Cervical spine injury

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.

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

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 1).

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 2).

Treatment of subaxial cervical spinal injury remains controversial. Both the anterior and posterior procedures have serious advantages and disadvantages 3) 4) 5).

The age factor modulates human cervical spine tolerance to impact injury 6).

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 7).

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.
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.
Hadley MN. Treatment of subaxial cervical spinal injuries. Neurosurgery. 2002;50(3):S156–S165.
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.
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.
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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