CERVICAL

INJURY
Normal Anatomy
Normal Anatomy
SPINAL CORD
DERMATOM
 Normal Anatomy
Functionally, the cervical spine is divided
into:
The upper cervical spine [occiput (C0)C1
C2]
The lower (sub-axial) cervical spine (C3C7).
 Normal Anatomy
Upper Cervical Spine:

The atlas-occiput
junction primarily allows
flexion/extension and
limited rotation.
Axial rotation at the
craniocervical junction
is restricted by osseous
as well as ligamentous
structures.
 Normal Anatomy
Lower (Subaxial) Cervical Spine:
The vertebrae of the lower cervical spine have a
superior cortical surface which is concave in the
coronal plane and convex in the sagittal plane.
This configuration allows flexion, extension, and
lateral tilt by gliding motion of the facets.
 Biomechanics of Cervical Spine
Trauma
The conditions under which neck injury
occurs include several key variables such
as:
impact magnitude.
impact direction.
point of application.
rate of application.
Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness
 Spinal Cord Injury
It is now well accepted that acute spinal cord
injury (SCI) involves both:
Primary injury mechanisms.
Secondary injury mechanisms.
 History
The cardinal symptoms of an acute cervical
injury are:
pain
loss of function (inability to move the head)
numbness and weakness
bowel and bladder dysfunction.
 Initial Management
Primary survey
A full general and neurological assessment
must be undertaken in accordance with the
principles of advanced trauma life support
(ATLS).
As always, the patients airway, breathing
and circulation (ABCin that order) are the
first priorities in resuscitation from trauma.
 Initial Management
Secondary survey
specific signs of injury including:
local bruising
deformity of the spine (e.g. a gibbus or an increased
interspinous gap)
vertebral tenderness.
The whole length of the spine must be palpated,
another spinal injury at a different level.
Diaphragmatic breathing invariably indicate a high
spinal cord lesion.
Hypotensive patient should always raise the
possibility of neurogenic shock attributable to spinal
cord injury in the differential diagnosis.
 Initial Management
Secondary survey
At the end of the secondary survey,
examination of the peripheral nervous
system must not be neglected.
 Physical examination
Inspection and palpation
Occiput to Coccyx
Soft tissue swelling and bruising
Point of spinal tenderness
Gap or Step-off
Spasm of associated muscles

Neurological assessment
Motor, sensation and reflexes
Cervical spine immobilization
Safe assumptions
Head injury and unconscious
Multiple trauma
Fall
Severely injured worker
Unstable spinal column

Hard backboard, rigid cervical collar and lateral

support (sand bag)

Neutral position
Philadelphia hard collar
Transportation of spinal cord-injured
patients
Emergency Medical Systems (EMS)
Paramedical staff
Primary trauma center
Spinal injury center
Cervical Spine Imaging Options

Plain films
AP, lateral and open mouth view
Optional: Oblique and Swimmers

Flexion-Extension Plain Films

to determine stability

CT
Better for occult fractures

MRI
Very good for spinal cord, soft tissue and
ligamentous injuries
 Management of SCI
Spinal motion restriction: immobilization devices
ABCs
Increase FiO2
Assist ventilations as needed with c-spine control
Indications for intubation :
Acute respiratory failure
GCS <9
Increased RR with hypoxia
PCO2 > 50
VC < 10 mL/kg
IV Access & fluids titrated to BP ~ 90-100 mmHg
 Principle of treatment

Spinal alignment
deformity/subluxation/dislocation reduction

Spinal column stability

unstable stabilization

Neurological status
neurological deficit decompression
Jefferson Fracture
Burst fracture of C1 ring

Unstable fracture

Increased lateral ADI on

lateral film if ruptured
transverse ligament and
displacement of C1 lateral
masses on open mouth view

Need CT scan
Hangmans Fracture

Extension injury

Bilateral fractures of
C2 pedicles
(white arrow)

Anterior dislocation of
C2 vertebral body
(red arrow)

Unstable
Burst Fracture

Fracture of C3-C7 from

axial loading

Spinal cord injury is

common from posterior
displacement of fragments
into the spinal canal

Unstable
Clay Shovelers Fracture

Flexion fracture of
spinous process

C7>C6>T1

Stable fracture
Flexion Teardrop Fracture

Flexion injury causing a

fracture of the
anteroinferior portion of
the vertebral body

Unstable because
usually associated with
posterior ligamentous
injury
Bilateral Facet Dislocation

Flexion injury
Subluxation of dislocated
vertebra of greater than
the AP diameter of the
vertebral body below it
High incidence of spinal
cord injury
Extremely unstable
TERIMAKASIH