What is the initial management for a patient with a neck ligament injury without fracture in the emergency department?

Emergency Department Management of Neck Ligament Injury Without Fracture

Immediate immobilization of the spine is recommended for any patient with suspected neck ligament injury to prevent neurological deterioration, even in the absence of fracture. 1, 2

Initial Assessment and Stabilization

• Apply appropriate cervical spine immobilization using a rigid neck brace for patients with suspected neck ligament injury to limit progression of neurological deficit 1, 2
• Maintain systolic blood pressure >110 mmHg to reduce mortality in patients with suspected spinal cord injury 2
• Classify patients based on clinical stability and presence of "hard signs" (requiring immediate surgical intervention) or "soft signs" (requiring further evaluation) 2

Imaging Protocol

• CT cervical spine without IV contrast is the recommended initial imaging for patients with suspected acute cervical spine trauma 1
• For patients with suspected ligamentous injury without fracture on CT, MRI of the cervical spine without IV contrast is the appropriate next imaging modality 1, 2
• CT angiography (CTA) should be performed if vascular injury is suspected, with 90-100% sensitivity and 98.6-100% specificity 2

Management Considerations

• Pure ligamentous injuries without fracture are rare, occurring in only 0.5% of unreliable trauma patients, but can lead to significant instability 3
• Prolonged immobilization with rigid cervical collars carries significant risks:
  • Decubitus ulcers develop in up to 38% of patients with prolonged collar use (>24 hours) 4
  • Most complications appear and rapidly escalate after 48-72 hours of immobilization 1
  • Recent evidence suggests cervical immobilization may increase mortality risk in certain populations, particularly older adults, those with unclear consciousness, and patients with major traumatic injuries 5

Special Airway Management Considerations

• If airway management is required:
  • Remove the anterior part of the cervical collar during intubation attempts to improve glottic visualization while minimizing cervical spine movement 1
  • Consider manual in-line stabilization (MILS) during intubation, but have a low threshold for discontinuing if difficulties arise 1
  • For intubation, use rapid sequence induction with direct laryngoscopy and a gum elastic bougie without Sellick maneuver 1, 2

Treatment Options

• Treatment depends on the severity of ligamentous injury and associated instability:
  • Stable injuries may be managed conservatively with collar immobilization 3
  • Unstable injuries often require surgical fusion 3
  • Capsular ligament laxity in the cervical spine is a major source of chronic neck pain and may require specialized treatment 6

Clearing the Cervical Spine

• For alert, reliable patients with no neurological deficits and normal CT imaging, the cervical collar can be removed after clinical examination confirms no midline tenderness 1
• For obtunded patients with normal CT imaging:
  • Recent guidelines suggest that follow-up MRI may not be necessary in all cases 1
  • Early collar removal should be considered to prevent complications of prolonged immobilization 4
  • If there is concern for pure ligamentous injury, MRI is the most appropriate imaging modality 1, 2

Common Pitfalls to Avoid

• Failing to maintain proper cervical spine immobilization during initial assessment 2
• Relying solely on physical examination without appropriate imaging in stable patients 2
• Prolonged use of cervical collars without clear indication, leading to pressure ulcers and other complications 4, 5
• Overlooking the possibility of craniocervical ligamentous injuries, which can occur without obvious dislocation 7