# CIM Case: Cervical Spine Trauma ## Clinical Scenario **Patient:** 23-year-old male **Presentation:** Motor vehicle accident (restrained driver, rear-ended), conscious and coherent, severe neck pain and midline tenderness, no neurological deficits **Relevant history:** No previous neck problems, no medical conditions, no anticoagulation **Examination findings:** - GCS 15, haemodynamically stable - Triple immobilisation in situ - Midline cervical tenderness C5-C6 level - Full power all myotomes (C5-T1, L2-S1) - Intact sensation all dermatomes - Normal reflexes, Babinski downgoing bilateral - Intact perianal sensation and anal tone - No priapism - No distracting injuries --- ## Investigations Provided ### Laboratory Results | Test | Result | Normal Range | Interpretation | |------|--------|--------------|----------------| | N/A | - | - | Bloods not primary investigation for isolated cervical trauma | ### Imaging **Image 1: CT Cervical Spine - Sagittal and Axial** **Radiological features:** - C5/6 unilateral facet dislocation (right-sided) - Anterior subluxation of C5 on C6 - Right C5/6 facet "locked" (perched) - Left C5/6 facet intact - No burst fracture component - No retropulsion into canal - Vertebral arteries appear intact on CT angiogram **Image 2: MRI Cervical Spine (if obtained)** **MRI findings:** - C5/6 disc disruption with posterior annular tear - Posterior ligamentous complex (PLC) disruption - Anterior longitudinal ligament (ALL) intact - No cord signal change (no cord oedema or haemorrhage) - Mild canal compromise but no cord compression - No epidural haematoma ## Questions & Model Answers **ATLS Primary Survey - Cervical Spine Trauma:** This patient has a cervical spine injury until proven otherwise. Systematic approach is essential. **Airway with C-spine protection:** | Assessment | This Patient | |------------|--------------| | Patent airway | Yes - speaking | | C-spine immobilisation | Maintain triple immobilisation | | Intubation risk | High - if airway compromise, need for MRI | **Breathing and Ventilation:** | Assessment | This Patient | |------------|--------------| | Respiratory rate | Normal (GCS 15) | | Chest expansion | Bilateral equal | | High cervical injury risk | C5 injury - watch for respiratory compromise | **Circulation:** | Assessment | This Patient | |------------|--------------| | Blood pressure | Normal (not hypotensive) | | Heart rate | Normal | | Neurogenic shock | Not present (no bradycardia/hypotension) | **Disability - Neurological Examination:** | Component | Finding | |-----------|---------| | **Motor** | Full power all levels | | **Sensory** | Intact all dermatomes | | **Reflexes** | Normal, Babinski downgoing | | **Sacral sparing** | Present (perianal sensation, anal tone) | | **ASIA Score** | E (Normal) | **ASIA Impairment Scale:** | Grade | Description | |-------|-------------| | A | Complete - no motor or sensory function S4-S5 | | B | Sensory incomplete - sensory but no motor below level, including S4-S5 | | C | Motor incomplete - motor function below level, majority key muscles <3 | | D | Motor incomplete - motor function below level, majority key muscles ≥3 | | E | Normal - motor and sensory function normal | **This Patient:** ASIA E - neurologically intact but has unstable cervical injury. > **Consultant Tip:** ASIA E doesn't mean safe to mobilise. Structural instability requires urgent assessment even without neurological deficit. **Imaging Interpretation:** **CT Findings - C5/6 Unilateral Facet Dislocation:** | Feature | Finding | |---------|---------| | Level | C5/6 | | Side | Right-sided locked facet | | Displacement | Anterior subluxation C5 on C6 | | Facet position | Right inferior facet of C5 "locked" anterior to C6 superior facet | | Left side | Intact facet articulation | | Canal compromise | Present but minimal | **Subaxial Cervical Spine Injury Classification (SLIC):** | Category | Finding | Points | |----------|---------|--------| | **Morphology** | | | | - No abnormality | | 0 | | - Compression | | 1 | | - Burst | | 2 | | - Distraction | | 3 | | - Rotation/translation | Unilateral facet dislocation | **3** | | **Disco-Ligamentous Complex (DLC)** | | | | - Intact | | 0 | | - Indeterminate | | 1 | | - Disrupted | Posterior ligament complex disrupted | **2** | | **Neurological Status** | | | | - Intact | No deficits | **0** | | - Root injury | | 1 | | - Incomplete cord injury | | 3 | | - Complete cord injury | | 2 | | **TOTAL** | | **5** | **SLIC Management Recommendations:** | Score | Recommendation | |-------|----------------| | 0-3 | Non-operative treatment | | 4 | Surgeon discretion | | ≥5 | **Operative treatment recommended** | **This Patient:** SLIC 5 - operative treatment recommended. **Unilateral vs Bilateral Facet Dislocation:** | Feature | Unilateral | Bilateral | |---------|-----------|-----------| | Mechanism | Flexion-rotation | Hyperflexion | | Displacement | <50% anterior subluxation | >50% (typically 100%) | | Stability | Unstable | Very unstable | | Neurology | Often intact or root injury | Higher cord injury risk | | Reduction | May reduce closed | Often irreducible closed | > **Consultant Tip:** Unilateral facet dislocation = flexion-rotation injury. Bilateral = pure hyperflexion. SLIC ≥5 generally warrants surgical stabilisation. **Imaging Algorithm for Cervical Spine Trauma:** **Step 1: CT Cervical Spine (already done)** | Indication | Purpose | |------------|---------| | Mechanism | High-energy trauma | | Clinical | Midline tenderness | | Information | Bony injury, alignment, fracture pattern | **Step 2: CT Angiography (CTA) - Vertebral Arteries** | Indication for CTA | This Patient | |--------------------|--------------| | Facet dislocation/subluxation | **Yes - indicated** | | Fracture involving transverse foramen | Check | | C1-C3 fractures | No | | Unilateral or bilateral | Unilateral - still indicated | **Vertebral Artery Injury Risk:** | Injury Pattern | VA Injury Risk | |----------------|----------------| | Unilateral facet dislocation | 24-46% | | Bilateral facet dislocation | 39-69% | | Fractures through transverse foramen | High | **This Patient:** CTA indicated - facet dislocation has significant VAI risk. **Step 3: MRI Cervical Spine** **Indications for MRI:** | Indication | Rationale | |------------|-----------| | **Neurological deficit** | Assess cord, disc, haematoma | | **Ligamentous injury (PLC)** | SLIC DLC assessment | | **Pre-reduction in dislocation** | Rule out disc herniation | | **Incomplete SCI** | Prognostication, surgical planning | **MRI Findings to Look For:** | Structure | Abnormal Finding | |-----------|------------------| | **Cord** | Signal change (oedema, haemorrhage) | | **Disc** | Herniation, disruption | | **PLC** | Interspinous ligament disruption | | **ALL/PLL** | Continuity | | **Epidural space** | Haematoma | **Controversy - Pre-reduction MRI:** | Approach | Rationale | |----------|-----------| | **MRI before reduction** | Rule out disc herniation that could compress cord | | **Immediate reduction** | Time-critical if SCI present; closed reduction under fluoroscopy | | **Current evidence** | Closed reduction safe if patient awake and examinable | **This Patient's Approach:** - Neurologically intact (ASIA E) - Can perform closed reduction awake under fluoroscopy - MRI post-reduction to assess DLC for surgical planning > **Consultant Tip:** In an AWAKE patient with no deficit, closed reduction under fluoroscopy is safe without pre-reduction MRI. In obtunded/intubated patients, MRI first is controversial but often performed. **Management of Unilateral Facet Dislocation:** **Initial Management:** | Step | Action | |------|--------| | 1 | Maintain immobilisation | | 2 | Complete ATLS assessment | | 3 | Document neurology (ASIA) | | 4 | CT + CTA ± MRI | | 5 | Reduction | **Reduction Options:** **Option 1: Closed Reduction with Skeletal Traction** | Step | Details | |------|---------| | **Setup** | Awake patient, fluoroscopy | | **Traction device** | Gardner-Wells tongs or halo ring | | **Pin placement** | Below temporal ridge, 1cm above pinna | | **Starting weight** | 4.5-6.8 kg (10-15 lbs) | | **Incremental weight** | Add 2.3-4.5 kg (5-10 lbs) per level | | **Maximum weight** | Approximately 20 kg for C5/6 | | **Manoeuvre** | Traction + slight flexion, then extension | | **Success rate** | 60-80% for unilateral, lower for bilateral | **Closed Reduction Technique:** | Phase | Action | Fluoroscopic Check | |-------|--------|-------------------| | 1. Traction | Apply longitudinal distraction | Disc space opens | | 2. Rotation | Gentle rotation toward locked side | Facet begins to disengage | | 3. Flexion | Slight flexion | Facet clears | | 4. Extension | Extend neck | Reduce and relocate | **Monitoring During Reduction:** | Assessment | Action if Change | |------------|------------------| | Neurological exam | Stop reduction immediately | | Pain | Expected, but severe pain = stop | | Overdistraction | Stop, reduce weight | **Option 2: Open Reduction and Fixation** | Indication | Rationale | |------------|-----------| | Closed reduction fails | Facet remains locked | | Disc herniation on MRI | Risk of cord compression with closed | | Delayed presentation | Facets often fixed after 1-2 weeks | | Associated