~&U•••I••II••••II•••••II••l!l*II.MAAli,I.!llii1¥••'I"II;!1••iliff,;'••••III•••••••a. )oi, et aJ. mOQ"ranh,. :" It Surg'(B~; J Neurosurg (Spine 31 96:285-291, 2002 ld :esults, in urles, ed 1. c dura] tears: 3-446, 1984 Cervical spine trauma associated with moderate and . of myeloa. .) 14:59--64. severe head injury: incidence, risk factors, and injury characteristics c resonance It Surg (BrJ transfers in LANGSTON T. HOLLY, M.D., DANIEL F. KELLY, M.D., GEORGE J. COUNELIS, M.D., reconstruc· THANE BLINMAN, M.D., DAVID L. McARTHUR, PH.D., M.P.H., AND H. GILL CRYER, M.D. 3 Saunders, Division ofNeurosurgery, Departments of Surgery and Epidemiology, University of California 1 Alnot JY at Los Angeles Center for Health Sciences, and the UCLA Brain Injury Research Center. juries, ell 1: Los Angeles; Division ofNeurosurgery, Harbor-UCLA Medical Center, Torrance, California; ;)-64 and Department ofNeurosurgery, University ofPennsylvania, Philadelphia, Pennsylvania II investiga_ iiagnosis of y intradural Object. Diagnosing and managing cervical spine trauma in head-injured patients is problematic due to an altered 531,1998 level of consciousness in such individuals. The reported incidence of cervical spine trauma in head-injured patients has tic value of generally ranged from 4 to 8%. In this retrospective study the authors sought to define the incidence of cervical injury lrg (lBr) 19: in association with moderate or severe brain injury, emphasizing the identification of high-risk patients. Methods. The study included 447 consecutive moderately (209 cases) or severely (238 cases) head injured patients laging tech­ who underwent evaluation at two Levell trauma centers over a 40-month period. Of the 447 patients, 24 (5.4%) suf­ -553,1995 fered a cervical spine injury (17 men and seven women; mean age 39 years; median Glasgow Coma Scale rGCS] score yelographic of 6, range 3-14). Of these 24 patients, 14 (58.3%) sustained spinal cord injuries (SCIs), 14 sustained injuries in the ns: discrep­ occiput-C3 region. and 10 underwent a stabilization procedure. Of the 14 patients with scrs, nine experienced an early Nerve 17: hypotensive andJor hypoxic insult. Regarding the mechanism of injury, cervical injuries occurred in 21 (8.2%) of 256 patients involved in motor vehicle accidents (MVAs), either as passengers or pedestrians, compared with three (1.6%) lries of the of 191 patients with non-MVA-associated trauma (p < 0.01). In the subset of 131 MVA passengers, 13 (9.9%) sus­ iO, 1968 tained cervical injuries. Patients with an initial GCS score less than or equal to 8 were more likely to sustain a cervi­ cal injury than those with a score higher than 8 (odds ratio [OR] 2.77. 95% confidence interval [CI] = 1.11-7.73) and were more likely to sustain a cervical SCI (OR 5.5, 95% CI 1.22-24.85). At 6 months or more postinjury, functional neurological recovery had occurred in nine patients (37.5%) and eight (33.3%) had died. Conclusions. Head-injured patients sustaining MVA-related trauma and those with an initial GCS score less than or )artment of equal to 8 are at highest risk for concomitant cervical spine injury. A disproportionate number of these patients sustain mogo862­ high cervical injuries, the majority of which are mechanically unstable and involve an SCI. The development of safer Jimac@ca. and more rapid means of determining cervical spine integrity should remain a high priority in the care of head-injured patients. KEyWORDS cervical spine injury traumatic brain injury spinal stabilization NDIVIDUALs who sustain traumatic brain injury are at severity, as measured by the GCS, has been associated increased risk of sustaining cervical spine injury com­ with a higher rate of cervical injury, few other risk factors 13 c4 I pared with victims of nonhead-related blunt trauma in this patient population have been identified. • Iden­ I injury. jJ The reported incidence of cervical spine trauma tifying such high-risk patients may be particularly useful i after clinically significant head injury has generally given that diagnosing and managing cervical spine in­ ranged from 4 to 8%.11,13.19c4 Although an increasing injury juries in head-injured patients is problematic due to an altered level of consciousness and the overall critical na­ ture of their injuries. Despite advances in imaging tech­ Abbreviations used in this paper: CI = confidence interval; CT = nologies and screening protocols, cervical spine injury I computerized tomography; GCS = Glasgow Coma Scale; GOS= ; Glasgow Outcome Scale; GSW == gunshot wound; MR == magnetic may go undetected even in optimum circumstances. resonance; MVA = motor vehicle accident; OR == odds ratio; SCI = Failure to recognize unstable cervical injuries during ini­ spinal cord injury; UCLA = University of California at Los An­ tial evaluation can result in serious neurological worsen­ geles. ing.' Increased neurological deficits have been reported to ril,2002 1. Neurosllrg: Spine / Volume 96/April. 