What is the appropriate emergency management and imaging protocol for a patient with a suspected cervical spine injury?

Emergency Management and Imaging Protocol for Suspected Cervical Spine Injury

Immediately immobilize the cervical spine using a rigid cervical collar combined with head blocks and backboard straps, then apply validated clinical decision rules (NEXUS or Canadian Cervical Rules) to determine if imaging is necessary, with CT being the imaging modality of choice when indicated. 1

Initial Stabilization and Immobilization

Spinal immobilization must begin at the accident scene and continue until cervical spine injury is definitively excluded. 2

• Apply a rigid cervical collar combined with supportive head blocks on a backboard with straps as this combination is most effective at limiting cervical spine motion 2
• Do not use sandbags and tape alone for immobilization—this long-standing practice is not recommended 2
• Use a lift-and-slide transfer technique rather than log-roll maneuvers when moving the patient, as this creates significantly less spinal motion 3
• Maintain immobilization throughout all resuscitation efforts, even if the patient is violent or has altered mental status 4

Critical Caveat on Collar Use

While rigid collars are standard, recent evidence suggests they may be unnecessary when head blocks with straps are already in place and can significantly reduce mouth opening, potentially complicating airway management 5. However, given the catastrophic consequences of missed injury, maintain full immobilization until imaging clearance is obtained.

Clinical Decision Rules for Imaging

Use either NEXUS or Canadian Cervical Rules to determine which patients require imaging—both have >99% sensitivity for detecting clinically significant injury. 1

NEXUS Criteria (Image if ANY of these 5 factors present):

• Focal neurologic deficit 1
• Midline spinal tenderness 1
• Altered level of consciousness 1
• Intoxication 1
• Distracting injury 1

NEXUS has 99.6% sensitivity and 99.9% negative predictive value but only 12.9% specificity, meaning most patients who meet criteria will not have injury, but it rarely misses significant injuries 1

Canadian Cervical Rules (More Complex Algorithm):

High-Risk Factors (Image immediately if present):

• Age >65 years 1
• Paresthesias in extremities 1
• Dangerous mechanism: falls from ≥3 feet/5 stairs, axial load to head, high-speed motor vehicle crash with rollover/ejection, bicycle collision, motorized recreational vehicle accident 1

If no high-risk factors, assess for low-risk factors that allow safe range-of-motion testing (simple rear-end collision, sitting position in ED, ambulatory at any time, delayed onset of neck pain, absence of midline tenderness) 1

Imaging Protocol

CT of the cervical spine is the imaging modality of choice when clinical criteria indicate imaging is necessary. 1

• CT has replaced plain radiography as the standard of care for trauma patients requiring cervical spine imaging 1
• Do not delay imaging waiting for complete clinical assessment in obtunded or intoxicated patients—proceed directly to CT 1
• MRI may be added if neurologic deficit is present or ligamentous injury is suspected despite normal CT 1

Airway Management Considerations

If airway intervention is required before spinal clearance, use videolaryngoscopy with manual in-line stabilization after removing only the anterior portion of the cervical collar. 6

• Videolaryngoscopy is preferred over conventional laryngoscopy as it reduces cervical spine movement 6
• Use jaw thrust rather than head tilt-chin lift for airway opening 6
• Avoid awake intubation routinely—videolaryngoscopy under anesthesia with appropriate precautions is equally safe and more practical 6
• Never apply traction during airway management as it causes clinically significant distraction 7

Screening for Blunt Cerebrovascular Injury (BCVI)

Screen for blunt cerebrovascular injury in high-risk patients, as this occurs in 3-4% of blunt trauma patients and can cause devastating stroke if missed. 1

Signs/Symptoms Requiring Vascular Imaging:

• Potential arterial hemorrhage from neck/face 1
• Cervical bruit in patient <50 years 1
• Expanding cervical hematoma 1
• Focal neurologic deficit (TIA, hemiparesis, vertebrobasilar symptoms, Horner syndrome) 1
• Neurologic deficit inconsistent with head CT findings 1

Risk Factors Requiring Vascular Imaging:

• Cervical spine fractures at C1-3 or involving transverse foramen at any level 1
• Cervical spine subluxation/dislocation 1
• Traumatic brain injury with GCS <6 1
• LeFort II/III fractures, basilar skull fracture, or mandible fracture 1
• Near hanging, clothesline-type injury, or seat belt abrasion with significant swelling 1

Multidisciplinary Approach

Employ a specialized multidisciplinary team for evaluation and treatment, as this approach has reduced mortality to 22% in multiply injured patients with cervical spine injury. 4

• Emergency medical stabilization takes precedence, but maintain cervical spine precautions throughout 4
• Screen for associated injuries: 24% of cervical spine injury patients have additional spine fractures elsewhere 4
• Maintain high suspicion—3-4% of all blunt trauma patients have cervical spine injury 1

Common Pitfalls to Avoid

• Never remove immobilization based solely on negative plain radiographs—CT is required for adequate clearance in trauma patients 1
• Do not delay imaging in obtunded patients hoping they will become examinable—prolonged cervical collar placement causes iatrogenic injuries 1
• Avoid over-reliance on cervical collars alone—they provide limited motion control and should be combined with head blocks 2, 3
• Do not perform clinical clearance in patients with GCS <15, intoxication, or distracting injuries—these patients require imaging regardless of examination findings 1