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Home , Cervical collar, Tenderness (medicine)

Pain in the Neck Cervical Spine in Athletes

LESSON 19

By Herman Kalsi, MD; Elizabeth Kaufman, MD, CAQ-SM; and Kori Hudson, MD, FACEP, CAQ-SM Dr. Kalsi is a senior emergency medicine resident at Georgetown University Hospital/Washington Hospital Center in Washington, DC. Dr. Kaufman is an attending physician in the Department of Sports Medicine at Kaiser Permanente San Jose in San Jose, CA. Dr. Hudson is an associate professor of emergency medicine at Georgetown University School of Medicine in Washington, DC. Reviewed by Michael Beeson, MD, MBA, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Devise a systematic approach for the evaluation of suspected c-spine injuries. n What is the appropriate initial assessment for a 2. Describe the history and physical examination findings suspected c-spine ? that should raise suspicion for a c-spine injury. n What history and physical examination findings 3. Explain evidence-based clinical decision tools that help should raise concern for a c-spine injury? determine the need for imaging of the cervical spine. n When should the cervical spine be imaged? 4. Recognize transient neurological deficits that can mimic more serious diagnoses. n What are the most common vascular injuries 5. Define the initial stabilization and management of a associated with c-spine trauma? suspected c-spine injury. n What are the most common transient neurological injuries associated with c-spine trauma? FROM THE EM MODEL n What has changed in the management of patients 18.0 Traumatic Disorders with c-spine injuries? 18.1 Trauma

Although musculoskeletal complaints are common among athletes who present to the emergency department, injuries to the neck, especially the cervical spine (c-spine), warrant serious concern. Clinicians must be prepared to recognize and manage the complex and potentially devastating complications associated with acute neck pain. In particular, injured athletes must be promptly evaluated for vertebral fractures, subluxation injuries, vascular injuries, intervertebral disc herniation, brachial plexus injuries, and/or nerve root injuries.

October 2018 n Volume 32 Number 10 3 CASE PRESENTATIONS ■ CASE ONE helmet lying approximately 10 feet the event and was able to immediately away from her. She reported get up without assistance, remove his A 24-year-old woman with a tenderness in her cervical spine, but potential c-spine injury arrives via helmet, and walk over to the sideline, her field examination was otherwise helicopter. She was transported where he was evaluated by the athletic normal. EMTs applied a cervical from a nearby trail after being trainer. He denied , nausea, collar and used a “scoop stretcher” to thrown from her horse. Her group, or blurry vision. transfer the patient to a cot. which was 45 minutes away from At the time of the injury, he had no On arrival at the emergency the nearest access road, stabilized midline c-spine tenderness, no step- department, the patient complains of offs or deformities, and complained her head and neck while waiting increasing neck pain. for EMS. Rescue personnel found only of pain and paresthesias in his left the patient to be awake, oriented, ■ CASE TWO arm. Approximately 10 minutes after and in a supine position, but A 16-year-old boy presents after the injury, however, his left arm began complaining of severe neck pain. being tackled during a high school to feel weaker, so his parents brought She did not lose consciousness football game. Upon falling to the him to the emergency department at the scene and could move her ground, he experienced a sharp, for further evaluation. On arrival, extremities; she denied headache, “electric pain” that originated in his he continues to complain of neck nausea, and blurry vision. neck and moved down his left arm. pain and unilateral upper-extremity EMTs noted the patient’s intact He did not lose consciousness during paresthesias and .

