Symptoms and Signs
The accurate clinical assessment of symptoms and signs is important in cervical spine trauma because it forms the basis of assessing the need for radiological studies. Below are five features that have been demonstrated to reliably stratify patients as having a significant risk of a cervical injury if present in the history and clinical presentation (51)
- Midline cervical spinal tenderness
- Evidence of intoxication
- Altered level of consciousness
- Focal neurological deficit
- History of a painful distracting injury
Children who satisfy any one of the above criteria are deemed at high risk of cervical injury and therefore require radiological evaluation.
Patterns of evolution
- Signs can be masked innitially: In very young children or in children with an associated impaired level of consciousness, signs of cervical injury may be difficult to elicit at the outset. Because of the high morbidity rate for a missed injury, extreme diligence is required in the early phases of trauma evaluation.
- Injury may occur as muscle spasm relaxes: It is important to remember that these injuries can reveal themselves later, as the muscle spasm associated with distracting injuries improve.
All patients at high risk for cervical spine injuries should be treated as injured until proven otherwise.
- ATLS protocol: In cases of multiple trauma, the child should be managed initially in accordance with ATLS guidelines (53). Other life-threatening or potentially disabling injuries need to be actively looked for in a logical and systematic fashion.
- Maintain homeostatic ventilation and circulation: Measures should be instituted to avoid hypotension, hypovolemia, anemia, hypoxia, and oxygen desaturation. Additionally, both hypo- and hypercarbia should be avoided with use of appropriate ventilatory support. A child with upper cervical spine injuries with diaphragmatic paralysis may benefit from reverse Trendelenberg positioning to facilitate ventilation.
- Immobilize appropriately and immediately: This will require the child be flat in bed with the appropriate orthotic device when indicated. In children younger than 8 years of age, the head-to-body ratio may require use of a shoulder roll to achieve a neutral cervical spine position.
- Maintain perfusion of spinal cord: For all pharmacological treatments, the effect on cord perfusion and neurological examination must be considered. Sedatives and analgesics may affect pO2 or mental status. Medications directed toward the cardiovascular system may cause hypotension and diminish cord perfusion.
- Document neurological state: A thorough neurological examination including testing of strength, sensation, level of consciousness, and deep tendon reflexes must be completed. Neurological evaluations must be accurately recorded and repeated at frequent intervals to identify evolving neurological injury.
- Initial radiological evaluation: (Criteria for imaging are discussed below). Cervical spine X-rays including anteroposterior and lateral views are obtained. Open mouth views are not routinely indicated in children less than 10 years. A CT scan is added if an injury is identified or the x-rays are inadequate. MRI can be considered if an injury is identified in other imaging or if a neurological deficit is present. Assessment should be made for continued cord compression if there is a persistent neurological deficit with MRI or CT as available.
Preparation for definitive intervention, non-emergent
- Immobilize cervical spine: During this time, the cervical spine should immobilized at least in a rigid cervical collar. A halo should be considered for more severe injuries, for upper cervical injuries, and in patients who will likely undergo several surgeries for their other injuries.
- Other injuries take precedence if no cord compression: If no cord compression is present, then treatment of cervical spine injuries may be delayed, particularly if other injuries are present that affect surgical risk. Common problems are moderate or severe TBI, pulmonary or cardiac contusions, compound or large-bone orthopedic injuries, and vascular or bowel injuries.
- Preparation for definitive intervention, emergent
- Determine evolution of neurological injury: The findings of the neurological examinations done at the scene of the accident and on arrival at the ER should be reviewed and compared with the examination done at the time of neurosurgical consultation.
- Determine mechanism of injury: A history of high-velocity trauma or painful distracting injury increases the likelihood of cervical spine injury.
- Evaluate bracing for stability: Consider the possibility of mechanical instability; reevaluate immobilization.
- Consider pharmacological intervention: Consider institution of pharmacological treatments for spinal cord injuries. If a high-dose methylprednisolone protocol is considered, remember that the NASCIS trials that explored it were conducted on a trauma population of individuals 13 years of age and older (54). In addition, steroids may impair postoperative wound healing and fusion.
- HOB, positioning and activity: Cervical spine precautions to include flat bed rest.
- VS: Hourly, or more frequent, neurological checks. Watch for neurogenic shock (hypotension with bradycardia).
- BP parameters: Normotensive or slightly hypertensive for age
- IVF and rate: Maintenance NS, avoid dehydration.