TERMINOLOGY
CLINICAL CLARIFICATION
• Group of injuries involving the neck due to a rapid, forceful, backwards motion6
• May involve the following: 6
○ Injury to vertebral and paravertebral structures (fractures, dislocations, ligamentous tears, and disc
disruption/subluxation)
○ Spinal cord injury (traumatic central cord syndrome secondary to cord compression or vascular insult)
○ Vascular injury (vertebral artery or carotid artery dissection)
○ Soft tissue injury around cervical spine (cervical strain/sprain)
CLASSIFICATION
• Cervical Injury classification25
○ Major cervical injury
– Radiographic or CT evidence of instability with or without associated or potential localized or central neurologic
findings 25
□ Presence of:
□ Displacement of more than 2 mm
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in any plane □ Wide vertebral body in any plane □ Wide interspinous/interlaminar space □ Wide facet joints □ Disrupted posterior vertebral body line □ Wide disc space □ Vertebral burst □ Locked or perched facets (unilateral or bilateral) □ "Hanged man" fracture of 2nd cervical vertebra □ Dens fracture □ Type III occipital condyle fracture ○ Minor cervical injury – Defined as having no radiographic and/or CT evidence of instability, are not associated with neurologic findings, and have no potential to cause the latter – Pertains to all types of fracture other than major cervical injury fractures • Subaxial Injury Classification- most commonly used18, 2 ○ Three categories – Morphology □ No abnormality – 0 □ Compression – 1 □ Burst - +1-2 □ Distraction (e.g. perched facet) – 3 □ Rotation or translation (e.g. facet dislocation – 4 – Disco-ligamentous complex □ Intact – 0 □ Indeterminate – 1 □ Disrupted – 2 – Neurological status □ Root injury – 0 □ Complete cord injury – 1 □ Incomplete cord injury – 2 □ Continuous cord compression – +1 – Scoring System to help facilitate surgical decision making □ 1-3 scoring can be treated nonoperatively □ 4 points can be treated nonsurgically or surgically □ 5 points or greater can be treated with surgery • National Emergency X-Radiography Utilization Study 26 ○ Determines whether patients with cervical spine trauma need imaging ○ Meeting all five criteria indicates low probability of injury ○ Criteria – No tenderness at the posterior midline of the cervical spine Cervical hyperextension injuries – No focal neurologic deficit – Normal level of alertness – No evidence of intoxication – No clinically apparent painful injury that might distract patient from the pain of the cervical spine injury • Canadian C-Spine Rule 11 ○ Determines whether patients with cervical spine trauma need imaging ○ Meeting all criteria indicates low probability of injury ○ Criteria – Glasgow Coma scale – 15 – Non-intoxicated patients without a distracting injury – No dangerous mechanism or extremity paresthesias – At least 1 “low-risk factor”: □ Simple rear end motor vehicle accident □ Ambulation at the accident scene □ No midline cervical tenderness □ Delayed onset of neck pain □ Sitting position at time of examination DIAGNOSIS CLINICAL PRESENTATION • History ○ A history of blow to the head or neck ○ Localized neck pain or tenderness ○ Neck stiffness ○ Muscle spasm in neck ○ Numbness or tingling sensation of an extremity • Physical examination ○ Signs/findings – External signs of trauma on the head/face and neck such as abrasions, lacerations, hematomas, or contusions, fracture, tooth loss – High index of suspicion in patients with significant head injuries – Posterior midline, bony point tenderness for bony injury – Paraspinal or lateral soft tissue tenderness suggestive of muscular/ligamentous injury – Anterior tenderness for carotid injury – Range-of-motion limitation – Hypotension – Paresthesias/numbness, weakness – Extremity weakness/paralysis – Neurologic deficits not explained by peripheral nerve injuries – Variable sensory changes below level of lesion (including paresthesias and dysesthesia) – Bladder/bowel dysfunction CAUSES AND RISK FACTORS • Causes ○ Blunt trauma due to motor vehicle accidents, sports injuries, accidental falls, and assaults • Risk factors and/or associations ○ Age – Trauma and sports injuries are more common in young adults – Traumatic central cord syndrome are more common in older adults 3 ○ Sex – More common in males 4 ○ Ethnicity/race – More common in whites ○ Other risk factors/associations – Facial