_of_rotatory_
atlanto_axial.4.aspx

and benefit.114 Animal models are being used to n Time- and Cost-Effective Strategies
regenerate astrocytes, neurons, and oligodendrocytes • Utilize clinical decision rules when deciding
in spinal contusion models. In 2018, the first neural whether to obtain imaging of the cervical spine.
stem cell transplantation in humans bore promising For patients in whom clinical decision rules are
results. Two of the 4 recipients showed motor and not applicable because of altered mental status
sensory improvement, while all 4 tolerated the due to a rapidly reversible cause (ie, drug or alco-
transplantation without complication.115 hol intoxication) and who have an otherwise nor-
mal neurological examination, consider maintain-
ing spinal motion restriction with close neurologic
n Disposition observation and reassessing once the patient has
Patients with SCI should be cared for at a center returned to baseline.
with the neurosurgical expertise to manage their • Remove patients from rigid backboards as soon
injuries. A systematic review found only low-quality as possible. Spinal motion restriction may be ac-
retrospective data that suggested admission to a complished by allowing the patient to lie supine
specialized spine injury center may reduce length of on a hospital gurney and transferring with log-roll
stay and complications.116,117 Multiple case series precautions. Early discontinuation of rigid boards
show improvement in outcomes of SCI patients who improves patient comfort and reduces the risk for
underwent routine ICU admission and structured pressure injuries.
treatment protocols, compared to historical controls • Obtain early surgical consultation for patients for
who did not routinely receive ICU-level care.49 High- whom there is a high suspicion for spinal injury.
quality retrospective studies demonstrate a high This may facilitate more rapid decision-making
rate of cardiopulmonary compromise, especially with regard to the type and extent of imaging
with higher cervical spine injuries.47,53,80 Therefore, and facilitate an earlier disposition.
admission to an ICU is recommended. • Consider CT angiography for patients with risk
Most neurologically intact patients with a diag- factors for blunt cerebrovascular injury. In patients
nosed spinal fracture without SCI warrant hospital with concomitant thoracic and/or abdominal
admission. The exception may be those with isolated trauma, consider obtaining CT angiography as
stable fractures that can be managed with a cervical part of the initial radiographic evaluation to avoid
collar or thoracolumbar bracing. It is reasonable to repeat dosing of iodinated IV contrast agents.
pursue orthopedic or neurosurgical consultation for
all patients with a spinal fracture in order to, at a mini-
mum, review the case and arrange outpatient follow-
up. Telephone or telehealth consultation may be ap-
propriate in institutions where neurosurgical consulta-
tion is not readily available. Patients who have been
determined to not have a spinal injury may be dis-
charged home without consultation. It is prudent to Table 10. Summary of Key Updates in
advise patients of warning signs of deterioration that
Management of Spinal Injuries
should prompt return to the emergency department.
Development of paresthesias, numbness, weakness, Anatomy and Updates Based on AO Spine Fracture
or clumsiness of the extremities; changes in bowel or Pathophysiology Classification
bladder habits; or altered sensation of the perineum Prehospital care • Application of selective rather than routine
spinal immobilization
or genitals are worrisome signs that demand immedi-
• Avoidance of backboard and use of
ate evaluation.24 alternative methods of spinal motion
restriction
Diagnostic studies • Development of thoracolumbar spine clinical
n Summary decision rules
Spinal injuries represent a significant challenge to • Recommendation of CT as first-line modality
emergency clinicians. Management requires expert for diagnostic imaging
• Addition of CT angiography for diagnosis of
decision-making from the risk-stratification of well-
vertebral artery injury
appearing patients to managing respiratory failure
Treatment • Application of video laryngoscopy and bougie
and shock in those with high cervical spine injuries. to improve success in intubation
Despite decades of experience with the care of • AANS/CNS recommendation against use of
spine-injured patients, there is little high-quality corticosteroids in treatment
data to answer many questions that arise during the
acute resuscitation. Nevertheless, some important Abbreviations: AANS, American Association of Neurological Surgeons;
CNS, Congress of Neurological Surgeons; CT, computed tomography.
advancements in care have been made in the past
decade. (See Table 10.) www.ebmedicine.net

Case Conclusions
For the 24-year-old man found down with head trauma…
You asked whether the patient was breathing spontaneously or whether he was showing signs of airway
obstruction such as stridor, hoarseness, or muffled voice. EMS responded that the patient was breathing
spontaneously and not showing any of these signs, so you recommended that the paramedics provide
spinal motion restriction without definitive airway management.
Upon his arrival, you decided the patient required intubation, and you anticipated challenges in terms
of minimizing spinal manipulation. You identified teammates who would be responsible for intubation and
maintaining inline immobilization. You verified the availability of 2 working suction catheters, bag-valve
mask, and monitors with oxygen saturation and end-tidal capnography.
CASE 1
You decided to use a video laryngoscope with a standard geometry Macintosh blade and bougie,
but made sure to have a hyperangulated blade, laryngeal mask airway, and surgical airway supplies
available. You reviewed with the team your plan for the first, second, and third attempts. You pretreated
the patient with IV fentanyl because you were concerned for concomitant head injury. You chose etomidate
and rocuronium, based on your patient’s hemodynamic status and your concern for head injury. You
preoxygenated him with a nonrebreather mask, avoiding hyperventilation.
Once medications were pushed and the patient was sedated and paralyzed, you had your colleague
remove the cervical collar and hold the c-spine throughout the intubation. You were able to get a grade 2
view of the cords using direct laryngoscopy and passed the bougie with no difficulty. Your patient did not
desaturate. After intubation, you rushed him to CT, where you confirmed a type 2 odontoid fracture and
intraparenchymal hemorrhage.
For the 64-year-old man who walked into the ED complaining of left-sided neck pain after he was in a
head-on car crash…
You recognized that this patient was a candidate for the Canadian cervical spine rule. You started by
determining whether he had any high-risk factors, and noted that he was 64 years old and had no extremity
paresthesia. His MVC was at a relatively low speed, and airbags were not deployed. Though it was not
suggestive of a particularly dangerous mechanism, you asked to see photos of the car and obtained more
CASE 2
information.
Next, you determined the presence of any low-risk factors. He had delayed onset of pain, only
paraspinal tenderness, and was ambulatory immediately after the incident. Before you proceeded
to dynamic testing, he was able to pull up a photo of the car on his phone, and it looked completely
deformed. You decided this qualified as a high-risk mechanism, so you placed your patient in a rigid
C-collar and obtained a CT of the cervical spine. Fortunately, there were no clinically significant findings on
imaging. You removed the collar and confirmed that he had no midline spinal tenderness and neurologic
deficit. He was discharged with a plan for primary care follow-up in 1 week.
For the young woman who was thrown from a horse onto her head and back…
You suspected a spinal injury and neurogenic shock; however, you wanted to avoid anchoring bias. You
placed 2 large-bore IVs and called for blood. An E-FAST exam was negative, the pelvis felt stable on exam,
and radiographs were negative. On the monitor, you noted sinus bradycardia, with a heart rate of 56 beats/
min and a blood pressure of 82/38 mm Hg.
CASE 3
The patient’s riding partner arrived and was able to tell you that she was thrown from the horse, landed
directly on her head, had no apparent thoracoabdominal injury, and was unable to move. The patient
had weak grip and no movement in her lower extremities. You decided that this was most consistent
with neurogenic shock and started norepinephrine at 5 mcg/hr. Her blood pressure improved to 125/90
mm Hg. CT scan demonstrated C5/C6 bilateral locked facets without evidence of hemorrhage. Your
neurosurgical colleagues rapidly came to the bedside and performed closed reduction. In discussion with
the neurosurgical team, you ultimately decided not to administer methylprednisolone, as there is not strong
evidence supporting improved outcomes.