Acute spinal cord injuries (SCIs) displays signs of impending respiratory degree of disability should be assessed. in athletes are rare (accounting for failure, the airway should be secured More specifically, athletes with suspected only 2.4% of all athletic-related before proceeding.4 c-spine injuries should be evaluated for hospitalizations), yet 9.2% of all SCIs Many physicians question the safety of signs of spinal and/or neurogenic shock. in the US are sustained during athletic emergency — using Spinal shock — a state of transient loss activity.1 Although football players, orotracheal intubation — with known of spinal cord function below the level wrestlers, and gymnasts are at greatest or suspected c-spine injuries; however, of the injury, including hyporeflexia or risk for c-spine trauma involving axial several studies have shown orotracheal areflexia with associated autonomic loading, hyperextension, traction, intubation with in-line stabilization dysfunction — occurs immediately after or rotation, such injuries can occur to be a safe and effective method for an injury. Spinal shock can cause an during almost any recreational activity, definitive airway management in patients acute, incomplete SCI that mimics a including those traditionally considered with suspected c-spine injuries.5-8 No complete SCI. noncontact sports, including baseball.1 consensus has been reached on whether The severity and duration vary with video-assisted laryngoscopy (VAL) is the spinal level and degree of injury, CRITICAL DECISION safer than direct laryngoscopy (DL) with but spinal shock usually lasts less than What is the appropriate initial respect to minimizing vertebral body 24 hours. Patients can experience 6 assessment for a suspected movement during the intubation process. an initial increase in blood pressure Studies have produced mixed results due to the release of catecholamines, c-spine injury? on the use of VAL. One study concluded quickly followed by hypotension. The As with all traumatic injuries, that there was no significant difference bulbocavernosus reflex (S2-S4) can be emergency physicians should approach between DL and VAL at any level of used to help diagnose spinal shock; patients with suspected c-spine injuries c-spine injury, while another found it can be tested by monitoring for the using the Advanced Trauma Life Support that c-spine motion was reduced by contraction of the anal sphincter in (ATLS) protocols, which strive not only 50% at the C2-C5 segment when VAL response to squeezing the glans penis to identify immediate threats to life, but was used.9,10 Regardless, current ATLS or clitoris, or to a slight tug on an also to minimize the risk of overlooking guidelines list orotracheal intubation with indwelling Foley catheter, in patients secondary and tertiary injuries.2 in-line manual c-spine stabilization as with acute paralysis after trauma. Generally, if the neck of a patient with a the definitive airway procedure in apneic Presence of the reflex indicates spinal potential c-spine injury has not already patients with trauma.9 In addition, a cord severance; its absence indicates been stabilized to minimize movement, it surgical airway should be considered if a spinal shock. The return of the reflex is essential to do so by providing in-line definitive airway is required and cannot typically indicates that the spinal shock stabilization before proceeding with the be established by other means.6 is resolving.3 evaluation.3 If a patient is not breathing, Once the airway and breathing have By comparison, neurogenic shock is unable to manage secretions, or been addressed, circulation and the is the body’s response to the sudden

4 Critical Decisions in Emergency Medicine loss of sympathetic control. It is a occur prior to equipment removal, as if a helmet was used and whether or distributive shock that manifests itself most athletic equipment is radiolucent. not it was damaged in the incident, as clinically with bradycardia, hypotension, If a long spine board is used for spinal this information can help stratify the flaccidity, and areflexia. Neurogenic stabilization during transport, it should direction and force of the injury.3 shock typically occurs in patients be removed upon arrival, maintaining with SCIs above the T6 level, as these in-line stabilization of the spine. A CRITICAL DECISION translate into greater than 50% loss of slider board can be used to minimize What history and physical sympathetic innervation, which leads motion during additional transfers. examination findings should raise to unopposed vagal tone, a decrease Once the long spine board and sports concern for a c-spine injury? in vascular resistance, and associated equipment are removed, a rigid cervical C-spine injuries are classified vascular dilation. For hypotensive collar should be applied, if not already according to the mechanism of trauma, trauma patients, it is crucial not only placed in the prehospital setting, and the extent of vertebral stability, and to distinguish between spinal and should remain in place until the cervical the morphology of the injury. As such, neurogenic shock, but also to rule out spine is “cleared,” either clinically or the most common injury patterns in hypovolemia as the cause of shock.3 radiographically. athletes are related to axial loading, Disability should be assessed by A more detailed history should flexion, extension, and rotation. One key performing a head-to-toe neurological be obtained, in conjunction with a purpose of the physical exam is to detect examination. If an athlete arrives secondary survey and a more detailed primary injuries, such as damage from wearing protective equipment, the exam. Ideally, the mechanism of injury direct contusion and axonal stretch, equipment may need to be removed should be determined so that the spinal compression by bone fragments, prior to full evaluation. If a spinal injury presence of coexisting injuries can be hematoma or intervertebral discs, is strongly suspected, initial imaging can ascertained. It is important to know and ischemia from damage due to the impingement on the spinal arteries.6 The cervical spine should be carefully FIGURE 1. Cervical Spine Injury, MRI Sagittal View inspected from the nuchal ridge to at least the spinous process of the first thoracic vertebra.11 In addition, clinicians should pay close attention to any obvious neck deformities or signs (Atlas) of instability. The posterior aspect of the neck should then be palpated by (Axis) placing thumbs on the spinous processes and applying circular pressure down the midline to detect tenderness. This process should be repeated 2 cm to 3 cm lateral to the midline on both sides to assess for facet pain. Depending on the mechanism of injury and complaint of pain, a focused assessment of the lateral and anterior aspects of the neck also should be considered.12,13 Physicians should suspect acute abnormalities if tenderness, deformity, edema, ecchymosis, and/or acute muscle spasm are present.3 Following inspection and palpation, a thorough neurological evaluation should be performed, including an assessment of sensation, motor function, and reflexes. Table 1 outlines the motor, sensory, and reflex functions that are lost or decreased with injury at the respective cervical This patient was involved in an automobile accident that resulted in intervertebral disc spinal levels. herniations compressing the spinal cord, primarily at the level of C4/C5 and C6/C7. The During the evaluation, both nerve image also depicts a reverse curvature of the cervical spine, a common injury sustained root and spinal cord injuries should when muscles and tendons are strained during high-velocity movements. be considered. Although sometimes

