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

What is your initial assessment and management of this patient?

Describe the imaging findings and classify this injury. What classification systems are relevant?

What additional imaging would you obtain and why? What is the role of MRI?

How would you manage this unilateral facet dislocation? Describe reduction options.

Closed reduction is successful. What are your surgical options for stabilisation?

What are the potential complications and what is the expected outcome for this patient?

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

ATLS first - complete primary survey before definitive imaging
Document neurology - ASIA score is baseline for all decisions
CTA for vertebral arteries - high risk of VAI with facet injuries
Closed reduction is safe - in awake, examinable patients
SLIC ≥5 = surgery - structural instability requires operative stabilisation
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).

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

Cervical Spine Trauma