Last updated January 6, 2022

Acute Cervical Spine And Spinal Cord Injuries

Recommendations

Immobilization

Spinal immobilization of all trauma patients with a cervical spine or SCI or with a mechanism of injury having the potential to cause cervical spinal injury is recommended. (Level II)
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Triage of patients with potential spinal injury at the scene by trained and experienced EMS personnel to determine the need for immobilization during transport is recommended. (Level II)
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Immobilization of trauma patients who are awake, alert, and not intoxicated; who are without neck pain or tenderness; who do not have an abnormal motor or sensory examination; and who do not have any significant associated injury that might detract from their general evaluation is not recommended. (Level II)
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Spinal immobilization in patients with penetrating trauma is not recommended because of the increased mortality from delayed resuscitation. (Level III)
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Transportation

Whenever possible, the transport of patients with acute cervical spine injuries or SCIs to specialized acute SCI treatment centers is recommended. (Level III)
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Clinical assessment neurological status

The ASIA international standards are recommended as the preferred neurological examination tool. (Level II)
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Clinical assessment functional status

The Spinal Cord Independence Measure is recommended as the preferred functional outcome assessment tool for clinicians involved in the assessment, care, and follow-up of patients with SCIs. (Level I)
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Clinical assessment pain

The International Spinal Cord Injury Basic Pain Data Set is recommended as the preferred means to assess pain, including pain severity, physical functioning, and emotional functioning, among SCI patients. (Level I)
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Radiographic assessment asymptomatic patient

In the awake, asymptomatic patient who is without neck pain or tenderness, who has a normal neurological examination, who is without an injury detracting from an accurate evaluation, and who is able to complete a functional range of motion examination, radiographic evaluation of the cervical spine is not recommended. (Level I)
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Discontinuance of cervical immobilization for these patients is recommended without cervical spinal imaging. (Level I)
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In the awake patient with neck pain or tenderness and normal high-quality CT imaging or normal 3-view cervical spine series (with supplemental CT if indicated), the following recommendations should be considered:
(1) Continue cervical immobilization until asymptomatic;
(2) Discontinue cervical immobilization after normal and adequate dynamic flexion/extension radiographs;
(3) Discontinue cervical immobilization after a normal MRI obtained within 48 h of injury (limited and conflicting Class II and Class III medical evidence); or
(4) Discontinue cervical immobilization at the discretion of the treating physician.
(Level III)
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Radiographic assessment symptomatic patient

In the awake, symptomatic patient, high-quality CT imaging of the cervical spine is recommended. (Level I)
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If high-quality CT imaging is available, routine 3-view cervical spine radiographs are not recommended. (Level III)
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If high-quality CT imaging is not available, a 3-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended. This should be supplemented with CT (when it becomes available) if necessary to further define areas that are suspicious or not well visualized on the plain cervical x-rays. (Level III)
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In the awake patient with neck pain or tenderness and normal high-quality CT imaging or normal 3-view cervical spine series (with supplemental CT if indicated), the following recommendations should be considered:
  1. Continue cervical immobilization until asymptomatic;
  2. Discontinue cervical immobilization after normal and adequate dynamic flexion/extension radiographs;
  3.  Discontinue cervical immobilization after a normal MRI obtained within 48 h of injury (limited and conflicting Class II and Class III medical evidence) or 
  4.  Discontinue cervical immobilization at the discretion of the treating physician.
(Level III)
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Radiographic evaluation in obtunded (or unevaluable) patients

In the obtunded or unevaluable patient, high-quality CT imaging is recommended as the initial imaging modality of choice. If CT imaging is available, routine 3-view cervical spine radiographs are not recommended. (Level I)
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If high-quality CT imaging is not available, a 3-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended. This should be supplemented with CT (when it becomes available) if necessary to further define areas that are suspicious  or not well visualized on the plain cervical x-rays. (Level I)
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Closed reduction

Early closed reduction is recommended. (Level III)
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Cardiopulmonary management

Management of patients with acute SCI in a monitored setting is recommended. (Level III)
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Maintaining a mean arterial blood pressure of 85-90 mm Hg after SCI is recommended. (Level III)
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Pharmacology management corticosteroids

Administration of methylprednisolone for the treatment of acute SCI is not recommended. Clinicians considering methylprednisolone therapy should bear in mind that the drug is not approved by the Food and Drug Administration for this application. There is no Class I or Class II medical evidence supporting the clinical benefit of methylprednisolone in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects, including death. (Level I)
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Pharmacology management GM- 1 ganglioside