Appendix. The American Spinal Injury Association Spinal Assessment Worksheet
INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name Date/Time of Exam
CLASSIFICATION OF SPINAL CORD INJURY
Examiner Name Signature
(ISNCSCI)
SENSORY SENSORY
RIGHT
MOTOR
KEY MUSCLES KEY SENSORY POINTS
Light Touch (LTR) Pin Prick (PPR)
KEY SENSORY POINTS
Light Touch (LTL) Pin Prick (PPL)
MOTOR
KEY MUSCLES LEFT
C2
C2
C2
C3 C3
C4 C2
C4
C3
C5
C3
C5
UER Wrist extensors C6 C4 C4
C6 Wrist extensors UEL
(Upper Extremity Right) Elbow extensors C7 T3
T2
C7 Elbow extensors (Upper Extremity Left)
C5
C8 C8
T4
T5
T1 T6 T1
T2 T7
T2
Comments (Non-key Muscle? Reason for NT? Pain? MOTOR
C8
T8
C6
Non-SCI condition?): T3 T3
C7
T1
T9 (SCORING ON REVERSE SIDE)
T4 Dorsum
T10 C6
T4 0 = Total paralysis
T5 T5 1 = Palpable or visible contraction
T11
2 = Active movement, gravity eliminated

T6 T6
T12
L1 3 = Active movement, against gravity
4 = Active movement, against some resistance
T7 Palm T7 5 = Active movement, against full resistance
T8 T8 NT = Not testable
S3 0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present
T9 L2
Key Sensory
Points
T9
T10 S4-5
T10 SENSORY
(SCORING ON REVERSE SIDE)
T11 L T11 0 = Absent NT = Not testable
T12 T12
2
L3 1 = Altered 0*, 1*, NT* = Non-SCI
L
S2 2 = Normal condition present
L1 3
L1
L2 L2
LER Knee extensorsL3 L3 Knee extensors LEL
(Lower Extremity Right) L4 L4
L4 (Lower Extremity Left)
Long toe extensors L5 L
4
L5
L5 Long toe extensors
S1 S1 S1
L5
S2 S2
S3 S3
(VAC) Voluntary Anal Contraction (DAP) Deep Anal Pressure
(Yes/No) S4-5 S4-5 (Yes/No)
RIGHT TOTALS LEFT TOTALS
(MAXIMUM) (50) (56) (56) (56) (56) (50) (MAXIMUM)
MOTOR SUBSCORES SENSORY SUBSCORES
UER +UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL
MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)
NEUROLOGICAL R L 4. COMPLETE OR INCOMPLETE? (In injuries with absent motor OR sensory function in S4-5 only) R L
3. NEUROLOGICAL 6. ZONE OF PARTIAL SENSORY
LEVELS 1. SENSORY Incomplete = Any sensory or motor function in S4-5
LEVEL OF INJURY
2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION MOTOR
as on reverse Most caudal levels with any innervation
Page 1/2 REV 04/19

This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
Muscle Function Grading ASIA Impairment Scale (AIS) Steps in Classification

