Management of Cervical Spine Injury | ORR

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Back to Journal »Orthopedic Research and Review» Volume 13

Management of Cervical Spine Injury-Literature Review

Author Okereke I, Mmerem K, Balasubramanian D

Published on September 28, 2021, the 2021 volume: 13 pages 151-162


Single anonymous peer review

Editor who approved for publication: Professor Clark Hung

Isaac Okereke, Kingsley Mmerem, Dhanasekaraprabu Balasubramanian Department of Traumatology and Orthopedics, Royal London Hospital, London, UK Communications: Isaac Okereke Department of Traumatology and Orthopedics, Royal London Hospital, UK Tel. Sex, over-reliance on ligament structure to maintain stability, making this section of the spine the most vulnerable to trauma. Common injury mechanisms include axial compression, hyperflexion, hyperextension, and rotational injury. Good pre-hospital care and comprehensive evaluation of patients with suspected cervical spine injury (CSI) in the emergency department can improve clinical outcomes. The purpose of the initial evaluation of patients with suspected CSI is to determine the presence of injury through thorough clinical and radiological evaluation, as missed injuries can be catastrophic. The treatment of cervical spine injury can be conservative, pharmacological or surgical, with the purpose of preventing the progression of SCI, stabilizing the spine, and allowing the patient to recover. Keywords: cervical spine injury, spinal fixation, spinal decompression, cervical spine evaluation

The cervical spine is composed of seven very special vertebrae, located between the proximal end of the skull and the distal end of the thoracic spine, which are connected to the craniocervical joint and the first thoracic vertebra respectively. The cervical spine supports the head and its movement, protects the spinal cord, and is a conduit that supplies blood vessels to the brain through the transverse foramina located transverse to the C3 to C7 vertebrae.

Due to the inherent bone instability of the cervical spine, excessive reliance on the ligament structure to maintain stability makes this part of the spine the most vulnerable to injury. For example, the lower cervical spine relies on static stabilizers such as the anterior longitudinal ligament, posterior longitudinal ligament, facet joint capsule, intervertebral disc, interspinous and supraspinal ligaments to maintain stability while providing maximum flexibility. 1

It is estimated that about 1,000 people in the UK suffer spinal cord injury (SCI) each year, of which cervical spine injury (CSI) accounts for a large portion of these injuries. There are 10,000 to 12,000 new cases of SCI each year in the United States, and two-thirds of patients are under 30 years of age. In a review of 65 studies, Milby et al. found that the prevalence of CSI in all trauma patients was 3.7%. In this study, the prevalence of CSI in alert patients was 2.8%, while the prevalence of patients who could not be evaluated clinically was 7.7%. 3 Most CSIs occur between 15 and 30 years of age, and among patients over 65.4 years of age, 5 In a 10-year retrospective multicenter analysis of CSI in southeastern Nigeria, Uche et al. found that males in the study cohort The distribution with women is 3.1:1. 6 Motor vehicle accidents, falls from heights, sports-related injuries and assaults are the most common causes of CSI among young people. 7 Among the elderly, non-traumatic causes of cervical spine injury that may be caused by osteoporotic compression fractures, spinal degenerative diseases, or compression fractures caused by spinal tumors are more common. C5/C6 and C6/C7 are the most commonly injured cervical vertebrae after trauma, followed by C1/C2 vertebrae. Common injury mechanisms are Jefferson-type fractures, occipital condyle fractures, or burst fractures of other vertebrae caused by axial compression; hyperflexion, hyperextension, and rotation type injuries. 8

The purpose of initial evaluation of suspected CSI patients is to "clear the cervical spine." The purpose of the cervical intervertebral space is to determine that there is no damage to the spine and to identify any injuries (if any) that may require continuous treatment with a collar or surgical intervention.

In the initial clinical evaluation of trauma patients suspected of having CSI, the ATLS® protocol should be followed and full attention should be paid to other limbs or life-threatening distracting injuries. The British Orthopaedic Association Trauma and Orthopaedic Association Standards (BOAST) guidelines for spinal clearance in trauma patients recommend that all patients involved in severe blunt trauma are assumed to be unstable spinal injuries. 8,9 It is suspected that the correct management of patients has suffered from CSI in the field. In the case of unstable spine injury, excessive exercise of the spine by untrained and overzealous first responders is one of the most common causes of secondary CSI. 10 Therefore, spine precautions should be taken immediately in the pre-hospital environment to stabilize the cervical spine. According to the guidelines of the National Institute for Health and Care Excellence (NICE) in the United Kingdom, reduce neck movement during patient exercise. 2 Current evidence supports the use of a cervical collar, spinal plate, and head fixation triad. A pair of sandbags or foam wedges. This can achieve fully online spinal fixation and substantially reduce head movement or rotation in the pre-hospital environment and during the initial evaluation of the hospital. 11,12 It should be noted that the spine board is a very hard surface, which is mainly designed to prevent spinal movement. Therefore, the patient should be immediately transferred to a softer mattress during use to prevent pressure sores. 13,14