fractures | May require direct fixation | **Surgical Approach Decision:** | Approach | Indication | |----------|------------| | **Anterior** | Disc herniation, need for discectomy | | **Posterior** | Failed closed reduction, need to unlock facet | | **Combined** | Severe instability, need for 360° fusion | **This Patient's Management:** 1. Attempt closed reduction with Gardner-Wells tongs 2. Awake, serial neurological exams 3. If successful → MRI → Surgical stabilisation 4. If fails → Open posterior reduction and fixation > **Consultant Tip:** Closed reduction is safe in awake patients. The key is serial neurological examination during reduction. Stop immediately if any change. **Surgical Stabilisation After Reduction:** **Why Surgery is Needed:** - SLIC ≥5 (unstable injury) - Disrupted disco-ligamentous complex - Risk of redislocation without stabilisation - Ligaments do not heal reliably **Surgical Options:** **Option 1: Anterior Cervical Discectomy and Fusion (ACDF)** | Aspect | Details | |--------|---------| | **Approach** | Left-sided (away from recurrent laryngeal nerve) | | **Position** | Supine, slight extension | | **Procedure** | Discectomy, interbody cage, anterior plate | | **Levels** | Single level (C5/6) | | **Fusion rate** | >95% single level | | **Advantages** | Direct disc removal, excellent fusion, familiar | **ACDF Technique Steps:** | Step | Action | |------|--------| | 1 | Smith-Robinson approach (left side) | | 2 | Expose C5/6 disc space | | 3 | Complete discectomy including posterior annulus | | 4 | Prepare endplates | | 5 | Size and place PEEK or allograft cage | | 6 | Anterior plate with unicortical screws | | 7 | Check alignment fluoroscopically | **Option 2: Posterior Cervical Fusion (PCF)** | Aspect | Details | |--------|---------| | **Approach** | Midline posterior | | **Instrumentation** | Lateral mass screws (C5) + pedicle or lateral mass (C6) | | **Advantages** | Direct facet reduction if needed, stronger construct | | **Disadvantages** | Higher blood loss, muscle dissection, neck stiffness | **Option 3: Combined Anterior-Posterior (360°)** | Indication | Rationale | |------------|-----------| | Severe instability | Complete ligamentous disruption | | Failed anterior alone | Construct concern | | Significant comminution | Need posterior tension band | **Decision Matrix for This Patient:** | Factor | Consideration | Favours | |--------|---------------|---------| | Successful closed reduction | Yes | Anterior | | Disc integrity | MRI shows disc disruption | Anterior (remove disc) | | Single level | Yes | Anterior sufficient | | Bone quality | Young, good | Either | | Neurological status | Intact | Anterior preferred | **Recommended Approach:** ACDF C5/6 **Post-operative Management:** | Phase | Management | |-------|------------| | Collar | Rigid collar 6-12 weeks | | Activity | No driving 6 weeks, no contact sport 6 months | | Follow-up | 2 weeks (wound), 6 weeks (X-ray), 3 months (fusion) | | Physio | Range of motion after collar removal | > **Consultant Tip:** For reduced unilateral facet dislocation in neurologically intact patient, ACDF is the workhorse. Posterior approach reserved for failed reduction or combined instability. **Complications of Cervical Spine Trauma and Treatment:** **1. Immediate Complications:** | Complication | Prevention/Management | |--------------|----------------------| | **Neurological deterioration** | Serial exams, MRI if change | | **Respiratory compromise** | Monitor, early intubation if needed | | **Aspiration** | NGT if impaired swallow | | **Vertebral artery injury** | CTA screening, neurosurgery if symptomatic | **2. Surgical Complications (ACDF):** | Complication | Incidence | Management | |--------------|-----------|------------| | **Dysphagia** | 10-20% early, <5% persistent | Soft diet, speech therapy | | **Hoarseness (RLN)** | 2-5% | Usually temporary | | **Oesophageal injury** | <1% | Repair, NPO, antibiotics | | **Haematoma** | 2-3% | Urgent evacuation if airway | | **Dural tear/CSF leak** | <1% | Primary repair, drain | | **Hardware failure** | <5% | Revision if symptomatic | | **Non-union** | 5-10% | Revision with graft ± posterior | **3. Airway Emergency - Post-operative Haematoma:** | Time | Concern | |------|---------| | **0-24 hours** | Peak risk | | **Signs** | Stridor, dyspnoea, neck swelling | | **Management** | Open wound at bedside, evacuate clot, intubate | **This is an emergency** - airway equipment and suture removal kit at bedside. **4. Long-term Complications:** | Complication | Risk | Prevention | |--------------|------|------------| | **Adjacent segment disease** | 