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cervical_spine_injury

Cervical spine injury

Approximately two thirds of cervical spine injuries occur within the subaxial cervical spine, with fractures occurring most often at C6 and C7 and dislocations occurring most commonly between C5-C6 and C6-C7 1).

Etiology

The most common causes of cervical spine injury are automobile accidents, followed by diving into shallow water, firearm injuries, and sports activities 2) 3).

There is a bimodal age distribution among patients with spinal cord injuries: the first peak occurs in patients between 15 and 24 years, and the second in patients over 55 years of age 4) 5) 6).

The age factor modulates human cervical spine tolerance to impact injury 7).

Classification

Cervical spine injury classification systems should be simple, easy to relate and remember, reliable guide for surgical planning, and predictor of outcome in clinical settings.

see AOSpine subaxial cervical spine injury classification system.

see Cervical spine fracture.

see Pediatric cervical spine trauma.

Clinically significant cervical spine injury caused as a result of penetrating trauma are rare.

see Penetrating neck trauma.

Clinical features

Neurological deterioration ranging from complete spinal cord injury (SCI) to incomplete spinal cord injury or single cervical radiculopathy are potential consequences.

Diagnosis

A missed cervical spine (CS) injury can have devastating consequences. When CS injuries cannot be ruled out clinically using the National Emergency X-Radiography Utilization Study low-risk criteria because of either a neurologic deficit or pain, the optimal imaging modality for CS clearance remains controversial.

Evaluation

The initial evaluation of patients for cervical spine injury involves a detailed physical examination with careful evaluation of the criteria to determine whether radiographic evaluation of the cervical spine is necessary.

Radiographic evaluation

Once screening the cervical spine with radiography has been determined necessary, plain radiography has traditionally been the initial screening test for patients at risk of cervical spine injury.

Realization that standard cervical spine radiography fails to identify all patients with cervical spine injuries has resulted in the use of additional radiographic studies including supine oblique views, flexion-extension radiographs, or computed tomography (CT) scanning.

Cervical spine CT scanning

Computed tomography is effective in the detection of clinically significant CS injuries in adults deemed eligible for evaluation who had a neurologic deficit or CS pain.

Is being utilized with increasing frequency as a screening test for patients with potential cervical spine injury. However, the appropriate screening test to rule out cervical spine injury in the blunt trauma patient is unclear.

Magnetic resonance imaging

For Resnick et al., magnetic resonance imaging does not provide any additional clinically relevant information 8).

The neurosurgical evaluation and management of athletes after cervical spine injury with T2 hyperintensity on MRI is challenging. Although the presence of T2 hyperintensity is evidence of spinal cord trauma, the long-term prognostic value on an athlete’s career and return-to-play (RTP) recommendations of this finding are poorly understood.

Much of the literature on cervical cord T2 hyperintensity relates to degenerative spine conditions. For example, several studies have examined the evolution of intramedullary T2 hyperintensity after ventral decompressive surgery for cervical spondylotic myelopathy (CSM) 9) 10).

Guidelines

In 2013 the American Association of Neurological Surgeons and the Congress of Neurological Surgeons released updated management guidelines for the acute cervical spine injury and spinal cord injury SCI.

Of 56 studies published in the Cochrane Library Central Register of Controlled Trials, 19 met inclusion criterion of acute cervical spine injury and are summarized across 4 subcategories: diagnosis, surgical stabilization, scopes/instrumentation, and therapeutic outcomes. Yup et al. confirm the utility of computed tomography for diagnosis, and improved outcomes associated with early (<24h) decompressive surgery. They describe advances in laryngoscopy and intubation under various SCI indications. They explore the benefits of continuous positive airway pressure protocols for reducing respiratory insufficiency, and patient education standards for transfer and mobility success. They report on ongoing randomized controlled trials (RCT) for surgical and therapeutic approaches for subpopulations of interest, including incomplete cord lesion, canal stenosis, and riluzole pharmacotherapy. They recommend a large, multicenter, prospective confirmatory RCT to assess the impact of timing of surgery versus conservative management in an effort to generate Class I evidence on the topic. Such a study should utilize shared, common variables as outlined by the National Institutes of Health SCI Common Data Elements to enable international collaboration and data pooling for robust, reproducible analyses 11).

