Evaluation and Management of Acute Cervical Spine Trauma

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 but associated 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 as females. 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 associated with 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