Cervical spine injury

Approximately two thirds of cervical spine injury occur within the subaxial cervical spine.

Cervical spine fracture epidemiology.

Cervical spine injury classification.

see Cervical spine fracture treatment.

Fractures of the cervical spine are a leading cause of morbidity and mortality in trauma patients, and a bony fracture is associated with 56% of cervical spinal cord injury.

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 1) 2) 3).

The fractures occurre most often at C6 and C7 and dislocations occurring most commonly between C5-C6 and C6-C7 4).

The most common causes of cervical spine injury are automobile accidents, followed by diving into shallow water, firearm injuries, and sports activities 5) 6).

see Trampoline injury.

Cervical spine injuries can occur in military scenarios from events such as underbody blast events. Such scenarios impart inferior-to-superior loads to the spine. The objective of this study is to develop human injury risk curves (IRCs) under this loading mode using Post Mortem Human Surrogates (PMHS). Twenty-five PMHS head-neck complexes were obtained, screened for pre-existing trauma, bone densities were determined, pre-tests radiological images were taken, fixed in polymethylmethacrylate at the T2-T3 level, a load cell was attached to the distal end of the preparation, positioned end on custom vertical accelerator device based on the military-seating posture, donned with a combat helmet, and impacted at the base. Posttest images were obtained, and gross dissection was done to confirm injuries to all specimens. Axial and resultant forces at the cervico-thoracic joint was used to develop the IRCs using survival analysis. Data were censored into left, interval, and uncensored observations. The Brier score metric was used to rank the variables. The optimal metric describing the underlying response to injury was associated with the axial force, ranking slightly greater than the resultant force, both with BMD covariates. The results from the survival analysis indicated all IRCs are in the “fair” to “good” category, at all risk levels. The BMD was found to be a significant covariate that best describes the response of the helmeted head-neck specimens to injury. The present experimental protocol and IRCs can be used to conduct additional tests, matched-pair tests with the WIAMan and/or other devices to obtain injury assessment risk curves (IARCs) and injury assessment risk values (IARVs) to predict injury in crash environments, and these data can also be used for validating component-based head-neck and human body computational models 7).

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

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.

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.

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).

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).

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).

The age factor modulates human cervical spine tolerance to impact injury 16).

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.

729 patients with Cervical Spine Trauma (CST) were retrospectively analyzed, including rates of vertebral artery injury (VAI), age at injury, cause of injury, cardiovascular history, smoking history, substance abuse history, embolization therapy, and antiplatelet or anticoagulant therapy prior or after injury. VAIs were identified and graded following the Modified Denver Criteria for Blunt Cerebrovascular Injury utilizing Magnetic Resonance Angiography and Computed Tomography Angiography (CTA). Brain scans were reviewed for stroke rates and statistically significant variations.

33 patients suffered penetrating trauma while 696 patients experienced blunt trauma. 81 patients met the criteria for analysis with confirmed VAI. VAI was more common in penetrating injury group compared to blunt injury group (64% vs 9%, P < 0.0005). However, low-grade VAI (<grade III) was more common in blunt injury group versus penetrating group (37% vs 14%, P < 0.05). The frequency of posterior circulation strokes did not vary significantly between groups (26.3% versus 13.8%, P = 0.21). Cardiovascular comorbidities were significantly more common in the blunt group (50%, P = 0.0001) compared to penetrating group (0%).

VAI occurs with a high incidence in penetrating CST. Although stroke risk following penetrating and blunt CST did not vary significantly, they resulted in serious complications in a group of patients. Further studying of this patient population is required to provide high-level evidence-based preventions for VAI complications 17).

1) , 6)
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Yoganandan N, Chirvi S, Pintar FA, Banerjee A, Voo L. Injury Risk Curves for the Human Cervical Spine from Inferior-to-Superior Loading. Stapp Car Crash J. 2018 Nov;62:271-292. PubMed PMID: 30608997.
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.
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.
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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.
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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.
AlBayar A, Sullivan PZ, Blue R, Leonard J, Kung D, Ozturk AK, Chen HI, Schuster J. Risk Of Vertebral Artery Injury And Stroke Following Blunt and Penetrating Cervical Spine Trauma: A Retrospective Review Of 729 Patients. World Neurosurg. 2019 Jul 3. pii: S1878-8750(19)31844-3. doi: 10.1016/j.wneu.2019.06.187. [Epub ahead of print] PubMed PMID: 31279109.
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