All patients should be assessed using the ISNCSCI injury scale before and after transplantation, as well as before and after surgery. 15 The American Spinal Injury Association (ASIA) grading (see Figure 1) is an improved version of the Frankel scoring system and is a general classification tool for spinal cord injuries based on standardized sensory and motor assessments. 16,17 It is used to determine the sensory and motor level physical condition of each side injury and whether the injury is complete or incomplete. The score is recorded according to the grades from A to E: A is a complete spinal injury, and E is the result of a normal neurological examination.

Clinical examination has shown that the sensitivity of identifying CSI is low. However, there is tenderness in the palpation of the spinous processes and cross-facet joints along the first cervical vertebrae to the first thoracic vertebrae. Continuous gaps or step deformities are in the cervical vertebrae structures and surrounding these structures. The presence of hematoma or edema indicates an acute injury. 18 In addition, patients with coma, patients with neck pain, and patients with evidence of neurological disease should suspect spinal cord injury. Hurt. Figure 1 continues. Figure 1 International standard for neurological classification of spinal cord injury. Reprinted from the American Spinal Injury Association: International Standards for the Neurological Classification of Spinal Cord Injuries, revised in 2019; Richmond, Virginia, available from: /.28

Figure 1 International standard for neurological classification of spinal cord injury. Reprinted from the American Spinal Injury Association: International Standards for the Neurological Classification of Spinal Cord Injuries, revised in 2019; Richmond, Virginia, available from: /.28

In accordance with the National Emergency Radiography Utilization Study Group (NEXUS) guidelines or the Canadian C Spine Rules (CCR), imaging decisions are made in alert and stable patients. NEXUS guidelines recommend that if the patient meets all five low-risk criteria, cervical radiology is not required: no midline tenderness, normal alertness, no signs of poisoning, no abnormal neurological findings, and no painful distracting injuries . 19 In a large group of CSI patients, plain radiographs (such as frontal AP, cross table side and open mouth odontoid) missed 61% of fractures, 36% of subluxations and dislocations, and gave 23% of false Of the patients with negative results, half of them suffered from unstable cervical spine injuries. 20 plain films have also been shown to be less sensitive to confused patients. In a study to determine the usefulness of X-ray films for patients with clinically suspected cervical spine fractures, Lange et al. found that the incidence of cervical spine fractures on X-ray films was 0.0%, and the overall positive rate was 6.4%. Computed tomography (CT) of the cervical spine. 21 CT scanners used to be called "Doughnuts of Death" due to delayed image acquisition. Because of their accuracy, ability to produce images in each spatial plane, cost-effectiveness and speed, they have replaced plain films for imaging suspected spinal injuries. 22-24 Cervical spine CT scan is the gold standard imaging method for patients with suspected cervical spine injury. 25

Although MRI scans are not suitable for cervical spine removal, they are useful aids for patients whose injuries cannot be well described using CT scans. They are more sensitive to soft tissue damage and can detect damage to the ligament complex (DLC). Pourtaheri et al. found that 48% of cervical MRI data included additional clinically useful information, causing 39% of patients to change management, and 24% of patients decided to operate on patients who were previously considered not to undergo surgery. 26 Disadvantages The disadvantages of MRI imaging are expensive, time-consuming, and a logistical challenge for patients with in-situ monitoring equipment. 27 Figure 2 shows the algorithm for preliminary assessment and management of suspected CSI in the emergency department. Figure 2 Suspected CSI management algorithm in the emergency department.

Figure 2 Suspected CSI management algorithm in the emergency department.

As defined by White and Panjabi, spinal stability is the ability of the spine to limit the mode of displacement under physiological loads, so as not to damage or irritate the spinal cord and nerve roots, and to prevent deformity or pain that causes disability due to structural changes. Instability (acute or chronic) refers to excessive displacement of the spine, which can lead to neurological deficits, deformities or pain. 29

In his landmark work, Punjab very elegantly conceptualized the stability of the spine as relying on the harmonious operation of three subsystems: the active musculoskeletal subsystem (muscles and tendons), the passive musculoskeletal subsystem (intervertebral discs, ligaments, Joints and soft tissues) and neural and feedback subsystems (force and motion sensors, nerves). 30 Therefore, dysfunction of any of these systems after trauma can lead to spinal instability.

