History and exam
Key diagnostic factors
common
concordant mechanism of injury
The most common mechanisms of injury include motor vehicle accidents, pedestrian trauma, violence, falls, and sports injuries.
Ask patients:
What happened when their injury occurred?
If they fell, how far did they fall?
Were they involved in a high speed accident?
If the patient was in a road traffic accident, was their vehicle overturned? How were they evacuated from the vehicle?
Were they ejected from the vehicle?
neck pain
The most common symptom associated with cervical injuries.
Determine location (e.g., level, midline vs. lateral), severity, quality (sharp or shooting into extremities vs. dull and aching), and whether there is radiation to shoulders, down the spine, or into the limbs.
Some patients will not be able to specify whether they have neck pain because of distracting injuries. Presume the spine is unstable until you have cleared the cervical spine with a CT scan.
In practice, the cervical spine is kept immobilised with a collar if the patient has midline cervical tenderness anytime during the physical examination.
risk factors
Risk factors for cervical spine injury include:
Age 18-40 or >65 years
Cervical spine injuries are encountered at all ages, but approximately 80% of injuries occur in patients aged 18-40. This age group is generally associated with higher velocity injuries consequent to motor vehicle accidents, while older people experience cervical spine injuries from relatively minor mechanisms of injury (e.g., falling from standing).
Dangerous mechanism of injury
A fall from a height >1 metre or 5 steps
An axial load to the head (e.g., diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accident).
Distracting traumatic injuries
Injuries such as limb fractures or chest and abdominal injuries can make the assessment of cervical spine difficult.
Approximately one third of patients with cervical spine and/or spinal cord injuries have an associated head injury.[17] See our topic Assessment of traumatic brain injury, acute.
Other diagnostic factors
common
reduced level of consciousness
Consider any patient with a reduced level of consciousness to be at risk of acute cervical spine injury until you complete the assessment.
paraesthesia in the limbs
Suggests potential neurological injury from spinal cord or nerve root compression or compromise.
motor weakness
Evaluate motor function using an ASIA (American Spinal Injury Association) chart as soon as possible if you suspect a spinal cord injury.[13] ASIA: International Standards for Neurological Classification of SCI (ISNCSCI) worksheet Opens in new window
A spinal cord injury may produce a classic pyramidal distribution of weakness, with flexors stronger than extensors in the upper extremities and extensors stronger than flexors in the lower extremities.
sensory loss
May be a sign of spinal injury.
Evaluate sensory function using an ASIA (American Spinal Injury Association) chart as soon as possible.[13] ASIA: International Standards for Neurological Classification of SCI (ISNCSCI) worksheet Opens in new window
bowel or bladder dysfunction
Urinary retention or urinary/faecal incontinence may suggest a spinal cord injury.[29]
Perform a rectal examination to assess for bulbocavernosus reflex (spinal shock) in catheterised patients.
uncommon
cranial nerve deficit
Injury at the occipital-cervical junction may lead to lower brainstem or cranial nerve injury.
Hoffman's sign
Adduction of the thumb when flicking the nail of an extended finger on the same hand indicates the presence of an upper motor neuron lesion.
Babinski's sign
An upgoing plantar response indicates presence of an upper motor neuron lesion.
neurogenic shock
Characteristic syndrome of hypotension and bradycardia seen following spinal cord injury at the level of T6 or higher. Neurogenic shock is caused by disruption of the sympathetic nervous system with preserved parasympathetic activity. This should be differentiated from other causes of shock (cardiogenic, hypovolaemic) which may also be present in the acute phase of injury.
spinal shock
Characteristic syndrome of areflexic paralysis following spinal cord injury. Spinal shock typically lasts 1-3 days but it may persist for several weeks, which can confound the clinical examination until return of reflexes.[31]
One 4-phase model of spinal shock has been proposed: 0-1 days, areflexia/hyporeflexia due to loss of supraspinal excitation, increased spinal inhibition, and resultant motor neuron hyperpolarisation; 1-3 days, return of reflexes due to neurotransmitter receptor upregulation and denervation supersensitivity; 1-4 weeks, hyper-reflexia due to synapse growth, particularly short-axoned interneurons; 1-12 months, hyper-reflexia due to long-axon synapse growth.[31] The return of bulbocavernosus reflex heralds the end of spinal shock.
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