0 = Total paralysis The following order is recommended for determining the classification of
1 = Palpable or visible contraction individuals with SCI.
A = Complete. No sensory or motor function is preserved
2 = Active movement, full range of motion (ROM) with gravity eliminated in the sacral segments S4-5. 1. Determine sensory levels for right and left sides.
3 = Active movement, full ROM against gravity The sensory level is the most caudal, intact dermatome for both pin prick
B = Sensory Incomplete. Sensory but not motor function and light touch sensation.
4 = Active movement, full ROM against gravity and moderate resistance in a is preserved below the neurological level and includes the
muscle specific position 2. Determine motor levels for right and left sides.
sacral segments S4-5 (light touch or pin prick at S4-5 or
5 = (Normal) active movement, full ROM against gravity and full resistance in a deep anal pressure) AND no motor function is preserved Defined by the lowest key muscle function that has a grade of at least 3 (on
functional muscle position expected from an otherwise unimpaired person supine testing), providing the key muscle functions represented by segments
more than three levels below the motor level on either side
NT = Not testable (i.e. due to immobilization, severe pain such that the patient above that level are judged to be intact (graded as a 5).
of the body.
cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM) Note: in regions where there is no myotome to test, the motor level is
presumed to be the same as the sensory level, if testable motor function
0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present a C = Motor Incomplete. Motor function is preserved at the
above that level is also normal.
most caudal sacral segments for voluntary anal contraction
Sensory Grading (VAC) OR the patient meets the criteria for sensory 3. Determine the neurological level of injury (NLI).
0 = Absent 1 = Altered, either decreased/impaired sensation or hypersensitivity incomplete status (sensory function preserved at the most This refers to the most caudal segment of the cord with intact sensation and
caudal sacral segments S4-5 by LT, PP or DAP), and has antigravity (3 or more) muscle function strength, provided that there is normal
2 = Normal NT = Not testable some sparing of motor function more than three levels below (intact) sensory and motor function rostrally respectively.
0*, 1*, NT* = Non-SCI condition present a the ipsilateral motor level on either side of the body. The NLI is the most cephalad of the sensory and motor levels determined in
(This includes key or non-key muscle functions to determine steps 1 and 2.
a
Note: Abnormal motor and sensory scores should be tagged with a ‘*’ to indicate an
motor incomplete status.) For AIS C – less than half of key
impairment due to a non-SCI condition. The non-SCI condition should be explained
in the comments box together with information about how the score is rated for muscle functions below the single NLI have a muscle 4. Determine whether the injury is Complete or Incomplete.
classification purposes (at least normal / not normal for classification). grade ≥ 3. (i.e. absence or presence of sacral sparing)
If voluntary anal contraction = No AND all S4-5 sensory scores = 0
When to Test Non-Key Muscles: D = Motor Incomplete. Motor incomplete status as AND deep anal pressure = No, then injury is Complete.
defined above, with at least half (half or more) of key muscle Otherwise, injury is Incomplete.
In a patient with an apparent AIS B classification, non-key muscle functions functions below the single NLI having a muscle grade ≥ 3.
more than 3 levels below the motor level on each side should be tested to 5. Determine ASIA Impairment Scale (AIS) Grade.
most accurately classify the injury (differentiate between AIS B and C).
E = Normal. If sensation and motor function as tested with Is injury Complete? If YES, AIS=A
Movement Root level the ISNCSCI are graded as normal in all segments, and the
patient had prior deficits, then the AIS grade is E. Someone
Shoulder: Flexion, extension, adbuction, adduction, without an initial SCI does not receive an AIS grade.
internal and external rotation C5 Is injury Motor Complete? If YES, AIS=B
Elbow: Supination Using ND: To document the sensory, motor and NLI levels, (No=voluntary anal contraction OR motor
the ASIA Impairment Scale grade, and/or the zone of partial function more than three levels below the motor
Elbow: Pronation level on a given side, if the patient has sensory
Wrist: Flexion
C6 preservation (ZPP) when they are unable to be determined
based on the examination results.
incomplete classification)
Finger: Flexion at proximal joint, extension C7 Are at least half (half or more) of the key muscles below the
Thumb: Flexion, extension and abduction in plane of thumb
neurological level of injury graded 3 or better?
Finger: Flexion at MCP joint
Thumb: Opposition, adduction and abduction C8
perpendicular to palm
Finger: Abduction of the index finger T1 If sensation and motor function is normal in all segments, AIS=E
Note: AIS E is used in follow-up testing when an individual with a documented
Hip: Adduction L2 SCI has recovered normal function. If at initial testing no deficits are found, the
Hip: External rotation L3 INTERNATIONAL STANDARDS FOR NEUROLOGICAL individual is neurologically intact and the ASIA Impairment Scale does not apply.
Hip: Extension, abduction, internal rotation CLASSIFICATION OF SPINAL CORD INJURY 6. Determine the zone of partial preservation (ZPP).
Knee: Flexion The ZPP is used only in injuries with absent motor (no VAC) OR sensory
Ankle: Inversion and eversion
L4 function (no DAP, no LT and no PP sensation) in the lowest sacral segments
Toe: MP and IP extension S4-5, and refers to those dermatomes and myotomes caudal to the sensory
and motor levels that remain partially innervated. With sacral sparing of
Hallux and Toe: DIP and PIP flexion and abduction L5 sensory function, the sensory ZPP is not applicable and therefore “NA” is
recorded in the block of the worksheet. Accordingly, if VAC is present, the
Hallux: Adduction S1 Page 2/2 motor ZPP is not applicable and is noted as “NA”.
American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2019; Richmond, VA.
Available at: https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/