Administration of GM-1 ganglioside (Sygen) for the treatment of acute SCI is not recommended. (Level I)
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Occipital condylar fractures diagnostic

  • CT is recommended to diagnose occipital condylar fractures.
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  • MRI is optional to diagnose occipital condylar fractures.
(Level III)
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Occipital condylar fractures treatment

External cervical immobilization is recommended for all types of occipital condyle fractures. (Level III)
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More rigid external immobilization in a halo vest device should be considered for bilateral occipital condylar fractures. (Level III)
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Halo vest immobilization or occipitocervical stabilization and fusion is recommended for injuries with associated atlanto-occipital ligamentous injury or evidence of instability. (Level III)
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AOD diagnostic

CT imaging to determine the condyle-C1 interval in pediatric patients with potential AOD is recommended. (Level I)
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If there is clinical or radiographic suspicion of AOD and plain radiographs are nondiagnostic, CT of the craniocervical junction is recommended. The condyle-C1 interval determined on CT has the highest diagnostic sensitivity and specificity for AOD among all radiodiagnostic indicators. (Level III)
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AOD treatment

Traction is not recommended in the management of patients with AOD and is associated with a 10% risk of neurological deterioration. (Level III)
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Atlas fractures

Treatment is based on specific fracture type and the integrity of the transverse ligament. (Level III)
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Odontoid fracture

Treatment of type II odontoid fractures based on 50 y of age. (Level II)
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Axis fractures odontoid

If surgical stabilization is elected, either anterior or posterior techniques are recommended. (Level III)
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Axis fractures hangman fracture

External immobilization is recommended. (Level III)
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Axis fractures miscellaneous body

External immobilization for the treatment of isolated fractures of the axis body is recommended. Consideration of surgical stabilization and fusion in unusual situations of severe ligamentous disruption and/or an inability to achieve or maintain fracture alignment with external immobilization is recommended. (Level III)
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In the presence of comminuted fracture of the axis body, evaluation for VAI is recommended. (Level III)
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Atlas/axis combination fractures

Treatment is based on characteristics of axis fracture. (Level III)
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Os odontoideum diagnostic

Plain radiographs with flexion/extension with or without CT or MRI are recommended. (Level III)
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Os odontoideum management

Occipital-cervical internal fixation and fusion with or without C1 laminectomy is recommended in patients with os odontoideum who have irreducible dorsal cervicomedullary compression and/or evidence of associated occipital-atlantal instability. (Level III)
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Ventral decompression should be considered in patients with os odontoideum who have irreducible ventral cervicomedullary compression. (Level III)
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Classification of subaxial injuries

  • SLIC and CSISS
(Level I)
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  • Harris and Allen
(Level III)
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Subaxial cervical spinal injuries

The routine use of CT and MRI of trauma victims with ankylosing spondylitis is recommended, even after minor trauma. (Level III)
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For patients with ankylosing spondylitis who require surgical stabilization, posterior long-segment instrumentation and fusion, or a combined dorsal and anterior procedure is recommended. Anterior standalone instrumentation and fusion procedures are associated with a failure rate of up to 50% in these patients. (Level III)
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Central cord syndrome

Aggressive multimodality management of patients with acute traumatic canal cord syndrome is recommended.

(Level III)
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Pediatric injuries diagnostic

CT imaging to determine the condyle-C1 interval for pediatric patients with potential AOD is recommended. (Level I)
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Cervical spine imaging is not recommended in children who are >3 y of age and who have experienced trauma and who:
  1. Are alert
  2. Have no neurological deficit
  3. Have no midline cervical tenderness
  4. Have no painful distracting injury
  5. Do not have unexplained hypotension
  6. And are not intoxicated.
(Level II)
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Cervical spine imaging is not recommended in children who are ,3 y of age who have experienced trauma and who:
  1. Have a Glasgow Coma Scale score >13
  2. Have no neurological deficit
  3. Have no midline cervical tenderness
  4. Have no painful distracting injury
  5. Are not intoxicated
  6. Do not have unexplained hypotension
  7. Do not have motor vehicle collision
  8. Do not have a fall from a height >10 ft or
  9. Do not have nonaccidental trauma as a known or suspected mechanism of injury.
(Level II)
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Cervical spine radiographs or high-resolution CT is recommended for children who have experienced trauma and who do not meet either set of the above criteria. (Level II)
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A 3-position CT with C1-C2 motion analysis to confirm and classify the diagnosis is recommended for children suspected of having AARF. (Level II)
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Anteroposterior and lateral cervical spine radiography or high-resolution CT is recommended to assess the cervical spine in children <9 y of age. (Level III)
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Anteroposterior, lateral, and open-mouth cervical spine radiography or high-resolution CT is recommended to assess the cervical spine in children ≥9 y of age. (Level III)
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High-resolution CT scan with attention to the suspected level of neurological injury is recommended to exclude occult fractures or to evaluate regions not adequately visualized on plain radiographs. (Level III)
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Flexion and extension cervical radiographs or fluoroscopy is recommended to exclude gross ligamentous instability when there remains a suspicion of cervical spinal instability after static radiographs or CT scan. (Level III)
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MRI of the cervical spine is recommended to exclude spinal cord or nerve root compression, to evaluate ligamentous integrity, or to provide information regarding neurological prognosis. (Level III)
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Pediatric injuries treatment