October 2018 n Volume 32 Number 10 5 difficult to detect, the presence of neurological deficits that indicate TABLE 1. Neurological Findings and Associated Anatomical Level multilevel involvement generally suggest C-Spine Level Deficit Found on Exam spinal cord trauma, rather than a nerve C1-C2 • Paresthesia in the occipital-parietal region root injury. Additionally, in the absence • Muscle weakness is rare of spinal shock, motor weakness with C3 • Paresthesia or numbness at the lower pinna, posterior portion of the intact reflexes indicates a spinal cord cheek, temporal area, and lateral aspect of the neck injury. In contrast, motor weakness with • Weakness is clinically not detectable absent reflexes often indicates a nerve • Analgesia is rare root lesion.3,6 C4 • No paresthesia Cervical spine injury can also present • A horizontal band of cutaneous analgesia along the spine of the more subtly, so it is important not to scapula, mid-deltoid area, and clavicle discount a serious injury due to a lack of • Slight weakness of the trapezius bilaterally pain, as neck pain may not necessarily be C5 • No paresthesia or sensory deficit severe or it may not be as severe as other • Weakness of the supraspinatus, infraspinatus, deltoid, and brachial distracting injuries.12 One study found biceps muscles • The biceps and brachioradialis reflexes are sluggish or absent that most patients with c-spine injuries C6 • Paresthesia in the thumb and index fingers did not present with a history of loss • Analgesia at the tips of the thumb and index fingers of consciousness or with neurological • Weakness of the biceps, brachialis, supinator brevis, and extensor deficits. Many had no evidence of carpi radialis craniofacial trauma, and some patients • The biceps reflex is sluggish or absent exhibited full range of cervical motion.14 C7 • Paresthesia in the index, middle, and ring fingers Regardless, any indication of neurogenic • Cutaneous analgesia at the dorsal aspect of the index and middle and/or spinal shock should raise concern fingers for a potential SCI. • Weakness in the triceps and flexor carpi radialis • The triceps reflex can be affected CRITICAL DECISION C8 • Paresthesia in the middle, ring, and little fingers • Cutaneous analgesia of the little finger When should the cervical spine • Weakness in the extensors of the thumb, extensor and flexor carpi be imaged? ulnaris, adductor pollicis, common extensor of the fingers, and Studies have shown the high cost and abductor indicis relatively low yield of indiscriminate T1 • Paresthesia and cutaneous analgesia at the ulnar aspect of the hand c-spine imaging in trauma patients. • Weakness of the intrinsic muscles of the hand However, significant variation exists between prehospital and emergency (Figure 1) provides more detailed The National Emergency department assessments, so clinicians imaging of the spinal cord, spinal canal, X-Radiography Utilization Study should avoid discontinuing spinal spinal ligaments, intervertebral discs, (NEXUS) and the Canadian C-Spine stabilization until the cervical spine has and paraspinal soft tissues, it can be Rule (CCR) are two widely used and been adequately assessed and cleared.15 particularly useful when neurological evidence-based decision tools that can be Standard x-rays remain the initial deficits are caused by hemorrhage, used to evaluate patients with suspected imaging study of choice for low-risk edema, or injury to the spinal cord. MRI cervical trauma to determine the need for patients and those without a significant can also help determine the acuity of imaging. These rules allow emergency mechanism of injury. For patients with bony injuries and aid in the assessment physicians to make objective decisions multiple traumatic injuries or a high of vascular injury.16,17 Despite access about imaging, which can result in suspicion for injury, however, many to CT scans and MRIs, it is important cost savings and reduced radiation hospitals now opt to use standard CT to remember that plain films can still exposure to patients. Both rules have scans as part of the initial evaluation of provide rapid assessment of alignment, been validated to provide useful, highly the cervical spine. CT scans can provide fractures, and soft-tissue swelling.6 sensitive criteria to ultimately reduce the greater detail and can create multi-axis Clinically, the mechanism of injury need for imaging.6,11,20 reconstructions that are better suited for alone should not determine the need for NEXUS has a 99.8% negative patients with high-risk injuries.6 radiological investigation. Although it is predictive value for c-spine injury with Although CT is an excellent modality rare to see an unstable c-spine fracture a sensitivity of 99% and specificity of for evaluating bony spine injuries, MRI or neurological deterioration due to 12.9%. Because of its low specificity, may be indicated in patients who, injury in an asymptomatic patient, researchers were concerned that despite a negative scan, have persistent emergency physicians should use clinical the NEXUS criteria still resulted in midline tenderness and/or neuro­ decision rules to help determine whether overimaging and thus developed the logical abnormalities. Since MRI low-risk patients can forego imaging.18,19 CCR. The objective in developing the