The cervical spine can be anatomically divided into axial (occipital-cervical junction and atlantoaxial vertebrae C1-C2) and inferior axis (C3-C7) segments. The central axis spine accounts for most of the flexion, extension and rotation of the cervical spine. Compared with the lower axis spine, it largely relies on the support of ligaments to maintain stability. Bogduk and colleagues describe the cervical spine as composed of four discrete functional and anatomical units: cradle (atlas), shaft, root (C2-C3 junction), and column (C3-C7). Mechanics has made a unique contribution. Cervical spine. 31

In the past few decades, several clinical classifications of spinal injuries have been developed to facilitate accurate and clear communication between clinicians. Older classifications are more mechanical, depend on the radiological form of the injury, lack severity levels, and therefore cannot predict stability and outcome. 31 The current classification system takes into account the overall situation of the patient and has higher validity, reliability and clinical consequences. They can accurately guide treatment and determine potential outcomes.

This is a highly unstable and destructive injury caused by the destruction of the bony ligaments of all the main stabilizers of the atlanto-occipital joint: the pterygoid ligament, the pericy membrane, and the atlanto-occipital joint capsule.

This injury usually occurs unilaterally secondary to axial trauma. Before CT and MRI imaging appeared, Anderson and Montesano and recently Tuli et al. classified them29,32

Isolated fractures of the C1 vertebrae are easy to diagnose on plain radiographs. The atlas is a bone ring, which means that fractures at this level almost always involve at least two points. Jefferson et al. described a typical 4-point burst fracture morphology. CT imaging is usually required to classify atlas fractures as stable or unstable burst fractures. Bone avulsion of the Atlanta transverse ligament (TAL) is usually an indicator of potential instability.

Odontoid fractures account for 20% of all cervical spine fractures and are secondary to avulsion injuries involving the apical ligament. 33 When they occur alone, they are stabilizing damage. Anderson and D'Alonzo originally classified odontoid fractures into three types based on the fracture pattern.

Traditionally called "Hangman fractures", these injuries are caused by the mechanism of hyperextension and hyperflexion injury, leading to traumatic spondylolisthesis of C2 and C3. The most commonly used classification system is the Levine and Edwards modified version of the Effendi classification. 34

These are fractures of the C2 vertebra.

AO Spine Upper Cervical Spine Injury Classification is a modern classification system designed to simplify and summarize the classification process of upper cervical spine injuries. The presence of nervous system signs and/or regulatory factors.

Type 1: Occipital and occipital-neck joint complex injuries Type 2: C1 ring and C1-2 joint complex injuries Type 3: C2 and C2-3 joint complex injuries

Injury type (A, B or C) A: Bone injury only-considered as stable injury B: Tension band injury-considered as potentially unstable injury C: Translation injury-considered as unstable injury

Nervous system signs (N) NX: Unable to examine the patient N0: No neurological deficit N1: Temporary nerve injury N2: Nerve root injury N3: Incomplete spinal cord injury N4: Complete spinal cord injury: Continuous spinal cord compression

Modification (M) M1: Injury with a significant possibility of instability M2: Non-surgical treatment leads to a high-risk injury that does not heal M3: Patient-specific factors that affect treatment (for example, age, smoking status, medical comorbidities, concurrent injury or Metabolic bone) disease) M4: Vascular damage or abnormality that affects treatment

The Allen-Ferguson classification of subaxial injuries is one of the historical classifications of subaxial injuries. It divides injuries into six types: compression-flexion, vertical compression, traction-flexion, compression-extension, traction-extension and lateral flexion. Recently, the AO classification and the Spine Classification (SLIC) and Severity Scales released by Vaccaro et al. in 2007 have been more widely used. The SLIC classification system is based on three factors: fracture morphology, nerve status, and the integrity of the intervertebral disc ligament complex (DLC). 35 Because of its higher intra-rater correlation and inter-rater intra-class correlation measurement, it is used more frequently at 0.83 and 0.71, respectively. 36,37 SLIC classifies injuries as follows: Injury morphology: No abnormality 0 1 point for compression, burst fracture, 2 points for traction, 3 points for traction (inhabiting small joints, hyperextension injury), 4 points for translational or rotational injury (dislocation of small joints), unstable teardrop-like or premature flexion/compression) consisting of intervertebral discs, anterior and posterior longitudinal ligaments, The intervertebral disc complex (DLC) formed by the interspinous ligament, the facet joint capsule and the ligamentum flavum: complete 0 points, uncertain 1 point (isolated MRI signal changes) or isolated spinous process widening) interrupted at 2 points (intervertebral disc widening) , Facet joint process or lock). Nervous system status: intact 0 points for root injury 1 point for complete spinal cord injury 2 points for incomplete spinal cord injury 3 points and (1) continuous spinal cord compression in the case of neurological deficits.