fractures – Osteoporosis – Conditions predisposing to spinal rigidity, such as ankylosing spondylitis or other spondyloarthropathies Cervical hyperextension injuries – Preexisting spinal stenosis which may be: □ Acquired: prior trauma, spondylosis □ Congenital: Klippel-Feil syndrome (congenital fusion of any 2 cervical vertebra) with cervical stenosis DIAGNOSTIC PROCEDURES • Primary diagnostic tools ○ History (trauma/injury) 7 ○ Physical/neurological examination7 ○ Diagnostic tests, e.g., radiography 10 – CT scan is gold standard for bony injury – MRI is gold standard for soft tissue injury associated with hyperextension • Laboratory ○ Rarely indicated unless there is suspicion of other medical conditions such as systemic illnesses or bleeding • Imaging ○ Radiography 10 – Canadian C-Spine (cervical-spine) Rule and the National Emergency X-Radiography Utilization Study 21 □ Decision rules which guide the use of cervical spine radiography in low risk patients with trauma □ An aid in emergency room triage 31 – Lateral view of the cervical spine may show □ Anterior intervertebral disk space widening □ Anterior vertebral body avulsion fragments □ Facet malalignment – Other radiographic findings include 31 □ Presence of soft tissue swelling □ Loss of normal smooth cervical lordosis □ Disc space narrowing □ Segmental kyphosis □ Antero/retrolisthesis of one vertebral body relative to another □ Splaying of the spinous process – For awake asymptomatic patient— radiography is not recommended □ 3-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended if CT is not available □ Cervical immobilization can be discontinued without cervical spinal imaging for patients without distracting injury or neurologic deficit who are able to complete a functional range-of-motion examination (sensitivity = 98.1%, negative predictive value = 99.8%). 15 □ Dynamic radiograph (flexion/extension) □ Evaluates spine stability and union based on the amount of movement in fractures during or after treatment 24 □ Limited use in acute setting as accurate films are difficult to obtain in patients with restricted range of motion31 □ Two week post injury for flexion/extension to give maximal effort – For awake symptomatic patient— radiography is not recommended □ 3-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended if CT is not available □ Cervical spine series should be supplemented with CT (when it becomes available) if necessary to further define suspicious areas or not well visualized areas on plain cervical x-rays □ Cervical immobilization should be continued until patient is asymptomatic and discontinued following normal and adequate dynamic flexion/extension radiographs or normal MRI obtained within 48 hours of injury – For obtunded or unevaluable patient— radiography is not recommended if CT is available but radiographs can be performed if CT is not available □ Cervical spine series should be supplemented with CT (when it becomes available) if necessary to further define suspicious areas or not well visualized areas on plain cervical x-rays □ Continue cervical immobilization until asymptomatic and discontinue following normal MRI obtained within 48 hours of injury ○ CT imaging23 – Test of choice for cervical spine injury – Recommended for the awake symptomatic patient and the obtunded unevaluable patient – Defines specific bone disorders 28 – Sensitivity of 95%-99% for cervical spine injury (Holmes and como) ○ MRI 28, 20 – Can diagnose central cord syndrome, intervertebral disc disruption, occult vascular injury, other soft tissue disorders such as hematoma and ligament tear Cervical hyperextension injuries • Functional testing ○ For neurological assessment 10 – American Spinal Injury Association international standards provide classification of spinal cord injury 10 □ Recommended neurological examination tool for assessment and care of acute spinal cord injury patients □ Consists of sensory and motor components used in □ determining the sensory/motor/neurological levels □ generating scores to characterize sensory/motor functioning □ determining completeness of the injury 14 ○ For functional outcome assessment 10 – The Spinal Cord Independence Measure III □ Recommended functional outcome assessment tool in the assessment, care, and follow-up of patients with spinal cord injuries □ Assesses functional recovery among adult patients with traumatic spinal cord lesions ○ Pain