6 Critical Decisions in Emergency Medicine have a significant risk of injury and radiography.21 However, it is important TABLE 2. NEXUS Criteria may warrant imaging, even without the to remember that stabilization and No midline c-spine tenderness on application of a clinical decision tool. In imaging of the spine should not take palpation these cases, even if none of the NEXUS precedence over life-saving diagnostic No focal neurological deficit criteria are present, c-spine imaging is still and therapeutic procedures.3,5 Normal alertness: GCS 15; alert and recommended.6,11 oriented to person, place, time, and/or The CCR helps determine the need CRITICAL DECISION events; able to correctly remember three objects at 5 minutes; and for c-spine imaging based on high-risk What are the most common appropriate response to external stimuli factors or the combination of low-risk vascular injuries associated with No distracting injuries, such as long- factors and a physical exam finding c-spine trauma? bone fractures, visceral injuries requiring (Table 3). The three high-risk factors surgical consultation, large lacerations that mandate imaging include age 65 For a patient with a suspected or burns, and crush injuries years and older, a dangerous mechanism c-spine injury, the need to evaluate Patient is not intoxicated of injury, and the presence of a sensory for skull and intracranial injuries is neurological deficit. Low-risk factors often recognized. Although traumatic CCR was to derive a highly sensitive include a simple rear-end collision, the vertebral artery injury is well recognized clinical rule with improved specificity ability to sit, ambulation at any point in trauma, it can often be overlooked that would allow physicians to be more in time after the injury, delayed onset of in a patient with c-spine trauma. 11,20,21 selective in the use of radiography. neck pain, and the absence of midline Its incidence increases greatly in the According to the NEXUS protocol, cervical tenderness. If patients have a presence of a head or c-spine injury. a c-spine injury cannot be excluded low-risk factor, they should be asked to Traumatic vertebral artery injuries if any of the following findings are rotate their head 45 degrees to the right are most commonly precipitated by present: midline cervical tenderness, and then 45 degrees to the left. If unable or a rotating or bending altered mental status, focal neurological to do so, imaging is required.20 mechanism. deficit, evidence of drug or alcohol Note inclusion criteria from the two Symptomatic injuries can manifest intoxication, or the presence of another studies differ: The Canadian c-spine posterior circulation ischemia, such injury that is considered painful enough study did not include children younger as dysarthria, ataxic gait, visual field to distract from a neck injury. If none than 16 years and patients with Glasgow defects, Horner syndrome, impaired of these criteria are noted, the patient is Coma Scale (GCS) scores less than 15, consciousness, or impaired balance considered low risk for a c-spine injury while the NEXUS study did. One article and coordination directly after injury. and, in most cases, does not require concluded that the CCR is superior to the However, many injuries can remain c-spine imaging (Table 2). Patients with NEXUS criteria with respect to sensitivity asymptomatic, which presents a clinical severe osteoporosis, advanced , and specificity for c-spine injury, and challenge. If an injury goes undetected, cancer, or degenerative bone disease use of the CCR would reduce rates of it can lead to potentially fatal posterior circulation ischemia.23,24 Traumatic vertebral artery injuries TABLE 3. Canadian C-Spine Rule20 appear to account for as much as 22% of blunt c-spine injuries; the incidence High-Risk Factors That Mandate Radiography can be upward of 70% in cases of • Age ≥65 years • Paresthesias in the extremities c-spine fracture. Thus, if the mechanism • Dangerous mechanism: of injury was significant enough to — Fall >1 m (or 5 stairs) produce a c-spine fracture, evaluation — Axial load to the head/spine (eg, diving injury) for vascular injuries is strongly — High-speed motor vehicle accidents (>100 km/hr) recommended.25,26 — Motorized recreational/all-terrain vehicle accidents Blunt traumatic vertebral artery — Ejection from a vehicle injuries tend to occur at junctions — Bicycle accident with an immovable object between fixed and mobile segments Low-Risk Findings That Allow for Further Evaluation With Range of Motion Testing of vessels, as shearing forces are Patients who DO NOT have one or more of the following should have radiographs: particularly overwhelming in • Simple, rear-end motor vehicle collision these regions. The more common • Patient in seated position in the emergency department • Patient ambulatory at any time since the injury mechanisms that produce such forces • Absence of midline neck tenderness are hyperflexion, hyperextension, • Delayed onset of neck pain distraction, and facet dislocation forces. Range of Motion Testing Cervical spine fractures that are more Can the patient move the neck 45 degrees to the right and left (regardless of pain)? likely to have coexisting vertebral If yes, then no imaging is required. artery injury are those that involve the C1-C3 segment and the foramen