Risk Management Pitfalls for Spinal Cord Injury
in the Emergency Department
1. “He didn’t have any tenderness.” Tenderness 6. “I ordered the CT 6 hours ago.” The delay
is an insensitive finding in spinal injury. If other between time of injury and definitive therapy for
elements of the history and physical examination a spinal injury requiring decompression is still
are concerning, such as presence of severe mid- a matter of some debate, but earlier diagnosis
line pain, a high-risk mechanism of injury, limited appears to be better. Whether several hours
range of motion of the spine, or neurological of delay has a significant effect on the ultimate
symptoms such as paresthesias, do not let the outcome is uncertain; however, it exposes the
absence of tenderness be falsely reassuring. clinician to unnecessary risk for litigation. Make
every attempt to expedite diagnostic and
2. “Spinal immobilization doesn’t matter.” De- therapeutic interventions in the high-risk patient.
spite the absence of definitive evidence sup-
porting the routine use of cervical collars or rigid 7. “A&O x4 PERRLA, CN II-XII intact, 5/5 all
boards for patients with suspected spinal injuries, extremities.” Beware of templated physical
spinal motion restriction is a recommended prac- examinations. Documentation of an inaccurate
tice for all patients with a known or suspected physical examination (ie, a “normal” neurological
SCI. This may be accomplished by having the pa- examination in the paraplegic patient) opens the
tient lay supine on a flat hospital gurney. Rough clinician to unnecessary medicolegal risk by call-
handling during transfers and excessive motion ing into question the accuracy of the entire chart.
should be avoided.
8. “CCR negative, discharge home.” When
3. “He was breathing OK when they took applying clinical decision rules, it is prudent
him to MRI. I don’t know what happened.” to review each of the elements of the rule. In
Respiratory compromise can be multifactorial particular, the Canadian c-spine rule involves
and progressive. Patients with spinal injuries, multiple discrete decisions and has several
especially to the high cervical spine, should be exclusion criteria. Documenting a person who
monitored closely at all times for development of fell 7 feet as “CCR negative” is inaccurate and
respiratory insufficiency or distress. Monitoring is opens the clinician to unnecessary risk. It may still
especially important if the patient leaves the ED be reasonable to defer imaging based on clinical
for an MRI. gestalt and the fact they are otherwise at low risk,
but this thought process should be made clear in
4. “But the CT was negative.” Spinal instability the note.
and SCI can exist despite a “negative” CT
study. In the setting of high-risk symptoms or 9. “But they said that was his baseline.” It is
an abnormal neurological examination, maintain challenging to evaluate patients with an abnormal
a high index of suspicion for occult injury. baseline examination. Do not overly rely on an
Acute traumatic central cord injury may present entry in the medical record that the patient has
without any vertebral misalignment or fracture. “residual deficits;” seek out collateral history from
Ligamentous injuries may be missed on CT and family or caregivers as much as possible. Do not
require MRI or dynamic imaging to diagnose. discount a report that the patient has undergone
an acute change.
5. “I know she has a cervical fracture, but she’s
young and healthy. I’ll bet her blood pres- 10. “I didn’t look at the CTs myself.” Review every
sure is always in the 80s. And she’s not tachy- radiographic study that is ordered. Radiologists
cardic.” Hypotension is associated with worsened are human and will miss things. Most fractures on
outcomes in SCI. Do not tolerate frank hypoten- CT are not subtle and can be identified by the
sion; aggressively work to identify and correct its practiced clinician. It is most helpful to review the
etiology. Do not allow warm extremities or the sagittal reconstructions. If you have questions
absence of tachycardia to be falsely reassuring; about a read, call the radiologist and discuss it
these are features of neurogenic shock. with them.

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36. Kornhall DK, Jørgensen JJ, Brommeland T, et al. The Nor- J Neurotrauma. 2018;35(3):461-466. (Retrospective cohort; 84
wegian guidelines for the prehospital management of adult patients)
trauma patients with potential spinal injury. Scand J Trauma 55. Plurad DS, Talving P, Lam L, et al. Early vasopressor use in criti-
Resusc Emerg Med. 2017;25(1). (Systematic review, guideline) cal injury is associated with mortality independent from volume
37. Fischer PE, Perina DG, Delbridge TR, et al. Spinal motion status. J Trauma. 2011;71(3):565-572. (Retrospective cohort;
restriction in the trauma patient – a joint position statement. 1349 patients)
Prehosp Emerg Care. 2018;22(6):659-661. (Practice guidelines) 56. Docimo S, Diggs L, Crankshaw L, et al. No evidence supporting
38. Velopulos CG, Shihab HM, Lottenberg L, et al. Prehospital the routine use of digital rectal examinations in trauma patients.
spine immobilization/spinal motion restriction in penetrating Indian J Surg. 2015;77(4):265-269. (Retrospective cohort
trauma: a practice management guideline from the Eastern study; 111 patients)
Association for the Surgery of Trauma (EAST). J Trauma Acute 57. Guldner GT, Brzenski AB. The sensitivity and specificity
Care Surg. 2018;84(5):736-744. (Clinical practice guideline) of the digital rectal examination for detecting spinal cord
39. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian c- injury in adult patients with blunt trauma. Am J Emerg Med.
spine rule for radiography in alert and stable trauma patients. 2006;24(1):113-117. (Retrospective cohort study; 1032 pa-
JAMA. 2001;286(15):1841-1848. (Prospective cohort; 8924 tients)
patients) 58. Hadley MN, Walters BC, Aarabi B, et al. Clinical assessment
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is the most important risk factor for odontoid fractures in the 2013;72(suppl_3):40-53. (Systematic review and guideline)
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analysis) 60. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of
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71. Schuster R. Magnetic resonance imaging is not needed to clear domized controlled trial. Can J Anaesth. 2009;56(6):412-418.
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2005;140(8):762. (Prospective cohort; 2854 patients) as a result of endotracheal intubation in patients with undiag-
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blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. copy. Anesth Analg. 2008;106(3):935-941. (Randomized trial;
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DOI: 10.1056/NEJM199005173222001