Injuries with a score of <3 can be treated conservatively, and those with a score of >5 can be treated with surgery. The management team prefers surgery or conservative treatment, which is usually indicated when the score is exactly 4.

Patients who are suspected of suffering from cervical spine fractures should be evaluated by clinicians to integrate their clinical history, examination results, and imaging results to guide classification and follow-up management.

The principles of treatment for patients with spinal injuries are: Decompression of the nerve structure to prevent or correct segmental collapse and deformity to restore normal spinal mechanics to avoid and deal with complications to promote early getting out of bed and rehabilitation

Until recently, the surgical treatment of spinal injury has made progress and development, non-surgical treatment has been the main method of spinal injury treatment. Although spinal surgery has made significant innovations and advances, conservative treatment can still play a role, whether it is in the initial stage of injury, later as an auxiliary means of surgery, or as the final treatment of spinal injury. Non-surgical treatment of cervical spine fractures uses traction and ideal external fixation, halo vests and cervical collars. Conservative treatment is applicable to all fractures that are not dislocated and unstable.

Traction of the bone and skull by skull clamp or halo ring can be used for facet joint subluxation/dislocation, burst fracture and high cervical spine fracture to fix and re-adjust the cervical spine. 38 Be wary of patients. Unilateral or bilateral facet joint dislocations are suitable for continuous neurological examination and can be clearly managed by closed reduction and reduction of skull traction. The recommendation for closed traction reduction is to start with a weight of 10 to 15 pounds, and then gradually increase by 5 to 10 pounds for each degree of injury as a series of neurological examinations. 39 However, the herniated disc may worsen. Therefore, during closed reduction, patients who are unresponsive or unable to cooperate with continuous neurological examinations should undergo an MRI scan before attempting closed reduction. Cranial traction is usually poorly tolerated by patients and may be the cause of the disease.

Cervical brace and cervical thoracic orthosis are suitable for the radical treatment of patients with lower cervical spine injury, or as a postoperative adjuvant treatment for patients with fixation problems. Compared with the skull traction technique, the collar is more comfortable for the patient, but often allows significant movement of the spine. Johnson and his colleagues describe three major categories of cervical orthoses: collars, poster supports, cervical thoracic supports, and halo vests. 40 The types of collars include soft collars, semi-rigid collars and rigid collars. Examples of semi-rigid collars are Philadelphia collars, Miami collars, Aspen collars and Malibu braces. The rigid collar is used for prehospital transportation of trauma patients with suspected cervical spine injury.

The cervical thoracic brace extends above the trunk and is suitable for stabilizing injuries and lower cervical spine injuries. The posterior brace is like a cervical-thoracic orthosis, which controls the head through a padded mandibular and occipital support with metal posts and flexible straps connecting the front and back components. Generally speaking, increasing the working length of the cervical orthosis can improve its ability to restrict the rotation and flexion of the lower cervical spine, but it has no effect on the scoliosis and flexion of the upper cervical spine. Compression fractures without posterior ligament or joint capsule involvement can be treated non-surgically with rigid cervical orthoses.

When rigid fixation of unstable cervical spine injuries is required, Halos vests can be used and can be used for the ultimate treatment of injuries. The halo is connected to the torso by a metal strip, which can be connected to the plastic vest. Elderly people with degenerative kyphosis and spondylopathy, cervical spine and type 3 odontoid fractures after falling, can usually be treated non-surgically in the halo vest.

From a drug point of view, only high-dose methylprednisolone sodium succinate (MPSS) has achieved some success in the landmark National Acute Spinal Cord Injury Study (NASCIS) trial, while all other drugs have been tested in clinical efficacy trials. No benefit is shown. 41 The role of MPSS is an immunosuppressant and anti-inflammatory drug. However, there are concerns about the effectiveness and safety of MPSS in patients with acute SCI. 42 After a systematic review of the use of MPSS in acute SCI by Fehlings et al., they recommended not to provide high-dose MPSS infusion to patients with acute SCI after 24 hours and 8 hours, and not to provide 48-hour infusion to patients with acute SCI. 43 The UK’s NICE guidelines clearly recommend against using MPSS in the treatment of acute SCI. 44 The various stages of development and evaluation include antibiotics such as minocycline, riluzole, Cethrin and Premarin.