October 2018 n Volume 32 Number 10 7 transversarium.23,27 In addition, carotid artery injuries can lead to stroke-like TABLE 4. Denver Screening Criteria for Blunt Cerebrovascular Injury23 symptoms, amaurosis fugax, Horner of BCVI syndrome, and neck pain.23 • Arterial hemorrhage Vascular surgery should be consulted • Cervical bruit for any suspected vascular injury. • Expanding hematoma in the neck For patients with suspected blunt • Focal neurological deficits that do not correlate with head CT findings cerebrovascular trauma, the Denver • Stroke on secondary CT scans criteria (Table 4) also can be used to Risk Factors for BCVI determine the need for screening CT • High-energy mechanism of injury angiography. In addition to routine — Mid-face fractures: Le Fort II or III–type injuries laboratory studies, it is important to — Cervical-spine fracture patterns, including subluxations, fractures that extend obtain a basic metabolic panel, type into the transverse foramen, and any fracture of C1-C3 and screen, coagulation screen, and — Basilar skull fracture with involvement of the carotid canal platelet count, particularly for patients • Diffuse axonal injury with GCS <8 taking anticoagulants and those who • Near hanging with anoxic injury may require radiological or surgical • Seat belt sign or other soft-tissue injury in the neck, leading to significant swelling intervention.23 and/or altered mental status CRITICAL DECISION which manifests as a sharp, stinging or with preserved cervical range of motion. What are the most common burning pain down one of the arms, These cases can be marked by notable transient neurological injuries and is usually due to a compression or weakness or decreased sensation in the associated with c-spine trauma? traction force in the region of the neck affected arm; however, this weakness Short-lived neck injuries include and shoulder. This type of injury can can be so transient that it resolves “stingers” (sometimes known as occur when a player’s head is abruptly by the time the athletic trainer or “burners”) and transient quadriplegia twisted toward or away from an impact physician evaluates the patient on the (also known as cervical cord to one of the shoulders. The player often field. Lastly, pulses should be normal. neurapraxia). These injuries can occur experiences sudden pain, as well as a The unilaterality, short duration of in almost any sport but most often occur paresthetic sensation in the distribution symptoms, and relatively pain-free in contact sports such as football and of a nerve down the unilateral arm. This range of neck motion can assist in wrestling. Stingers are more common discomfort typically lasts seconds to discriminating between a stinger and a and reportedly affect as much as minutes, and the majority of strength more serious SCI.6,29 50% of athletes involved in collision and sensation returns within 24 hours. By contrast, patients with transient sports. Transient quadriplegia is much However, in some instances, it can take quadriplegia typically have a bilateral less common, with an incidence of up to 6 weeks for strength and sensation burning and tingling pain, with an approximately 1.3 per 10,000 athletes, to completely return.28,29 associated loss of strength and sensation but it is notably more dangerous.28 Neck tenderness and muscle spasms in the affected arms and/or legs. This A stinger is a neurapraxia of the may or may not be present in patients weakness can range from a mild decrease cervical nerve roots or brachial plexus, with stingers, but they usually present in strength to complete paralysis, and symptoms can last up to 36 hours. Transient quadriplegia is usually caused by a hyperextension injury to the neck, as well as axial loading of the neck. It is more commonly seen in patients that have some degree of cervical spinal stenosis or disc protrusion.6,28 n For an apneic patient with a suspected c-spine injury, follow the Advanced Trauma Life Support guidelines by maintaining in-line spinal immobilization, If an injury is due to transient securing the airway, and then moving on to the rest of the primary survey. quadriplegia, strength and sensation will resolve, but it is difficult to know in the n To determine which patients need c-spine imaging, use the Nexus criteria or Canadian C-Spine Rule to guide the decision. early moments after an injury whether a severe neurological deficit is present. n Remember that stabilization and imaging of the spine should not take Even athletes with a rapid return of all precedence over life-saving diagnostic and therapeutic procedures. neurological function should be carefully n Stingers and transient quadriplegia are often diagnoses of exclusion. It observed and prevented from returning may be necessary to obtain imaging studies or a consultation with a spine to play until after a spine specialist can expert to rule out more serious conditions. perform a complete evaluation.28 If an