102. Ahuja CS, Schroeder GD, Vaccaro AR, et al. Spinal cord injury— n CME Questions
what are the controversies? J Orthop Trauma. 2017;31(4):S7-
S13. (Review) Current subscribers receive CME credit
103. Bracken MB. Steroids for acute spinal cord injury. Cochrane absolutely free by completing the
Database Syst Rev. 2012 Jan 18;1(1):CD001046. (Cochrane following test. Each issue includes 4 AMA
review; 8 randomized controlled trials) PRA Category 1 CreditsTM, 4 ACEP
104. Cotler HB, Miller LS, DeLucia FA, et al. Closed reduction of cer- Category I credits, 4 AAFP Prescribed
vical spine dislocations. Clin Orthop Relat Res. 1987(214):185- credits, or 4 AOA Category 2-A or 2-B credits.
199. (Case series; 24 patients)
Online testing is available for current and archived
105. Gelb DE, Hadley MN, Aarabi B, et al. Initial closed reduction
of cervical spinal fracture-dislocation injuries. Neurosurgery.
issues. To receive your free CME credits for this
2013;72(suppl_3):73-83. (Systematic review and guideline) issue, scan the QR code below with your
106. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed smartphone or visit www.ebmedicine.net/E1021
decompression for traumatic cervical spinal cord injury: results
of the surgical timing in acute spinal cord injury study (STAS-
CIS). PLoS ONE. 2012;7(2):e32037. (Prospective cohort trial;
313 patients)
107. ter Wengel PV, Martin E, De Witt Hamer PC, et al. Impact of
early (<24 h) surgical decompression on neurological recovery
in thoracic spinal cord injury: a meta-analysis. J Neurotrauma.
2019;36(18):2609-2617. (Systematic review and meta-analy-
sis; 1075 patients) 1. Which element of the history from EMS may
108. Wilson JR, Tetreault LA, Kwon BK, et al. Timing of decom- be critical in determining the applicability of
pression in patients with acute spinal cord injury: a systematic clinical decision rules?
review. Global Spine J. 2017;7(3_suppl):95S-115S. (Systematic
a. The mechanism of injury
review)
b. Whether oxygen was administered in the
109. ter Wengel PV, De Witt Hamer PC, Pauptit JC, et al. Early
surgical decompression improves neurological outcome after prehospital environment
complete traumatic cervical spinal cord injury: a meta-analysis. c. The type of prehospitalization spinal motion
J Neurotrauma. 2019;36(6):835-844. (Systematic review and reduction employed
meta-analysis; 1126 patients) d. Whether lights and sirens were used for
110. Phillips WA, Hensinger RN. The management of rotatory transport
atlanto-axial subluxation in children. J Bone Joint Surg Am.
1989;71(5):664-668. (Case series; 23 patients)
2. When caring for a patient with a high cervical
111. Powell EC, Leonard JR, Olsen CS, et al. Atlantoaxial rotatory
subluxation in children. Pediatr Emerg Care. 2017;33(2):6. (Pro- spine injury, what signs should you be
spective case control study; 1600 patients) attuned to that may signal impending airway
112. Pang D, Li V. Atlantoaxial rotatory fixation: Part 2—new di- obstruction?
agnostic paradigm and a new classification based on motion a. Hypotension
analysis using computed tomographic imaging. Neurosurgery. b. Bradycardia
2005;57(5):941-953. (Prospective cohort; 40 patients)
c. Wide pulse pressure
113. Pang D. Spinal cord injury without radiographic abnormalities in
d. Stridor
children. J Neurosurg. 1982;57:16. (Case series; 24 patients)
114. Gao L, Peng Y, Xu W, et al. Progress in stem cell therapy for
spinal cord injury. Stem Cells Int. 2020;2020:1-16. (Review) 3. Which of the following precludes the
115. Curtis E, Martin JR, Gabel B, et al. A first-in-human, phase 1
application of the Canadian cervical-spine rule?
study of neural stem cell transplantation for chronic spinal cord a. A patient with a prior laminectomy
injury. Cell Stem Cell. 2018;22(6):941-950. (Clinical trial) b. A patient who is 35 years old
116. Maharaj MM, Hogan JA, Phan K, et al. The role of special- c. A patient who fell roller-skating
ist units to provide focused care and complication avoidance d. A patient with well-controlled schizophrenia
following traumatic spinal cord injury: a systematic review. Eur
Spine J. 2016;25(6):1813-1820. (Systematic review)
4. What is an appropriate first-line test to
117. Theodore N, Aarabi B, Dhall SS, et al. Transportation of patients
with acute traumatic cervical spine injuries. Neurosurgery.
definitively evaluate for cervical spine
2013;72(suppl_3):35-39. (Systematic review and guideline) fracture?
a. CT myelography
b. CT without contrast
c. Ultrasound
d. Dynamic fluoroscopy

5. Which of the following is NOT an acceptable 9. You are caring for a patient with a C4 burst
option for evaluating the patient with severe fracture with spinal cord compression. The
persistent cervical spine pain, midline neck attending neurosurgeon plans to operate on
tenderness, and negative initial imaging? the patient in 12 to 18 hours, You reply...
a. Obtaining flexion/extension films a. That is unacceptable because early operation
b. Obtaining an MRI is associated with harm
c. Maintaining cervical immobilization until b. That is unacceptable because decompression
asymptomatic must be performed within 3 hours
d. Encouraging aggressive cervical range-of- c. That is a reasonable plan, and it represents
motion exercises and treating the pain the current best understanding of the
literature
6. Which of the following is NOT a risk factor for d. That is a reasonable plan because there is
cerebrovascular injury? no literature to guide the timing of surgical
a. Near-hanging with anoxic brain injury therapy
b. LeFort I fracture
c. C1-C3 fractures 10. What is an appropriate strategy to assess the
d. Basilar skull fracture cervical spine of a patient with head trauma
and clinical intoxication with a blood alcohol
7. Which of the following would NOT be an level of 460 mg/dL?
appropriate strategy to manage the airway of a. Apply the NEXUS criteria and clinically clear
a patient requiring intubation? the cervical spine
a. Orotracheal intubation with direct b. Apply the Canadian cervical-spine rule and
laryngoscopy clinically clear the cervical spine
b. Orotracheal intubation with video c. Maintain cervical immobilization until the
laryngoscopy patient is clinically sober and assessable
c. Blind nasotracheal intubation d. Immediately discharge to self-care
d. Fiberoptic-assisted nasotracheal intubation
8. You are caring for a patient with an incomplete

spinal injury due to bilateral locked facets at
C4-C5 with no other injury identified. What
is an appropriate first-line therapy in this
situation?
a. Administer high-dose methylprednisolone for
48 hours
b. Perform emergent closed reduction with
skeletal traction
c. Assess stability with flexion/extension films
d. Perform immediate cricothyrotomy
Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II
• Always acceptable, safe • Safe, acceptable Class III Indeterminate
• Definitely useful • Probably useful • May be acceptable • Continuing area of research
• Proven in both efficacy and effectiveness • Possibly useful • No recommendations until further
Level of Evidence: • Considered optional or alternative research
Level of Evidence: • Generally higher levels of evidence treatments
• One or more large prospective studies • Nonrandomized or retrospective stud- Level of Evidence:
are present (with rare exceptions) ies: historic, cohort, or case control Level of Evidence: • Evidence not available
• High-quality meta-analyses studies • Generally lower or intermediate levels • Higher studies in progress
• Study results consistently positive and • Less robust randomized controlled trials of evidence • Results inconsistent, contradictory
compelling • Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2021 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Clinical Pathway for Emergency Department
Management of Blunt Cervical Trauma in Adult Patients
Patient presents to ED with blunt trauma and concern