The indications for surgical treatment of SCI are: unstable injury. Progressive neurological deterioration. Used for early activities in patients with nerve damage. Patients with a high incidence of late complications, such as 30° kyphosis or a height drop of more than 50%.

The immediate goal of surgery is to readjust the spine, decompress the nerve components, and provide mechanical stability. Surgical options for the treatment of sub-cervical injuries include anterior decompression (discectomy/vertebectomy) and fusion, posterior stabilization with or without decompression, and a combination of anterior and posterior spine circumferential approaches. 45 It should also be considered that patients who are surgically stable are still unable to move under proper support. 46

The widely accepted two-strike theory of spinal cord injury describes the cascade of the initial primary injury caused by trauma-induced tears or intramedullary hematoma formation, and the subsequent secondary injury mechanisms that exacerbate the destruction of nerve tissue. 34 Wilson and others strongly recommend that early decompression surgery can reduce secondary spinal cord injury based on available data, and surgical decompression and spinal stabilization (within 24 hours) spinal cord injury should be used when medically feasible. 46,47 Spine surgeons have reached a consensus on the management of SCI patients with early surgery, but early surgery for patients with complete injury is still controversial. The Timing of Surgery Study for Acute Spinal Cord Injury (STASCIS) is a multi-center international study that recruited patients with cervical SCI between the ages of 16 and 80. The results showed that the ASIA grade of early surgery patients improved by 19.8% ≥ 2 (14.2 ± 5.2 hours), while the late stage The improvement rate for surgical patients was 8.8% (48.3 ± 29.3 hours). 48,49

The decision on the best method is mainly based on the shape of the damage. Robinson and Smith described the anterior spinal approach for the first time in their landmark paper in 1935. This approach is best used when adequate decompression and removal of the vertebral body are required. 50 This approach usually has slight muscle splits and is therefore considered to be more beneficial to patients after surgery. The upper cervical spine injuries suitable for the anterior approach include type 2 dentate nail fractures, Jefferson fractures, and Hangman fractures that are directly screwed by traction and dislocation.

The posterior approach has excellent alignment and stability, and ensures anatomical reduction of the facet joints. It has better biomechanical stability in cadaver studies and can be used for C2 lateral mass screw placement and Pars screw fixation in the upper cervical spine. However, there is no evidence to support the use of one method over another. Brodke et al. reported that there were no significant differences between the two approaches in terms of fusion rate, neurological recovery, or long-term outcome. 51 Highly unstable fracture/dislocation/subluxation requires a combined approach for spinal decompression, anterior column height restoration, and posterior complex reconstruction.

Complications of anterior surgery include: esophageal injury, recurrent or superior laryngeal nerve injury, vertebral artery and carotid artery injury. Other complications are posterior longitudinal ligament ossification (PLL), adjacent segment degeneration (ASD), and false joints. Screw misplacement leads to spinal cord and nerve root damage and kyphosis after laminectomy are some complications of posterior surgery. Rare complications after surgery include postoperative nerve damage, common C5 and C8-T1 nerve palsy, Horner syndrome, Priest-Turner syndrome (PTS), and surgical site infections. Figure 3 shows the standard algorithm for cervical spine injury management. 52 Figure 3 Algorithm for surgical treatment of cervical spine injury. 52

Figure 3 The surgical treatment algorithm for cervical spine injury. 52

Although cervical spine injury is not common, it is a catastrophic event that can lead to long-term disability. The evaluation of patients with suspected CSI requires a high degree of suspicion, careful clinical and radiological evaluation, and a personalized treatment plan. The treatment aims to stop the progression of SCI and stabilize the spine so that the patient can recover. Although conservative treatment has always been the mainstay of treatment, recent advances in surgical technology and more favorable results have led to a more aggressive surgical intervention.

Ethical approval is not required for this review.

IO conceptualized this review and wrote the first draft of the manuscript. KM and DB contributed to literature review, research design, data extraction, and critically reviewed the final manuscript. The first draft of the manuscript was written by IO, and all authors contributed. All authors reviewed and agreed to all versions of the article before submission, during revision, accepting the final version for publication, and any major changes introduced during the proofreading phase. All authors agree to be responsible for the content of the article.

No funds were received for this research.

The authors report no conflicts of interest in this work.

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