8 Critical Decisions in Emergency Medicine athlete has paralysis or a significant to ensure that no additional, associated outcomes with mild hypothermia in a neurological deficit, injuries occurred. Throughout this rat model.31 Another recent prospective should be instituted immediately, and process, clinicians must ensure that study was done, in which 20 patients the athlete should be transported by the patient remains hemodynamically with a complete SCI were treated with a ambulance to the nearest emergency stable and that no signs or symptoms combination of surgical decompression, department for further evaluation. suggest neurogenic or spinal shock.3 glucocorticoid administration, and Emergency physicians must remember A consultation with a neurological regional hypothermia. These patients that stingers and transient quadriplegia surgeon should be considered, and/or experienced a better recovery rate are often diagnoses of exclusion. Many the transfer of the patient to a facility than expected for traditional forms of times, patients have a severe neck strain with neurosurgical capabilities should be treatment.32 or herniated disc that mimics some of arranged, if needed. Given the potential confounding the symptoms associated with these Over the years, the administration factors, how much of the recovery was transient processes. It is crucial that of methylprednisolone to patients with due to cooling alone is unclear. Again, more serious conditions are excluded spinal injuries has been the topic of the benefit of steroid treatment for cord before making these diagnoses. Thus, much debate. Although the drug was injury was not supported with Class I it may be necessary to obtain imaging once considered the standard of care, evidence, but the investigators felt studies or to consult a spine expert. With there is limited evidence to support its that research into the effects of cord standard radiographs, nondisplaced benefit in treating traumatic SCIs in cooling should be expanded. An optimal and minimally displaced fractures can humans.6 Randomized, controlled trials neuroprotective temperature was not be difficult to see. Additionally, the have shown limited efficacy and many defined; however, other studies have also degree of cervical instability cannot be adverse outcomes for certain patient been promising enough to encourage accurately obtained on standard c-spine groups that receive methylprednisolone further research to investigate the use of x-rays, so a CT of the cervical spine 6,32 for acute SCI. In recent years, enough cooling in patients with acute SCIs. should be performed if more serious evidence has mounted that the conditions are suspected. An MRI is Summary administration of methylprednisolone required if suspicion of a herniated disc Emergency physicians must be for the treatment of acute SCI is no injury, spinal stenosis, or spinal cord able to identify and correctly manage longer recommended. Furthermore, the contusion exists.28 patients with suspected c-spine injuries, Food and Drug Administration has not including assessing concerning physical CRITICAL DECISION approved the use of methylprednisolone examination findings and high-risk for the treatment of acute SCI, as no What has changed in the mechanisms of injury. Clinical decision Class I or Class II medical evidence rules — the NEXUS, CCR, and Denver management of patients with supports its clinical benefit. However, criteria — can help guide imaging and c-spine injuries? much Class I, II, and III evidence management planning. In addition to Once a physician suspects or diagnoses exemplifies the harmful side effects, spinal cord and bony injuries, physicians a c-spine injury, a few key precautions including death, associated with high- must be aware of common vertebral, should be taken. First and foremost, the dose steroids.30 vascular, and soft-tissue injuries that cervical spine must be immobilized. If Evidence is also emerging regarding are associated with c-spine trauma. the mechanism was significant enough the use of therapeutic cooling for They also must be familiar with updates to cause a c-spine injury, a thorough patients with acute SCIs. In 2011, in treatment options. Since athletes investigation must then be performed investigators found improved SCI account for roughly 10% of SCIs in the United States, emergency physicians must be aware of which sports and mechanisms place a patient at high risk for injury.