for cervical spine or cord injury
NO Is patient stable and without signs of neurogenic shock?
YES
• Initiate cervical immobilization Does patient meet ALL criteria? • Discontinue cervical immobilization
(Class I) • Awake • (Class I)
• Image the cervical spine with • Asymptomatic • No cervical imaging indicated
noncontrast CT; use 3- or 5-view • No neck pain or tenderness YES (Class I)
plain film if CT unavailable (Class I) • No distracting injury • Evaluate and manage for any other
• Resuscitate with MAP goal of 85-90 • Full functional range of motion concerns
mm Hg (Indeterminate) • Normal neurologic examination
• Maintain inline cervical stabilization
during intubation (Class III) NO
• Initiate or continue spinal motion

restriction with cervical collar and
adjuncts, as appropriate
• Image the cervical spine with
noncontrast CT; use 3- or 5-view
plain film if CT unavailable (Class I)
• Consider CTA if additional injuries or
mechanism is high-risk by Denver
Criteria (see Table 9) (Class II)
Spinal injury identified?
YES NO
High suspicion for ligamentous injury, • Manage additional injuries as

• Do NOT administer methyl-
central cord syndrome, or other spinal appropriate
prednisolone unless recommended NO
cord injury, based history and physical • May consider discontinuation
by consultant (Class I)
examination? of spinal immobilization in the
• Transfer to acute specialized SCI
center (Class III) obtunded patient (Class II)
YES • If no other concerns identified,
• Obtain neurosurgical or orthopedic
spine consultation consider discharge home with close
• Consider MRI to aid in defining follow-up and return precautions
• Obtain MRI to evaluate for
injury (Class III)
ligamentous injury or cord injury
(Class II)
• Assess stability with flexion/
Consider CTA in cases of: extension films (Class III)
• Cervical spine fracture, especially
C1-C3 or involving transverse
foramen (Class II)
or
Continue observation and reassess
• If high risk by Denver criteria YES Spinal injury identified? NO
(Indeterminate)
(see Table 9) (Class II)
Complete remainder of trauma Abbreviations: CT, computed tomography; CTA, computed tomographic angiography; MAP, mean
evaluation. Admit or transfer to ICU arterial pressure; MRI, magnetic resonance imaging; SCI, spinal cord injury; SCIWORA, spinal
(Class II) or spinal injury center cord injury without radiographic abnormality.
(Indeterminate)
For Class of Evidence Definitions, see page 24.

CME Information
In upcoming issues of Date of Original Release: October 1, 2021. Date of most
Emergency Medicine Practice recent review: September 10, 2021. Termination date:
October 1, 2024.
Accreditation: EB Medicine is accredited by the Accredi-
tation Council for Continuing Medical Education (ACCME) to provide
SEPTEMBER 2021 | VOLUME 23 | ISSUE 9
continuing medical education for physicians. This activity has been
planned and implemented in accordance with the accreditation require-
Emergency Medicine Practice Evidence-Based Education • Practical Application
ments and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a
CLINICAL CHALLENGES:
maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim
• What are the critical signs of
acute mountain sickness?
only the credit commensurate with the extent of their participation in the
• Which medical conditions
make high-altitude travel
activity.
contraindicated?
• How should patients be
Specialty CME: Included as part of the 4 credits, this CME activity is
advised to prepare for high-
altitude travel?
eligible for 4 Trauma CME credits.
ACEP Accreditation: Emergency Medicine Practice is approved by
Authors
Ninad A. Shroff, MD, FAAEM
the American College of Emergency Physicians for 48 hours of ACEP
Associate Program Director, Emergency
Medicine Residency, St. Joseph’s University
Medical Center, Paterson, NJ
Category I credit per annual subscription.
Jerome Balbin, MD
Medical Director of Simulation/Core Faculty/
Attending Physician, Department of Emergency
High-Altitude Illness: AAFP Accreditation: The AAFP has reviewed Emergency Medicine
Medicine, St. Joseph’s University Medical Center,
Paterson, NJ Updates in Prevention, Practice, and deemed it acceptable for AAFP credit. Term of approval is
Oluwaseun Shobitan, MD
Attending Physician, East Orange General
Identification, and from 07/01/2021 to 06/30/2022. Physicians should claim only the credit
Hospital, East Orange, NJ
Treatment commensurate with the extent of their participation in the activity.
n Abstract
Peer Reviewers
Charlotte Goldfine, MD
High-altitude illness is a continuum of syndromes that includes the • 4.00 Enduring Materials, Self-Study AAFP Prescribed Credit(s)-
potential for death. Understanding how to prevent altitude illness
Department of Emergency Medicine, Division
of Medical Toxicology, Brigham and Women’s
Hospital, Boston, MA
and how to treat it if it occurs is fundamental to trip planning
and is an important role of medical advisors to travelers. Gradual
Emergency Department Management of Cervical Spine Injuries
Ryan LaFollette, MD
Assistant Program Director, Assistant Professor,
University of Cincinnati Emergency Medicine,
ascent, along with pharmacotherapy where indicated, are the
mainstays of prevention. Travelers with certain chronic medical
conditions may require additional pretravel counseling and
AOA Accreditation: Emergency Medicine Practice is eligible for 4
Cincinnati, OH preparation. Diagnostic recognition of the differing manifestations
of high-altitude illness as well as recommendations on appropriate
Category 2-A or 2-B credit hours per issue by the American Osteopathic
Prior to beginning this activity, see “CME
Information” on page 20.
therapeutic options are discussed in detail.
Association.
Needs Assessment: The need for this educational activity was deter-
For online access, scan with your mined by a practice gap analysis; a survey of medical staff, includ-
ing the editorial board of this publication; review of morbidity and
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Cover Image: Lateral x-ray of cervical spine showing bilateral facet joint
dislocation. Illustration by Yok_onepiece.

