What is the recommended initial assessment and management for a suspected cervical spine injury?

Initial Assessment and Management of Suspected Cervical Spine Injury

Immediate Immobilization at Scene

Apply immediate cervical spine immobilization using a rigid cervical collar combined with head blocks and straps on a backboard for all trauma patients with suspected cervical spine injury. 1, 2

• Use manual in-line stabilization (MILS) immediately at the scene and maintain throughout transport 2
• The combination of rigid collar, supportive blocks, and backboard straps is the most effective method for limiting cervical spine motion 3
• Do not use sandbags and tape alone—this method is inadequate and not recommended 3
• Transport patients directly to Level 1 trauma centers within the first hours after injury, as this reduces morbidity, mortality, and enables earlier surgical intervention 2, 4

Hemodynamic Stabilization

Maintain systolic blood pressure >110 mmHg continuously from the moment of assessment to reduce mortality. 5, 2, 4

• Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration 2, 4
• Place an arterial line for continuous accurate blood pressure monitoring 4
• Hypotension below these thresholds significantly increases mortality risk 2, 4

Airway Management (If Required)

Remove the anterior portion of the cervical collar during intubation attempts while maintaining manual in-line stabilization—never leave the collar fully in place. 1, 2, 4

• Use videolaryngoscopy in preference to direct laryngoscopy, as it reduces cervical spine movement and improves first-pass success rates 1, 2, 4
• Consider using a stylet or bougie as an adjunct during intubation with cervical immobilization 1
• Use jaw thrust rather than head tilt plus chin lift when simple airway maneuvers are needed 1, 2
• Minimize cervical spine movement during pre-oxygenation and facemask ventilation 1, 2
• Have a low threshold for removing MILS if it worsens glottic view and causes difficult intubation, as MILS has very limited evidence for reducing secondary spinal cord injury 1
• The actual risk of secondary spinal cord injury from airway management is extremely low (0.34% in meta-analysis), so do not delay necessary airway management 2

Imaging Protocol

Obtain CT cervical spine without IV contrast as the initial imaging study for all patients with suspected cervical spine injury. 5, 4

• If CT shows suspected ligamentous injury without fracture, proceed to MRI of the cervical spine without IV contrast 5, 4
• Perform CT angiography if vascular injury is suspected (90-100% sensitivity, 98.6-100% specificity) 5
• CT scan is the gold standard imaging modality for suspected cervical spine fractures 6

Neurological Assessment

• Perform documented neurological assessment according to the impairment scale 6
• Assume all patients with significant mechanism of injury have an unstable spinal injury until proven otherwise 6
• Identify respiratory complications immediately, as they are life-threatening in high cervical injuries 2

Clearing the Cervical Spine

For alert, reliable patients with no neurological deficits and normal CT imaging, remove the cervical collar after clinical examination confirms no midline tenderness. 5

• For obtunded patients with normal CT imaging, follow-up MRI may not be necessary in all cases 5
• If there is concern for pure ligamentous injury, MRI is the most appropriate imaging modality 5

Critical Pitfalls to Avoid

• Prolonged immobilization with rigid cervical collars carries significant risks, with most complications appearing after 48-72 hours 5
• Never rely exclusively on extrication-type collars alone to immobilize the neck—they have limited ability to control motion in injured models 7
• Do not use succinylcholine after 48 hours post-injury due to risk of life-threatening hyperkalemia from denervation hypersensitivity 4
• Failing to maintain blood pressure targets increases mortality and neurological deterioration 2, 4
• Delaying transport to Level 1 trauma centers worsens outcomes 2

Multidisciplinary Planning

• Implement multidisciplinary planning, preparation, and optimization of human factors before airway management 1, 2
• Use cognitive aids and checklists to maintain situational awareness during the peri-intubation period 1
• Ensure regular training in videolaryngoscopy with cervical spine immobilization for all clinicians who perform intubation in this setting 1