Assessment 10 – Spinal Cord Injury Basic Pain Data Set □ Recommended pain assessment tool for patients with spinal cord injuries which includes □ Pain severity □ Physical functioning □ Emotional functioning □ Standardized the collection and reporting of pain in patients with spinal cord injury • Procedures ○ Angiography 23 – General explanation □ Vertebral artery injury may be suspected in cervical hyperextension injuries □ Angiography is performed to rule out dissection and/or post-traumatic aneurysm – Indication □ Computed tomographic angiography— recommended screening tool for selected patients after blunt cervical trauma who meet the modified Denver Screening Criteria for suspected vertebral artery injury 23 □ Conventional catheter angiography— recommended for the diagnosis of vertebral artery injury in selected patients after blunt cervical trauma especially if concurrent endovascular therapy is being considered – Contraindications □ Presence of electronic or metallic device (pacemaker, metallic aneurysm clips), vascular stents, or metallic iron in the body □ Diabetes □ Renal failure □ Allergy to dye □ Pregnancy – Interpretation of results □ Show vascular lacerations and contrast extravasation, occlusions, and dissections in both the cervical carotid and vertebral arteries • Other diagnostic tools ○ Denver Screening Criteria, modified8
– Screening tool to diagnose vertebral and carotid artery dissection and/or injury after blunt head and neck trauma
(blunt cerebrovascular injury)
DIFFERENTIAL DIAGNOSIS
• Most common
○ Degenerative cervical spine disease
– Presents with axial neck pain and neurological complications such as radiculopathy and myelopathy
– No history of trauma is a differentiating feature
– Cervical spine radiograph shows degenerative disc or joint
– Cervical MRI shows bone destruction, nerve compression, or intradural/epidural process
○ Non-traumatic neck pain
– Presents with symptoms caused by secondary infection (pain with fever), neoplasia, or inflammation (arthritis)
– No history of trauma is a differentiating feature
– Cervical spine radiograph, CT scan or MRI show bony destruction, neoplastic lesions, vertebral osteomyelitis
– Laboratory findings of blood test include erythrocyte sedimentation rate and C-reactive protein which are elevated in
infection, malignancy or arthritis; and CBC shows elevated WBC in infection
Cervical hyperextension injuries
TREATMENT
GOALS
• To relieve symptoms and stabilize spinal column and fracture
• Correct hypotension if present
• To prevent neurological deterioration and permanent disability
12 DISPOSITION • Admission criteria ○ Depends on the injury, clinical judgment, radiographic findings, and need for surgical intervention ○ In the emergency room, triage of neck due to trauma is based on the the National emergency X-Radiography Utilization Study and the Canadian C-Spine Rule 30 ○ Criteria for ICU admission10 – Hemodynamic instability – Cardiac rate disturbances – Pulmonary dysfunction – Hypoxemia • Recommendations for specialist referral ○ Refer to a neurosurgeon to evaluate any spinal cord injury ○ Refer to orthopedic surgeon to evaluate unstable fracture TREATMENT OPTIONS • Initial cervical spine injury management should include ○ Spinal mobilization (Backboard, cervical collar, lateral head support) which should be removed at the hospital to avoid potential complications 5 ○ Follow the ABCDE (airway, breathing, circulation, disability, exposure) procedure detailed by Advanced Trauma Life Support of the American College of Surgeons • Treatment depends on the symptomatic and radiographic presentation • Treatment can range from emergency surgical decompression and/or fixation, to immobilization by halo or rigid collar, to physical therapy exercises and analgesia • For central cord syndrome 27 ○ Conservative treatment (cervical collar, physical therapy, steroids unless contraindicated) • For vertebral artery injury 23 ○ Anticoagulants such as heparin ○ Endovascular if anticoagulants are contraindicated • Drug therapy ○ Corticosteroids – Methylprednisolone 10 □ Controversial in spinal cord injury □ Significant higher rate of complications with Methylprednisolone administration4 □ Risk benefit analysis should be performed prior to use as side effects may outweigh clinical benefit 22 – Glycosaminoglycans □ Heparin, low molecular weight 10 □ Indication – recommended as prophylaxis for