REFERENCES 1. Schroeder GD, Vaccaro AR. Cervical spine injuries in n Ignoring high-risk patients who do not fit clinical decision rules. Patients with the athlete. J Am Acad Orthop Surg. 2016 Sep; 24(9):e122-e133. severe osteoporosis, advanced arthritis, cancer, or degenerative bone disease 2. Williams MJ, Lockey AS, Culshaw MC. Improved have a significant risk of c-spine injury and may warrant imaging, even without trauma management with advanced trauma life support (ATLS) training. J Accid Emerg Med. 1997 the application of a clinical decision tool. Mar;14(2):81-83. n Administering methylprednisolone for the treatment of an acute spinal cord 3. American College of Surgeons, Committee on Trauma. ATLS: Advanced Trauma Life Support for injury, which is no longer recommended. Doctors. 8th ed. Chicago, IL: American College of n Failing to maintain a high index of suspicion for vascular and soft-tissue injuries Surgeons; 2008. 4. McGill J. Airway management in trauma: an update. associated with c-spine injuries, especially when neurological symptoms Emerg Med Clin North Am. 2007 Aug;25(3):603- do not match head CT findings. Left undetected, these injuries can lead to 622,vii. 5. Walls RM. Airway management in the blunt trauma potentially fatal outcomes. patient: how important is the cervical spine? Can J Surg. 1992 Feb;35(1):27-30.

October 2018 n Volume 32 Number 10 9 CASE RESOLUTIONS ■ CASE ONE her helmet sustained visible damage, and 3/5 muscle strength in flexion of concern for intracranial injury existed, his left elbow. It was reassuring that The 24-year-old woman thrown from a horse underwent an so a noncontrast head CT was ordered he did not lose consciousness during assessment of her airway, breathing, in addition to a c-spine CT. The head the incident and was ambulatory and circulation that revealed an CT did not reveal any evidence of immediately afterward; however, intact airway. She had nonlabored acute bleeding or fractures; the c-spine the development of decreased and regular respirations, as well CT did not reveal any fractures, muscle strength after the injury was as strong and equal pulses in all dislocations, or obvious areas of concerning. four extremities. She was acting instability. Fortunately, the clinician found appropriately. She had a 3-cm The patient continued to complain no evidence of cervical step-offs occipital laceration, in addition to of neck discomfort and a feeling of or midline tenderness, and the significant midline tenderness in the being unable to support her head. patient had full and complete cervical spine upon palpation, but Since the imaging was unremarkable range of motion, with only mild no step-off, crepitus, or edema. No for vertebral pathology, concern discomfort. The patient’s ability carotid bruits were appreciated. for possible ligamentous injury was to fully range his neck, in addition Given the patient’s midline investigated. She continued to have to being ambulatory after the fall, cervical tenderness, the cervical normal neurovascular exams and made a transient neurological collar was not removed. Because she remained hemodynamically stable. injury more likely than a significant did not have any thoracic midline She was discharged on a nonsteroidal SCI. Given that his symptoms tenderness, step-off, or lower- anti-inflammatory medication in a were unilateral and he had some extremity paresthesias, she was Miami J cervical collar, and a follow-up remaining strength in the affected cleared from use of the rigid spine appointment was made to see a spine extremity, the emergency physician board. The remainder of the exam surgeon. suspected he had a stinger. The boy showed 5/5 strength in the proximal was monitored in the emergency and distal muscle groups, in both ■ CASE TWO department as his paresthesias the upper and lower extremities. No The 16-year-old football player’s resolved, and his strength improved abnormalities were found on her airway, breathing, and circulation were to 4+/5 in the affected extremity. sensory exam. intact. A head-to-toe exam was only He was ultimately discharged and Because her mechanism of injury significant for decreased sensation instructed to follow up with his was a fall from over 5 feet and along the ulnar side of his left forearm team physician.