2002 285 L. T. Holly, et al, :'ervical spine traum, occur in 3 to 10% in patients with SCI after arriving at the Patients. with .combined craniocervical inj~ries Were hospital. 13 managed m the mtensIve care umt after stabIlIzation Or The goals of this study were to determine the incidence after surgical evacuation of an intracranial hematoma. In­ and characteristics of cervical spine injuries in patients divid~als with defini~ive or presumed SCI received methyl_ who sustained moderate or severe head trauma. We also predmsolone, as mdIcated by the SCI protocol outlined in Level of Injury sought to identify risk factors for combined craniocervical the National Acute Spinal Cord Injury Study II.' Central trauma to identify more effectively the high-risk patient venous catheters were placed, and hemodynamic sUpport Oc-Cl Fx-SL early in their hospitalization. with intravenous fluids and vasopressor agents were used Oc-Cl SL to maintain adequate blood pressure. Depending on the nu­ Col Fx ture of the cervical injury, severity of head injury. and car­ Col Fx Clinical Material and Methods CI-2 SL diopulmonary stability, patients were initially muintained CI-2 SL Patient Population in a cervical collar, placed in cervical traction in which CI-2 SL Gardner-Wells tongs were used, placed in a halo vest, or Between December 1992 and March 1996,464 patients C2-3 Fx-SL taken to the operating room to undergo open reduction and C-2 Fx with moderate or severe head injury (postresuscitation GCS internal cervical fusion. In all cases of severe head injury C-2Fx scores of 3-12 or > 12 with abnormal findings demon­ (GCS Scores 3-8) and in some cases of moderate injury C2-3 Fx-SL strated on head CT scans) were admitted to either the UCLA (GCS Scores 9-14) in which CT scanning demonstrated C3-4 Fx-SL or Harbor-UCLA Medical Centers. Of these patients, 287 C3-4 Fx-SL evidence of mass effect, intracranial pressure ICP monitor­ were prospectively emolled into the UCLA Brain Injury C3-S Fx-SL ing was performed. In such patients, goals of head injury Research Center program. Informed consent was obtained C-4 Fx management included maintenance of intracranial pressure CS-6 Fx-SL from family members of all participants in the study. An less than 20 mm Hg and cerebral perfusion pressure higher CS-6 Fx-SL additional 160 patients were recruited into the program but than 70 mm Hg. Global neurological outcome was deter­ C-S Fx were not emolled. Because the overall age, sex, and injury mined at 6 months postinjury by the GOS. Favorable out­ C6-7 Fx characteristics of the emolled and nonemolled patients did C-6 Fx come was defined as good recovery or moderate disability not differ substantially, these two patient groups were com­ C6-7 Fx-SL and poor outcome as severe disability, persistent vegetative bined for the purposes of this study, yielding a total of 447 e-7 Fx state, or death. 15 C-7 Fx moderately or severely head injured patients evaluated dur­ C7-Tl SL ing this time period. An additional 17 patients were exclud­ Statistical Analysis ed from this study because data regarding characteristics of * Patients are pres, Data were managed by Paradox (version 7; Corel Corp., juries involving leve their head injuries were insufficient. injUry with punctate To identify the head-injured patients with concomitant Ottowa, Ontario, Canada) and analyzed using SPSS (ver­ HT = hypotensive in cervical spine injury, the UCLA Brain Injury Research sion 8, SPSS Inc., Cary, NC) and PEPI (version 3; devel­ mod = moderate; M' Center database was reviewed and retrospective chart re­ oped by 1. H. Abramson, The Hebrew University of Jeru­ ery; SAH = subaracJ views were performed. All head-injured patients with doc­ salem, Jerusalem, Israel; accessible at www.myatt.demon. umented cervical spinal cord and/or spinal column trau­ co.uk). Statistics for tabular data included chi-square and ma were included. The GCS scores, Abbreviated Injury Fisher exact tests; a probability value of 0.05 was used for 1 Scores, and Injury Severity Scores were documented in all significance. Odds ratio statistics with 95% CIs were used I patients. I Potential risk factors and injury-related character­ to compare the difference in risk of cervical spine injury lOt d . h istics were documented including age, sex, mechanism of due to MVA- and non-MVA-related causes of injury. and in ,live, an fractures wIt ou injury, location of injury, GCS score, presence of neurolog­ those with initial GCS scores of 8 or less or greater than 8. lThe injuries were first doc ical deficits, and occurrence of hypotension or hypoxia l:!diographs in 18 patients identified in the prehospital setting or within 24 hours of llwo of the six patients, ce !'lrated on the original pIa hospitalization.