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Normal Anatomy
Normal Anatomy
Normal Anatomy
• Functionally, the cervical spine is divided
– The upper cervical spine [occiput (C0)–C1–
– The lower (sub-axial) cervical spine (C3–C7).
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
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
• The conditions under which neck injury
occurs include several key variables such
– 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.
• 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
• As always, the patient’s airway, breathing
and circulation (“ABC”—in 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
• 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 Swimmer’s

– Flexion-Extension Plain Films

• to determine stability

– CT
• Better for occult fractures

• 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
Hangman’s 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 Shoveler’s 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
Bilateral Facet Dislocation

• Flexion injury
• Subluxation of dislocated
vertebra of greater than
½ the AP diameter of the
vertebral body below it
• High incidence of spinal
cord injury
• Extremely unstable