What is the appropriate management for a patient with a clothesline neck injury, potentially involving cervical spine instability and other associated injuries?

Management of Clothesline Neck Injury

Patients with clothesline-type neck injuries require immediate cervical spine immobilization, high-resolution CT angiography to evaluate for blunt cerebrovascular injury (BCVI), and CT of the entire cervical spine with sagittal reconstructions to assess for cervical spine fractures and instability, as clothesline mechanism is specifically identified as a high-risk factor for BCVI and cervical spine injury. 1

Immediate Assessment and Stabilization

High-Risk Mechanism Recognition

• Clothesline-type injury is explicitly listed as a risk factor for BCVI, particularly when associated with significant swelling, pain, or altered mental status 1
• This mechanism creates anterior neck trauma with potential for both vascular and cervical spine injury 1
• Immediate cervical spine immobilization should be applied until instability is excluded 1

Critical Clinical Indicators to Assess

Look specifically for:

• Signs of BCVI: Potential arterial hemorrhage from neck/face, cervical bruit in patients <50 years, expanding cervical hematoma, focal neurologic deficits (TIA, hemiparesis, vertebrobasilar symptoms, Horner syndrome), or neurologic deficit inconsistent with head CT 1
• Cervical spine injury indicators: Midline cervical tenderness, neurologic deficit, GCS <15, or visible neck deformity 1, 2
• Airway compromise: Expanding hematoma, stridor, or respiratory distress requiring urgent airway management 1

Imaging Protocol

Primary Imaging Studies

• High-resolution CT of entire cervical spine at 1.5-2mm collimation with sagittal reconstructions is the gold standard, detecting >99% of cervical spine injuries 1, 2
• CT angiography of the neck vessels is mandatory given the clothesline mechanism's association with BCVI 1
• Plain radiographs are inadequate and should not be used as they miss approximately 15% of cervical injuries and have only 36% sensitivity 2

Advanced Imaging Indications

• MRI cervical spine without contrast is indicated if: neurologic deficits are present, CT shows concerning findings requiring soft tissue evaluation, or high clinical suspicion persists despite negative CT 1, 2, 3
• MRI has 95-100% sensitivity for detecting ligamentous disruption, cord compression, and soft tissue injuries that CT may miss 2, 3
• MRI is critical because isolated ligamentous injuries can cause instability without visible fractures on CT 3

Airway Management Considerations

If Intubation Required

• Videolaryngoscopy is preferred over direct laryngoscopy as it produces less cervical spine movement and vertebral canal narrowing 1
• Manual in-line stabilization should be maintained during intubation, though rigid collars may paradoxically cause movement at the craniocervical junction 2
• Awake tracheal intubation is often impractical in trauma settings and videolaryngoscopy has become the preferred approach 1

Cervical Spine Clearance Algorithm

For Alert, Cooperative Patients

Clinical clearance is appropriate if ALL of the following are met 1:

• GCS 15, fully alert
• No intoxicants
• No neck pain or midline tenderness
• No distracting injuries
• Full, pain-free range of motion

For Obtunded or Unreliable Patients

Group 1 (Expected to be evaluable within 48-72 hours, e.g., intoxicated): 1

• Perform baseline three-view cervical spine films and thoracolumbar AP/lateral films
• Evaluate clinically when patient becomes reliable
• Consider high-resolution CT if clinical evaluation remains concerning

Group 2 (Unlikely evaluable within 48-72 hours, e.g., severe head injury, multiple injuries): 1

• Three-view cervical spine films
• High-resolution CT (1.5-2mm slices) of entire cervical spine with sagittal reconstructions
• If interpreted as normal by senior radiologist, cervical spine may be assumed stable
• This approach detects >99.5% of cervical spine injuries 1

Critical Pitfalls to Avoid

Imaging Errors

• Do not rely on plain radiographs alone - they have only 36% sensitivity and miss approximately 15% of cervical injuries 2
• Do not assume negative CT excludes all injury - isolated ligamentous injuries require MRI for detection 2, 3
• Do not miss the cervicothoracic junction - up to 60% of cervical injuries occur at this location 2

Management Errors

• Do not prolong collar immobilization unnecessarily - collars should be removed as soon as feasible once spine is cleared, as prolonged immobilization causes 1-3% muscle strength loss per day and significant morbidity 4, 5
• Do not delay MRI if neurologic symptoms develop - missed or delayed diagnosis produces 10 times higher rates of secondary neurological injury (10.5% vs 1.4%) 2
• Do not discharge without vascular imaging - clothesline mechanism mandates BCVI evaluation given the specific risk profile 1

Mortality and Morbidity Considerations

• Up to 4.3% of cervical fractures may be missed, with 67% of these patients suffering neurological deterioration 2
• Secondary spinal cord injury from missed instability carries devastating consequences including permanent quadriplegia 3
• BCVI can present with delayed stroke if not identified and treated appropriately 1