thromboembolism – NSAIDs □ Can be used in patients with low probability of neurologic injury following assessment □ Treats cervical strain/sprain □ Aspirin □ Ibuprofen – Opiates □ Morphine • Nondrug and supportive care ○ Physical therapy, nutritional support 10 ○ Procedures – Closed reduction by traction-reduction10 □ General explanation □ Reduces spinal deformity in awake patients □ Indication Cervical hyperextension injuries □ To prevent neurologic deterioration □ Contraindications □ External immobilization □ Treatment for fractures such as occipital condyle fractures of isolated fractures of the axis □ Surgical procedures such as internal fixation and fusion □ Indicated to treat fractures such as those involving the odontoid • Comorbidities ○ Spinal stenosis/spondylosis ○ Closed head injuries (mild traumatic brain injury, cerebral contusions, intracranial hemorrhage) ○ Facial fractures ○ Other spinal injury (thoracic or lumbar) non-contiguous spinal fractures as high as 20% ○ Soft-tissue trauma ○ Osteoporosis ○ Osteopenia ○ Malignancies (e.g., prostate, breast, colon) with bony metastases ○ On anticoagulation therapy (should be discontinued if significant soft-tissue or bony injury is found); secondary to risk of epidural bleed or need for surgical intervention ○ Acute disc herniation • Special populations ○ Young adults ○ Elderly COMPLICATIONS AND PROGNOSIS COMPLICATIONS • Nonunion/malunion of fractures • Persistent instability requiring a second procedure • Reactions and infection related to orthosis • Embolic ischemic events and pseudoaneurysm formation after vascular dissection • Persistent symptoms and pain/late whiplash syndrome • Cervical radiculopathy PROGNOSIS • Overall, the most important prognostic factor is the initial neurologic status 29 • Other prognostic factors include 29 ○ Stiffness of the neck ○ Muscle spasm ○ Preexisting degenerative spondylosis • A prognostic study reported that 29 ○ 56% of symptomatic patients were symptom-free when reassessed after 2 years after injury (Norris and watts) ○ 19% had restricted neck movements ○ 10% with neurological signs recovered • For fracture dislocation16 ○ Hangman fracture: 93–100% fusion rate after 8–14 weeks external immobilization ○ Odontoid fracture, fusion rate by type: Type I approximately 100% with external immobilization alone; Type III, 85% with external immobilization, 100% with surgical fixation • For central cord syndrome 17 ○ Spontaneous recovery of motor function in >50% of cases over several weeks ○ Younger patients (<50 years old) are more likely to regain function ○ Leg, bowel, and bladder functions return first; upper extremities follow, but recovery is often incomplete, especially manual dexterity ○ Poor prognosis in patients with advanced age, lower initial American spinal injury association motor score and development of spasticity 19 ○ Follow-up depends on the severity of injury; all patients with hyperextension injuries should receive follow-up care SCREENING AND PREVENTION SCREENING • At-risk populations Cervical hyperextension injuries ○ Elderly white male greater than 65 years of age 31 ○ Young adults PREVENTION • Wear seatbelts • Use proper safety equipment in sports activities • Fall prevention intervention program and exercise for the elderly 1 SYNOPSIS KEY POINTS • Cervical hyperextension injuries are a group of injuries involving the neck due to a rapid, forceful, backwards motion caused by trauma • This condition may involve the vertebral/paravertebral structures, spinal cord (central cord syndrome), vascular (vertebral artery or carotid artery dissection), and soft tissues around the cervical spine (cervical strain/sprain). • Clinical presentation includes neck pain or tenderness, limited range of motion, and with external signs of trauma. • CT is the diagnostic test of choice for cervical hyperextension injuries. • MRI is most sensitive for soft tissue injury associated with hyperextension injury. • Comorbidities may include spinal stenosis, osteopenia, and acute disc herniation. • Treatment can range from emergency surgical decompression and/or fixation, to immobilization by halo or rigid collar, to physical therapy exercises and analgesia. • Complications include nonunion/malunion of fractures, persistent symptoms and instability, and infections. • Prognosis is good in younger patients but poor in patients with advanced age. URGENT ACTION • Neurologic deterioration • Hemorrhage • Cardiopulmonary disturbances PITFALLS • Vertebral artery injury can easily be overlooked in the initial evaluation of patients with cervical spine trauma 31 • Assume a spine injury until it is ruled out 10 • Never attribute neurologic abnormalities solely to the presence of drugs or alcohol 10
