Trauma Medular

E v a l u a t i o n an d
Management of
Acute Cervical
S p i n e Tr a u m a
Laura Pimentel,

MD

a,b,

*, Laura Diegelmann,

MD

a,c

KEYWORDS
 Cervical spine  Trauma  Fracture  Injury  Vertebrae

The evaluation and management of cervical spine injuries is a core component of the
practice of emergency medicine. The incidence of serious cervical spine injuries is low
butassociated rates of death and disability are high; therefore, the emergency physician must have a strong knowledge base to identify these injuries as well as clinical
skills that will protect the patient’s spine during assessment. Cervical spine injury
causes an estimated 6000 deaths and 5000 new cases of quadriplegia in the United
States each year.1 Males are affected 4 times as frequently asfemales.
Two to three percent of blunt trauma patients who undergo cervical spine imaging
are diagnosed with a fracture. The second vertebra is most commonly injured,
accounting for 24% of fractures; the sixth and seventh vertebrae together account
for another 39% of fractures.2 From a clinical perspective, it is crucial for the emergency physician to diagnose a fracture. In the NEXUS trial,56.7% of cervical spine
fractures were unstable and another 13.9% were otherwise classified as clinically
significant.2 Older age is an important risk factor for cervical spine injury: patients
65 years or older have a relative risk twice that of younger trauma victims.3 The associated mortality rate in this age group is 24%.4
A disproportionate number of cervical spine injuries are associatedwith moderate
and severe head injuries sustained in motor vehicle crashes. Head-injured patients
are almost 4 times as likely to have a cervical spine injury as those without head
injuries. Those at highest risk have an initial Glasgow Coma Scale (GCS) score of 8
or lower and are likely to sustain unstable injuries in the high cervical spine.5
a

Department of Emergency Medicine, Universityof Maryland School of Medicine, 110 South
Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
b
Department of Emergency Medicine, Maryland Emergency Medicine Network, 110 South
Paca Street, Baltimore, MD 21201, USA
c
Department of Emergency Medicine, University of Maryland Medical Center, 110 South Paca
Street, Baltimore, MD 21201, USA
* Corresponding author. Department ofEmergency Medicine, University of Maryland School of
Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201.
E-mail address: lpimentel@memn.org
Emerg Med Clin N Am 28 (2010) 719–738
doi:10.1016/j.emc.2010.07.003
0733-8627/10/$ – see front matter Ó 2010 Elsevier Inc. All rights reserved.

emed.theclinics.com

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Pimentel & Diegelmann

The focus of this article is theevaluation and management of blunt cervical spine
trauma by the emergency physician. The authors begin by reviewing the pertinent
anatomy of the cervical spine. Specific cervical spine fractures are discussed, with
an emphasis on unstable injuries and associated spinal cord pathology. The association of vertebral artery injury with cervical spine fracture is addressed, followed by
a review of themost recent literature on prehospital care. The authors then review initial
considerations in the emergency department, including cervical spine stabilization and
airway management. The most current recommendations for cervical spine imaging
with regard to indications and modalities are covered. Finally, the emergency department management and disposition of patients with spinal cord injuriesare reviewed.
ANATOMY

The cervical spine consists of 7 cervical vertebrae, the spinal cord, intervertebral discs
beginning at the C2-C3 interspace, a complex network of supporting ligaments, and
neurovascular structures. General vertebral anatomy consists of an annular body
and the vertebral arch, including the symmetric pedicles, laminae, superior and inferior
articular surfaces,...