Collar Up: Navigating Cervical Spine Injuries

-Case-

A 34-year-old extremely active man is rushed to the ED by EMS after a gnarly mountain biking crash. EMS was kind enough to place a cervical collar en route to your ED. He’s wincing, clutching his neck, and every movement sends a jolt of pain shooting down his arms. He says, “I tried getting up after the crash, but my arms felt weak and tingly.” His vitals are stable, ABCs are secure, and he notes some cervical spinal point tenderness.

This patient is one that would be quickly whisked off to the CT scanner. What are we worried about finding on imaging?

-Evaluation-

Cervical spine fractures are much more than your average neck pain. Spinal cord protection is key, and the stakes are high. Let’s break it down.

Unsurprisingly, neck pain is the hallmark presenting symptom. Midline tenderness on palpation (like in our case above) is a big red flag. Neurologic symptoms like weakness, numbness, or tingling in the extremities should clue you that the spinal cord may be involved.

Our evaluation continues with assessing range of motion and associated injuries.  Injuries with mechanisms dangerous enough to cause cervical spine fractures often don’t exclusively affect the neck! Here, we think about head trauma, thoracic fractures, and abdominal injuries. A FAST exam is crucial for these trauma patients to look for these other injuries.

Now, who needs imaging? NEXUS and Canadian C-Spine Rules to the rescue:

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  • NEXUS criteria states if there is no midline tenderness, GCS is 15, and there are no neuro deficits, intoxication, or distracting injuries, you might skip imaging
  • Canadian C-Spine Rule suggest that high-risk features like age >65, a dangerous mechanism, or paresthesias mean you’re getting imaging, no questions asked

For our imaging options, a CT scan is the gold standard. It’s fast, sensitive, and great for finding fractures. An x-ray misses spinal fractures way too much to rely it on alone and MRI is usually reserved following positive CT scans or when you’re worried about the spinal cord or ligament injuries despite a negative CT. If you are at an institution with neurosurgery, they’ll often suggest that a symptomatic patient with a C-spine fracture on CT should get an MRI, as well.

Let’s dive into some common unstable C-spine fractures you should know – the boards love these.

  • Jefferson Fracture: C1 burst fracture from axial loading (classically “diving headfirst into shallow water”)
  • Hangman’s Fracture: Bilateral C2 pars fractures from hyperextension (think rear-end collisions)
  • Odontoid Fracture: A broken dens (C2); Types II and III? Both unstable and scary
  • Teardrop Fracture: Highly unstable, caused by extreme flexion or extension

-Management-

You’ve successfully ID’d a cervical spine fracture – now what?

Immobilize, immobilize, immobilize! And that cervical collar? Make sure it stays on – moving the patient could worsen spinal cord damage. If you need to roll them, please log roll and only with a team. In addition, any fracture that’s unstable or in a patient with neurologic compromise gets an immediate call to neurosurgery and/or ortho.

Alternatively, though once the darling of spinal cord injury management, steroids are now controversial and not routinely recommended. Definitive treatment, rather, depends on the type of fracture. Stable fractures warrant a cervical collar and follow-up imaging while unstable fractures require surgery or halo fixation (and sometimes both).

-Fast Facts-

  • The “red flag” combo of neck pain + neuro symptoms = fracture until proven otherwise
  • CT is key! Once stabilized and the patient is safe to leave the trauma bay, imaging comes first
  • Stability Rules: know which fractures need urgent intervention

For cervical spine fractures, keeping the spinal cord safe is crucial to prevent devastating outcomes. When neck pain comes through the door, you immobilize, image, and act fast!

Want to read more about this topic? Click ✨here✨to read our in-depth study guide!

Cheers,

Tamir Zitelny, MD

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