warm) in the left upper and lower extremities; decreased strength and movement of the right upper and lower extremities and of the left abdominal muscles; lack of triceps and biceps reflexes in the right upper extremity; atypical response of patellar, Achilles (hyper) reflexes in the right lower extremity; abnormal cremasteric reflex in the right groin; fracture in cervical vertebrae #7; and significant swelling in the C7-T12 region of the spinal canal (Signs and symptoms, n.d.). The objective complaint of a severe headache could also be consistent with a spinal cord injury (Headache, nausea, and vomiting,
Valani, R., Mikrogianakis, A., & Goldman, R. (2004). Cardiac concussion (commotio cordis). Canadian Journal of Emergency Medicine, 2004(6), 428-430.
a) Urinalysis with significantly increased amounts of blood (via dipstick and sediment), protein, and leukocytes as well as slightly increased bilirubin and slightly decreased pH;
The current patient may be experiencing a range of traumatic injuries after his accident, the injuries that the paramedic will focus on are those that are most life threatening. These injuries include: a possible tension pneumothroax or a haemothorax, hypovolemic shock, a mild or stable pelvic fracture and tibia fibula fracture.
requiered to determine treatment. Lab tests or imaging is often requiered as well. It’s chronic,
The car accident could damage ones spinal cord if it was crushed or hit hard enough. If the spinal cord is severed, the peripheral nerves may detach from the spinal cord. Detachment may lead to pressure applied by other organs or bones. The wreck may cause broken bones that would compress the spi...
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning on urination, and decreased urine output for three days.
Trauma nursing is a rewarding career that is financially beneficial, allows you to work in high intensity situations, and is appropriate for people with a personality where they have the ability to remain calm in high stress situations. In trauma nursing a beginner is already making quite a bit of money while being able to do things such as saving people’s lives. It’s a job that involves working in situations where it depends on a person and their team to save a person and it’s important to be to stay calm and respond adequately to the situation. Trauma nursing is an eye-opening career that, if you can handle it, will really enjoy.
..., Ducker, T.B., ….. Young, W. (1997). International Standards for Neurological and Functional Classification of Spinal Cord Injury: International Medical Society of Paraplegia, 35, 266 – 274.
-“Find evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord and optic nerves AND
MEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II melitius , and...
This was his second episode since 10 days ago where he develop the same pain at his right flank. He suddenly experienced severe pain 8 hours before admission when the pain shifts to his right lower quadrant of his abdomen. The onset is at 6.30 am before worsening at 10 p.m to 2 p.m. He described the pain as continuous sharp pain and gradually increased in severity. There is no radiation of the pain. The pain was exaggerated on movement and touch. There were no relieving factor and he scale the severity as 7/10. He experienced fever for 1 day prior to admission. It was a mild grade continuous fever. He does not experienced chills and rigor. The patient does not experience any nausea or vomiting, no dysphagia, no pain during micturition and no alteration in bowel habit. He experienced loss of appetite but not notice any weight loss.
This is an overview of the spinal deformation called Scoliosis. What Scoliosis is as a whole, as well as a breif mention of other spinal deformations that are in a similar catagory as Scoliosis. The causes of scoliosis, and how it develops in people who suffer from the deformation. How Scoliosis is diagnosed and the symptoms it causes people to suffer in cases that are both mild and severe; are all topics that'll be covered.
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.