Which of the following is true
regarding cervical trauma?
A The mortality associated with
atlanto-occipital dislocation is 100%.
B Most mortality in cervical trauma is
not the direct result of neural
compression.
C With the advent of CT, no other
imaging is needed for evaluation of the
cervical spine.
D In a neurologically intact patient
with neck pain, the cervical spine can be
cleared immediately with normal
findings on plain cervical radiographs.
E Methylprednisolone should be
started immediately in any trauma patient
suspected of having cervical trauma,
regardless of the findings on neurologic
examination or the time of injury.
Explanation-
Evaluating, treating, or possibly clearing
the cervical spine in a trauma patient is a
procedure that can be complex at times.
In fact, the spine trauma guidelines state
that there is insufficient evidence to even
support treatment guidelines. Initial
immobilization of a trauma victim’s
cervical spine is commonplace with
most emergency medical service
systems. The neck continues to be
immobilized until the spine can be
cleared by clinical assessment or
radiographic imaging. The process of
evaluating begins with a careful history
and physical examination. In the absence
of any suspicious mechanism of injury
and with an asymptomatic patient
(awake, alert, neurologically intact, not
intoxicated, without neck
pain/tenderness, and without other
injuries that prevent appropriate
assessment of the spine or that distract
the patient), imaging is unlikely to be
necessary. However, a symptomatic
patient requires imaging. A three-view
cervical spine series (anteroposterior,
lateral, and odontoid views) is
recommended, sometimes supplemented
by computed tomography to better
define suspicious or poorly visualized
areas on plain cervical radiographs. The
diagnostic performance of helical CT
scanners has a sensitivity approaching
99% and specificity approaching 93%.
Because of this, many trauma centers
have proposed relying exclusively on
CT to evaluate the cervical spine.
However, the CT-generated artifact,
especially in coronal and sagittal
reconstructions, may distort the true
anatomy of the cervical spine.
Nonetheless, missed injuries on CT are
extremely rare and the majority are
ligamentous. In an awake and
neurologically intact patient with neck
pain, three-view plain cervical
radiographs and CT are recommended to
evaluate bony pathology. If pain is still
present despite normal findings on
radiography and CT, either magnetic
resonance imaging or dynamic
flexion/extension films are
recommended. Atlanto-occipital
dislocation, or craniocervical junction
dislocation, occurs in approximately 1%
of patients with cervical spine trauma
and has been noted in 18% to 19% of
patients with fatal cervical spine injuries
at autopsy. Although the entity was
previously perceived as an infrequent
injury resulting in death, improved
emergency management has recently
provided increased survivors. Most
mortality in patients with cervical spine
trauma results from anoxia secondary to
respiratory arrest from other injuries.
The use of steroids, in particular
methylprednisolone, after spinal cord
injury is a matter of great debate. The
original studies performed involved
patients with known neurologic deficits
seen within 8 hours of injury. A 30-
mg/kg bolus, followed by a 23-hour
infusion of 5.4 mg/kg/h, is the usual
protocol. Even in this scenario, the
degree of functional motor improvement
is questionable, and side effects such as
sepsis and pneumonia may occur.
Therefore, no level I evidence exists to
support the use of methylprednisolone
for spinal cord injury, although many
physicians still follow the protocol
based on levels II and III data. However,
in the setting of a neurologically intact
patient or a patient with spinal cord
injury but outside the 8-hour window,
data suggest that steroids should not be
administered.
Answer- B
regarding cervical trauma?
A The mortality associated with
atlanto-occipital dislocation is 100%.
B Most mortality in cervical trauma is
not the direct result of neural
compression.
C With the advent of CT, no other
imaging is needed for evaluation of the
cervical spine.
D In a neurologically intact patient
with neck pain, the cervical spine can be
cleared immediately with normal
findings on plain cervical radiographs.
E Methylprednisolone should be
started immediately in any trauma patient
suspected of having cervical trauma,
regardless of the findings on neurologic
examination or the time of injury.
Explanation-
Evaluating, treating, or possibly clearing
the cervical spine in a trauma patient is a
procedure that can be complex at times.
In fact, the spine trauma guidelines state
that there is insufficient evidence to even
support treatment guidelines. Initial
immobilization of a trauma victim’s
cervical spine is commonplace with
most emergency medical service
systems. The neck continues to be
immobilized until the spine can be
cleared by clinical assessment or
radiographic imaging. The process of
evaluating begins with a careful history
and physical examination. In the absence
of any suspicious mechanism of injury
and with an asymptomatic patient
(awake, alert, neurologically intact, not
intoxicated, without neck
pain/tenderness, and without other
injuries that prevent appropriate
assessment of the spine or that distract
the patient), imaging is unlikely to be
necessary. However, a symptomatic
patient requires imaging. A three-view
cervical spine series (anteroposterior,
lateral, and odontoid views) is
recommended, sometimes supplemented
by computed tomography to better
define suspicious or poorly visualized
areas on plain cervical radiographs. The
diagnostic performance of helical CT
scanners has a sensitivity approaching
99% and specificity approaching 93%.
Because of this, many trauma centers
have proposed relying exclusively on
CT to evaluate the cervical spine.
However, the CT-generated artifact,
especially in coronal and sagittal
reconstructions, may distort the true
anatomy of the cervical spine.
Nonetheless, missed injuries on CT are
extremely rare and the majority are
ligamentous. In an awake and
neurologically intact patient with neck
pain, three-view plain cervical
radiographs and CT are recommended to
evaluate bony pathology. If pain is still
present despite normal findings on
radiography and CT, either magnetic
resonance imaging or dynamic
flexion/extension films are
recommended. Atlanto-occipital
dislocation, or craniocervical junction
dislocation, occurs in approximately 1%
of patients with cervical spine trauma
and has been noted in 18% to 19% of
patients with fatal cervical spine injuries
at autopsy. Although the entity was
previously perceived as an infrequent
injury resulting in death, improved
emergency management has recently
provided increased survivors. Most
mortality in patients with cervical spine
trauma results from anoxia secondary to
respiratory arrest from other injuries.
The use of steroids, in particular
methylprednisolone, after spinal cord
injury is a matter of great debate. The
original studies performed involved
patients with known neurologic deficits
seen within 8 hours of injury. A 30-
mg/kg bolus, followed by a 23-hour
infusion of 5.4 mg/kg/h, is the usual
protocol. Even in this scenario, the
degree of functional motor improvement
is questionable, and side effects such as
sepsis and pneumonia may occur.
Therefore, no level I evidence exists to
support the use of methylprednisolone
for spinal cord injury, although many
physicians still follow the protocol
based on levels II and III data. However,
in the setting of a neurologically intact
patient or a patient with spinal cord
injury but outside the 8-hour window,
data suggest that steroids should not be
administered.
Answer- B
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