The Emergency Medicine Practice Editorial Board
EDITOR-IN-CHIEF Marie-Carmelle Elie, MD Ali S. Raja, MD, MBA, MPH RESEARCH EDITORS
Associate Professor, Department of Executive Vice Chair, Emergency Medicine,
Andy Jagoda, MD, FACEP Emergency Medicine & Critical Care Massachusetts General Hospital; Professor Aimee Mishler, PharmD, BCPS
Professor and Chair Emeritus, Department Medicine, University of Florida College of of Emergency Medicine and Radiology, Emergency Medicine Pharmacist, Program
of Emergency Medicine; Director, Center Medicine, Gainesville, FL Harvard Medical School, Boston, MA Director, PGY2 EM Pharmacy Residency,
for Emergency Medicine Education and Valleywise Health, Phoenix, AZ
Research, Icahn School of Medicine at Nicholas Genes, MD, PhD Robert L. Rogers, MD, FACEP,
Mount Sinai, New York, NY Associate Professor, Department of Joseph D. Toscano, MD
FAAEM, FACP
Emergency Medicine, Icahn School of Chief, Department of Emergency Medicine,
Assistant Professor of Emergency Medicine,
ASSOCIATE EDITOR-IN-CHIEF Medicine at Mount Sinai, New York, NY San Ramon Regional Medical Center, San
The University of Maryland School of
Ramon, CA
Kaushal Shah, MD, FACEP Medicine, Baltimore, MD
Michael A. Gibbs, MD, FACEP
Vice Chair for Education, Department of Professor and Chair, Department of INTERNATIONAL EDITORS
Alfred Sacchetti, MD, FACEP
Emergency Medicine, Weill Cornell School Emergency Medicine, Carolinas Medical Assistant Clinical Professor, Department of Peter Cameron, MD
of Medicine, New York, NY Center, University of North Carolina School Emergency Medicine, Thomas Jefferson Academic Director, The Alfred Emergency
of Medicine, Chapel Hill, NC University, Philadelphia, PA
EDITORIAL BOARD and Trauma Centre, Monash University,
Steven A. Godwin, MD, FACEP Melbourne, Australia
Saadia Akhtar, MD, FACEP Robert Schiller, MD
Professor and Chair, Department of Chair, Department of Family Medicine,
Associate Professor, Department of Andrea Duca, MD
Emergency Medicine, Assistant Dean, Beth Israel Medical Center; Senior Faculty,
Emergency Medicine, Associate Dean for Attending Emergency Physician, Ospedale
Simulation Education, University of Florida Family Medicine and Community Health,
Graduate Medical Education, Program Papa Giovanni XXIII, Bergamo, Italy
COM-Jacksonville, Jacksonville, FL Icahn School of Medicine at Mount Sinai,
Director, Emergency Medicine Residency,
Mount Sinai Beth Israel, New York, NY New York, NY Suzanne Y.G. Peeters, MD
Joseph Habboushe, MD MBA Attending Emergency Physician, Flevo
Assistant Professor of Emergency Medicine, Scott Silvers, MD, FACEP
William J. Brady, MD Teaching Hospital, Almere, The Netherlands
NYU/Langone and Bellevue Medical Associate Professor of Emergency Medicine,
Professor of Emergency Medicine and
Medicine; Medical Director, Emergency Centers, New York, NY; CEO, MD Aware Chair of Facilities and Planning, Mayo Clinic, Edgardo Menendez, MD, FIFEM
LLC Jacksonville, FL Professor in Medicine and Emergency
Management, UVA Medical Center;
Operational Medical Director, Albemarle Medicine; Director of EM, Churruca Hospital
Eric Legome, MD Corey M. Slovis, MD, FACP, FACEP of Buenos Aires University, Buenos Aires,
County Fire Rescue, Charlottesville, VA Chair, Emergency Medicine, Mount Sinai Professor and Chair Emeritus, Department Argentina
West & Mount Sinai St. Luke's; Vice Chair, of Emergency Medicine, Vanderbilt
Calvin A. Brown III, MD
Director of Physician Compliance, Academic Affairs for Emergency Medicine, University Medical Center, Nashville, TN Dhanadol Rojanasarntikul, MD
Mount Sinai Health System, Icahn School of Attending Physician, Emergency Medicine,
Credentialing and Urgent Care Services,
Medicine at Mount Sinai, New York, NY Ron M. Walls, MD King Chulalongkorn Memorial Hospital;
Department of Emergency Medicine,
Professor and COO, Department of Faculty of Medicine, Chulalongkorn
Brigham and Women's Hospital, Boston, Keith A. Marill, MD, MS Emergency Medicine, Brigham and University, Thailand
MA Associate Professor, Department of Women's Hospital, Harvard Medical School,
Peter DeBlieux, MD Emergency Medicine, Harvard Medical Boston, MA Stephen H. Thomas, MD, MPH
School, Massachusetts General Hospital, Professor & Chair, Emergency Medicine,
Professor of Clinical Medicine, Louisiana
Boston, MA CRITICAL CARE EDITORS Hamad Medical Corp., Weill Cornell
State University School of Medicine; Chief
Experience Officer, University Medical Medical College, Qatar; Emergency
Angela M. Mills, MD, FACEP William A. Knight IV, MD, FACEP,
Center, New Orleans, LA Physician-in-Chief, Hamad General Hospital,
Professor and Chair, Department of FNCS Doha, Qatar
Emergency Medicine, Columbia University Associate Professor of Emergency Medicine
Deborah Diercks, MD, MS, FACEP,
Vagelos College of Physicians & Surgeons, and Neurosurgery, Medical Director, EM Edin Zelihic, MD
FACC
New York, NY Advanced Practice Provider Program; Head, Department of Emergency Medicine,
Professor and Chair, Department of
Associate Medical Director, Neuroscience Leopoldina Hospital, Schweinfurt, Germany
Emergency Medicine, University of Texas Charles V. Pollack Jr., MA, MD, ICU, University of Cincinnati, Cincinnati, OH
Southwestern Medical Center, Dallas, TX FACEP, FAAEM, FAHA, FACC, FESC
Clinician-Scientist, Department of Scott D. Weingart, MD, FCCM
Daniel J. Egan, MD
Emergency Medicine, University of Professor of Emergency Medicine; Chief,
Harvard University Affiliated Emergency
Mississippi School of Medicine, Jackson MS EM Critical Care, Stony Brook Medicine,
Medicine Residency, Massachusetts General
Stony Brook, NY
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Points & Pearls
QUICK READ
Emergency Department
Management of Cervical
Spine Injuries
OCTOBER 2021 | VOLUME 23 | ISSUE 10
Points
Pearls
• In the United States, some 60% of patients with
cervical spine injury have complete or incomplete • Clinical data linking spinal immobilization with
tetraplegia.3,4 improved outcomes are lacking or of low qual-
• Unstable fractures are those in which bone ity; however, multiple harms of immobilization
deformity is likely to increase and may lead to have been noted.28,31-34 For a summary of the
development or worsening of spinal cord com- guidelines on immobilization, see Table 5.
promise.6 • The most immediate life threats in spinal
• Spinal injuries involving the anterior column tend cord injury are airway obstruction, respiratory
to be stable; injuries tend to be unstable if mul- insufficiency or failure, and systemic
tiple columns or the posterior column are injured hypotension due to neurogenic shock.
or disrupted. • The American Spinal Injury Association work-
• Spinal cord injury (SCI) may occur without spinal sheet for grading spinal injuries can be viewed
fracture; the most clinically important is acute in the Appendix, page 18.
traumatic central cord syndrome, which is typi- • Imaging decisions can be aided by use of the
cally associated with elderly patients with pre- NEXUS tool or the Canadian c-spine rule (CCR).
existing spinal stenosis. See Table 7 and Figure 4.
• The primary phase of SCI results from the me- • CT has a sensitivity between 90%-100% for
chanical effect on the spinal cord from impact, spinal injury; a complete c-spine 3-view plain
compression, distraction, or laceration. film series has sensitivity of 37%-64%. MRI is the
• The secondary phase of SCI results from a cas- imaging of choice, as it optimizes visualization
cade of progressive damage that can persist for of the site of cord lesion.
weeks or months.
• In the setting of new neurologic deficit or symp-
toms, nontraumatic spinal cord compression
should be considered. injury. Routine screening of asymptomatic patients
• Visceral injury, vascular injury, and muscle spasm without high-risk features is not recommended by
are additional causes of posttraumatic back pain. guidelines.72-75
• C-spine trauma can lead to loss of protective air- • For patients needing emergent intubation, an
way reflexes;42 onset can be delayed for hours or orotracheal approach with rapid sequence induc-
days. Stridor, hoarseness, or muffled voice should tion and muscular relaxation with continuous cervi-
raise concern for obstruction. cal stabilization is generally preferred.81,82,85-87
• Respiratory complications are the most signifi- • Current guidelines recommend maintaining a
cant cause of morbidity and mortality. Monitor mean arterial pressure (MAP) of 85-90 mm Hg for
work of breathing and pulse oximetry; systemic the first 7 days.49
hypoxia may exacerbate neurologic injury.47-49 • Recent evidence has shown that spinal cord perfu-
• Neurogenic shock has been reported to be as sion pressure (SCPP) predicts functional recovery,
high as 43% in c-spine injury.53,54 prompting strategies aimed at the targeting of
• CT is insensitive for ligamentous injury; plain SCPP, rather than rigid MAP goals.96,98
film and MRI can be used, but in a patient with • Corticosteroids are not recommended unless
normal CT and normal motor examination, no recommended by a consultant, due to conflicting
further imaging is warranted.71 evidence regarding benefit versus harm.69,102,103
• The Denver screening criteria (see Table 8) • Closed reduction and decompression are potential
can be used to assess for blunt cerebrovascular surgical options.