2-3% per year | Minimise fusion levels | | **Chronic neck pain** | 10-20% | Physio, ergonomics | | **Stiffness** | Expected at fused level | Accept as necessary trade-off | **Prognosis for This Patient:** | Outcome | Expected | |---------|----------| | **Neurological** | Excellent - ASIA E, remain intact | | **Pain** | Resolution of acute pain over 6-12 weeks | | **Function** | Return to full activities | | **Fusion** | >95% at single level | | **Return to work** | 6-12 weeks (desk job earlier) | | **Driving** | 6 weeks post-op | | **Contact sport** | 6+ months, some advise against | **Prognostic Factors (if there was SCI):** | Factor | Better Prognosis | |--------|------------------| | **ASIA grade** | Incomplete (B, C, D) > Complete (A) | | **Age** | Younger | | **Initial improvement** | Any improvement in first 72 hours | | **MRI** | No haemorrhage, minimal oedema | | **Timing of surgery** | Early decompression if incomplete SCI | **Counselling Points for This Patient:** 1. Successful reduction achieved - excellent sign 2. Surgery is to stabilise spine and prevent future problems 3. Single-level fusion has minimal impact on neck motion 4. Full return to activities expected 5. Small risk of complications (discuss dysphagia, hoarseness) 6. Adjacent segment disease is a long-term consideration > **Consultant Tip:** This patient has an excellent prognosis - young, neurologically intact, successful reduction. Counsel about surgical risks but emphasise expected full recovery. --- ## Key Teaching Points ### Pattern Recognition **This pattern suggests Cervical Spine Trauma (Unilateral Facet Dislocation):** - High-energy mechanism (MVA) - Severe neck pain with midline tenderness - Flexion-rotation injury pattern - May be neurologically intact despite significant instability **Comparison - Unilateral vs Bilateral Facet Dislocation:** | Feature | Unilateral | Bilateral | |---------|-----------|-----------| | Mechanism | Flexion-rotation | Hyperflexion | | Subluxation | <50% | >50% (usually complete) | | Stability | Unstable | Very unstable | | Neurology | Often intact, root possible | Higher cord injury risk | | Reduction | Often successful closed | More difficult | | Approach | ACDF often sufficient | Often 360° | ### Critical Management Points 1. **ATLS first** - complete primary survey before definitive imaging 2. **Document neurology** - ASIA score is baseline for all decisions 3. **CTA for vertebral arteries** - high risk of VAI with facet injuries 4. **Closed reduction is safe** - in awake, examinable patients 5. **SLIC ≥5 = surgery** - structural instability requires operative stabilisation 6. **ACDF is workhorse** - for reduced unilateral facet dislocation --- ## Common Examiner Follow-ups **Q: "What is the role of steroids in acute SCI?"** | Agent | Recommendation | |-------|----------------| | Methylprednisolone (NASCIS II/III protocol) | **Not routinely recommended** | | Evidence | NASCIS studies had methodological flaws | | Current practice | Not standard of care in most centres | | Risks | Infection, GI bleed, hyperglycaemia | | Exception | Some centres still use within 8 hours of injury | **Conclusion:** Most spine surgeons do not administer high-dose steroids. Individual centres may vary. --- **Q: "When would you obtain MRI before attempted reduction?"** | Situation | Recommendation | |-----------|----------------| | **Awake, examinable patient** | Can attempt closed reduction without MRI | | **Obtunded/intubated patient** | MRI first to rule out disc herniation (controversial) | | **Neurological deficit present** | MRI to assess cord, plan decompression | | **Failed closed reduction** | MRI before open surgery | The controversy centres on the theoretical risk of disc herniation compressing the cord during reduction. Evidence suggests closed reduction in awake patients is safe because neurological change prompts immediate cessation. --- **Q: "What are the indications for emergency surgery in cervical spine trauma?"** | Indication | Rationale | |------------|-----------| | **Incomplete SCI with cord compression** | Decompress to maximise recovery | | **Progressive neurological deficit** | Stop ongoing injury | | **Unreducible dislocation** | Open reduction needed | | **Bilateral locked facets with SCI** | Urgent reduction required | Neurologically intact patients with stable injuries can be managed semi-electively (within 24-48 hours). --- ## Related Topics - Spinal Cord Injury Assessment and Management - ATLS in Trauma - Cervical Spine Clearance - Thoracolumbar Fractures - Whiplash and Soft Tissue Cervical Injury - Hangman's Fracture - Jefferson Fracture