Treatment

If a patient arrives with an intact neurologic examination despite gunshot wound or stab wounds to the neck, the incidence of a cervical spine injury that requires a therapeutic intervention is minute. As a result, in a neurologically intact and examinable patient, a cervical collar should be immediately removed to facilitate the remaining components of the diagnostic evaluation 12).

Treatment of subaxial cervical spinal injury remains controversial. Both the anterior and posterior procedures have serious advantages and disadvantages 13) 14) 15).

Outcome

The cervical spine injury represents a potential devastating disease with 6% associated in-hospital mortality.

Cervical spine injury complicates the care of approximately 4% of injured patients admitted to trauma centers across the United States.

1)
Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR; NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001 Jul;38(1):17-21. PubMed PMID: 11423806.
2)
Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use. Radiology. 1999;211(3):759–65.
3) , 4)
Barros Filho TEP, Oliveira RP, Barros EK, Von Uhlendorff EF, Iutaka AS, Cristante AF, et al. Ferimento por projétil de arma de fogo na coluna vertebral: estudo epidemiológico [Gunshot wounds of the spine: epidemiological study] Coluna/Columna. 2002;1(2):83–7. Disponível em: http://www.plataformainterativa2.com/coluna/html/revistacoluna/volume1/ferimento_projetil.htm. Acessado em 2012 (9 out).
5)
Kraus JF, Franti CE, Riggins RS, Richards D, Borhani NO. Incidence of traumatic spinal cord lesions. J Chronic Dis. 1975;28(9):471–92.
6)
Cristante AC, Barros Filho TEP, Marcon RM, Letaif OB, Rocha ID. Therapeutic approaches for spinal cord injury. Clinics (Sao Paulo) 2012;67(10):1219–24.
7)
Yoganandan N, Chirvi S, Voo L, Pintar FA, Banerjee A. Role of age and injury mechanism in cervical spine injury tolerance under head contact loading. Traffic Inj Prev. 2017 Jul 24:0. doi: 10.1080/15389588.2017.1355549. [Epub ahead of print] PubMed PMID: 28738168.
8)
Resnick S, Inaba K, Karamanos E, Pham M, Byerly S, Talving P, Reddy S, Linnebur M, Demetriades D. Clinical Relevance of Magnetic Resonance Imaging in Cervical Spine Clearance: A Prospective Study. JAMA Surg. 2014 Jul 30. doi: 10.1001/jamasurg.2014.867. [Epub ahead of print] PubMed PMID: 25076462.
9)
Sarkar S, Turel MK, Jacob KS, Chacko AG. The evolution of T2-weighted intramedullary signal changes following ventral decompressive surgery for cervical spondylotic myelopathy. J Neurosurg Spine. 2014;21(4):538-546.
10)
Vedantam A, Rajshekhar V. Change in morphology of intramedullary T2- weighted increased signal intensity after anterior decompressive surgery for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2014;39(18):1458-1462.
11)
Yue JK, Upadhyayula P, Chan AK, Winkler EA, Burke JF, Readdy WJ, Sharma S, Deng H, Dhall SS. A review and update on the current and emerging clinical trials for the acute management of cervical spine and spinal cord injuries - Part III. J Neurosurg Sci. 2015 Nov 24. [Epub ahead of print] PubMed PMID: 26606433.
12)
Ball CG. Penetrating nontorso trauma: the head and the neck. Can J Surg. 2015 Aug;58(4):284-5. Review. PubMed PMID: 26022154; PubMed Central PMCID: PMC4512872.
13)
Hadley MN. Treatment of subaxial cervical spinal injuries. Neurosurgery. 2002;50(3):S156–S165.
14)
Maiman DJ, Barolat G, Larson SJ. Management of bilateral locked facets of the cervical spine. Neurosurgery. 1986;18(5):542–547. doi: 10.1097/00006123-198605000-00005.
15)
Payer M. Clinical Article: Immediate open anterior reduction and antero-posterior fixation/fusion for bilateral cervical locked facets. Acta Neurochir. 2005;147:509–514. doi: 10.1007/s00701-005-0502-x.
cervical_spine_injury.txt · Last modified: 2017/11/14 14:44 by administrador