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OCTOBER 2021 | VOLUME 23 | ISSUE 10

Emergency Medicine Practice Evidence-Based Education • Practical Application

For online access, scan with your

• EMS says the man was found down on the street.

she appears uncomfortable.

n Introduction comprehensively reviewed to provide the best avail-

OCTOBER 2021 • www.ebmedicine.net 2 ©2021 EB MEDICINE

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Figure 2. The Denis 3-Column Model of Spinal Stability

View A View B View C

OCTOBER 2021 • www.ebmedicine.net 4 ©2021 EB MEDICINE

to red flags such as an immunocompromised state or Upper motor neurons

history of cancer or intravenous (IV) drug use will help

Table 1. Incomplete Spinal Cord Injuries

Brown-Séquard syndrome • Penetrating injury • Ipsilateral motor function,

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Type: Bilateral cervical facet

Fig. 36.12. A–F, Odontoid fracture, type CHA

Type: Atlantoaxial dislocation Asymmetry in

predisposed to ligament laxity, masses of C1

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Table 2. Unstable Spinal Fractures (Continued from page 6)

(hangman’s fracture) TABLE 36.1

• C2 anterior subluxation FLEXION Tip of

longitudinal ligament Subluxation

Bursting fracture of vertebral body Stable

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• Spinal cord injury without radiographic abnormality (SCIWORA)

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Table 5. Guidelines for Prehospital Spinal Immobilization22,35-37

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Abbreviation: NEXUS, National Emergency X-Radiography Utilization

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Plain Films Assessing Ligamentous Stability

An online tool for the NEXUS NO

An online tool for the Canadian C-Spine Rule NO

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Figure 6. Atlantoaxial Rotatory Fixation

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2 = Active movement, gravity eliminated

Page 1/2 REV 04/19

Muscle Function Grading ASIA Impairment Scale (AIS) Steps in Classification

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8. You are caring for a patient with an incomplete

Class of Evidence Definitions

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Patient presents to ED with blunt trauma and concern

NO Is patient stable and without signs of neurogenic shock?

• Initiate or continue spinal motion

Spinal injury identified?

High suspicion for ligamentous injury, • Manage additional injuries as

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CEO: Stephanie Williford