Reduction with manipulation or halter traction is recommended for patients with acute AARF (<4-wk duration) that does not reduce spontaneously. Reduction with halter or tong/halo traction is recommended for patients with chronic AARF (>4-wk duration). (Level III)
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Internal fixation and fusion are recommended in patients with recurrent and/or irreducible AARF. (Level III)
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Operative therapy is recommended for cervical spine injuries that fail nonoperative management. (Level III)
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SCIWORA diagnostic

MRI of the region of suspected neurological injury is recommended in a patient with SCIWORA. (Level III)
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Radiographic screening of the entire spinal column is recommended. (Level III)
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Assessment of spinal stability in a SCIWORA patient is recommended using flexion/extension radiographs in the acute setting and at late follow-up, even in the presence of an MRI negative for extraneural injury. (Level III)
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SCIWORA treatment

External immobilization of the spinal segment of injury is recommended for up to 12 wk. (Level III)
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Early discontinuation of external immobilization is recommended for patients who become asymptomatic and in whom spinal stability is confirmed with flexion and extension radiographs.

(Level III)
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Avoidance of “high-risk” activities for up to 6 mo after SCIWORA is recommended. (Level III)
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VAI diagnostic

CT angiography is recommended as a screening tool in selected patients after blunt cervical trauma who meet the modified Denver Screening Criteria for suspected VAI. (Level I)
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Conventional catheter angiography is recommended for the diagnosis of VAI in selected patients after blunt cervical trauma, particularly if concurrent endovascular therapy is a potential consideration, and can be undertaken in circumstances in which CT angiography is not available. (Level III)
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MRI is recommended for the diagnosis of VAI after blunt cervical trauma in patients with a complete SCI or vertebral subluxation injuries. (Level III)
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VAI treatment

It is recommended that the choice of therapy for patients with VAI, anticoagulation therapy vs antiplatelet therapy vs no treatment, be individualized on the basis of the patients’ VAIs, their associated injuries, and their risk of bleeding. (Level III)
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The role of endovascular therapy in VAI has yet to be defined; therefore, no recommendation regarding its use in the treatment of VAI can be offered. (Level III)
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Venous thromboembolism prophylaxis

Early administration of venous thromboembolism prophylaxis (within 72 h) is recommended. (Level II)
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Vena cava filters are not recommended as a routine prophylactic measure but are recommended for select patients who fail anticoagulation or who are not candidates for anticoagulation and/or mechanical devices. (Level III)
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Nutritional support

Indirect calorimetry as the best means to determine the caloric needs of SCI patients is recommended. (Level II)
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Nutritional support of SCI patients is recommended as soon as feasible. It appears that early enteral nutrition (initiated within 72 h) is safe but has not been shown to affect neurological outcome, length of stay, or incidence of complications in patients with acute SCI. (Level III)
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Recommendation Grading

Overview

Title

Acute Cervical Spine And Spinal Cord Injuries

Authoring Organization

Publication Month/Year

March 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this article is to provide an overview of the changes in the recommendations for the management of patients with acute cervical spinal cord injuries (SCIs) as a result of new evidence or broadened scope

Target Patient Population

Patients with acute spinal cord injuries

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Radiology services

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013116 - Spinal Cord, D013131 - Spine, D013119 - Spinal Cord Injuries, D066193 - Cervical Cord

Keywords

spinal cord injury, cervical spine, spine

Source Citation

Neurosurgery, Volume 60, Issue CN_suppl_1, August 2013, Pages 82–91, https://doi-org.ezproxylocal.library.nova.edu/10.1227/01.neu.0000430319.32247.7f