6. Kanwar R, Delasobera BE, Hudson K, Frohna W. 13. American Spinal Injury Association. International 23. Biffl WL, Cothren CC, Moore EE, et al. Western Emergency department evaluation and treatment Standards for Neurological Classification of Spinal Trauma Association critical decisions in trauma: of cervical spine injuries. Emerg Med Clin North Am. Cord Injury. Revised ed. Chicago, IL: American screening for and treatment of blunt cerebrovascular Spinal Injury Association; 2000: 1-23. injuries. J Trauma. 2009 Dec;67(6):1150-1153. 2015 May;33(2):241-282. 14. Walter J, Doris PE, Shaffer MA. Clinical presentation 24. Taneichi H, Suda K, Kajino T, Kaneda K. Traumatically 7. Criswell JC, Parr MJ, Nolan JP. Emergency airway of patients with acute cervical spine injury. Ann induced vertebral artery occlusion associated with management in patients with cervical spine injuries. Emerg Med. 1984 Jul;13(7):512-515. cervical spine injuries: prospective study using Anaesthesia. 1994 Oct;49(10):900-903. 15. Domeier RM, Evans RW, Swor RA, et al. The reliability magnetic resonance angiography. Spine (Phila Pa 1976). 2005 Sep 1;30(17):1955-1962. 8. Shatney CH, Brunner RD, Nguyen TQ. The safety of prehospital clinical evaluation for potential spinal 25. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine of orotracheal intubation in patients with unstable injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999 Oct-Dec;3(4):332-337. fracture patterns predictive of blunt vertebral artery cervical spine fracture or high . injury. J Trauma. 2003 Nov;55(5):811-813. Am J Surg. 1995 Dec;170(6):676-680. 16. Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. AJR Am J Roentgenol. 26. Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery 9. Robitaille A, Williams SR, Tremblay MH, Guilbert 2001 Sep;177(3):677-679. injuries associated with cervical spine injuries: a F, Thériault M, Drolet P. Cervical spine motion review of the literature. J Spinal Disord Tech. 2008 17. Hunter BR, Keim SM, Seupaul RA, Hern G. Are Jun;21(4):252-258. during tracheal intubation with manual in- plain radiographs sufficient to exclude cervical 27. Bailes JE, Hadley MN, Quigley MR, Sonntag line stabilization: direct laryngoscopy versus spine injuries in low-risk adults? J Emerg Med. 2014 VK, Cerullo LJ. Management of athletic injuries of GlideScope videolaryngoscopy. Anesth Analg. 2008 Feb;46(2):257-263. the cervical spine and spinal cord. Neurosurgery. Mar;106(3):935-941. 18. Roberge RJ, Samuels JR. Cervical spine injury in 1991 Oct;29(4):491-497. low-impact blunt trauma. Am J Emerg Med. 1999 10. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical 28. Cantu RC. Stingers, transient quadriplegia, and Mar;17(2):125-129. spine motion: a fluoroscopic comparison during cervical spine stenosis: return to play criteria. Med 19. Kreipke DL, Gillespie KR, McCarthy MC, Mail intubation with lighted stylet, GlideScope, and Sci Sports Exerc. 1997 Jul;29(7 Suppl):S233-S235. JT, Lappas JC, Broadie TA. Reliability of indications Macintosh laryngoscope. Anesth Analg. 2005 Sep; 29. Resnick DK. Updated guidelines for the management for cervical spine films in trauma patients. J Trauma. 101(3):910-915. of acute cervical spine and spinal cord injury. 1989 Oct;29(10):1438-1439. Neurosurgery. 2013 Mar;72 Suppl 2:1. 11. Hoffman JR, Wolfson AB, Todd K, Mower WR. 20. Stiell IG, Wells GA, Vandemheen KL, et al. The 30. Hulbert RJ, Hadley MN, Walters BC, et al. Selective cervical spine radiography in blunt Canadian c-spine rule for radiography in alert Pharmacological therapy for acute spinal cord injury. trauma: methodology of the National Emergency and stable trauma patients. JAMA. 2001 Oct 17; Neurosurgery. 2013 Mar;72 Suppl 2:93-105. X-Radiography Utilization Study (NEXUS). Ann Emerg 286(15):1841-1848. 31. Kao CH, Chio CC, Lin MT, Yeh CH. Body cooling Med. 1998 Oct;32(4):461-469. 21. Steill IG, Clement CM, McKnight RD, et al. The ameliorating spinal cord injury may be neurogenesis-, Canadian c-spine rule versus the NEXUS low-risk anti-inflammation- and angiogenesis-associated in 12. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific criteria in patients with trauma. N Engl J Med. 2003 rats. J Trauma. 2011 Apr;70(4):885-893. monograph of the Quebec Task Force on - Dec 25;349(26):2510-2518. 32. Hansebout RR, Hansebout CR. Local cooling for Associated Disorders: redefining “whiplash” and its 22. Desouza RM, Crocker MJ, Haliasos N, Rennie A, traumatic spinal cord injury: outcomes in 20 patients management. Spine (Phila Pa 1976). 1995 Apr 15; Saxena A. Blunt traumatic vertebral artery injury: a and review of the literature. J Neurosurg Spine. 2014 20(8 Suppl):1S-73S. clinical review. Eur Spine J. 2011 Sep;20(9):1405-1416. May; 20(5):550-561.

10 Critical Decisions in Emergency Medicine