Acute cervical spine trauma in adults

Use the Advanced Trauma Life Support protocol to assess and stabilise any patient with suspected trauma. Start with a rapid primary survey using a <C>ABCDE approach:[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41 [24]Committee on Trauma, American College of Surgeons. ATLS: Advanced trauma life support program for doctors. 10th ed. Chicago, IL: American College of Surgeons; 2018.

• Catastrophic haemorrhage

• Airway with in-line spinal immobilisation

• Breathing

• Circulation

• Disability (neurological)

• Exposure and environment.

Protect the patient's cervical spine with manual in-line spinal immobilisation (particularly during any airway intervention) at all stages of the assessment for spinal injury (see Diagnosis recommendations section) or if the assessment cannot be done.[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41 If you suspect a head injury, see our topic Assessment of traumatic brain injury.

Additional treatment recommended for SOME patients in selected patient group

Carry out and maintain (until the spine is cleared) full in-line spinal immobilisation if the patient has:[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41

• A high-risk factor for cervical spine injury by the Canadian C-spine rule

• A low-risk factor for cervical spine injury by the Canadian C-spine rule AND the patient is unable to actively rotate their neck 45 degrees to both left and right

Do not carry out or maintain full in-line spinal immobilisation if the patient:[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41

• Has low-risk factors for cervical spine injury by the Canadian C-spine rule AND

• Is pain free AND

• Is able to actively rotate their neck 45 degrees to both left and right.

[Figure caption and citation for the preceding image starts]: Canadian C-spine rule. A&E, accident and emergency department; GCS, Glasgow Coma Scale; MVC, Motor vehicle collision. ✝Adapted from Stiell IG, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 17;286(15):1841-8. [Citation ends].

The UK’s National Institute for Health and Care Excellence recommends CT scanning first line in adults who are identified by the Canadian C-spine rule as requiring imaging.[14]National Institute for Health and Care Excellence. Head injury: assessment and early management. May 2023 [internet publication]. https://www.nice.org.uk/guidance/ng232

When immobilising the spine, manually stabilise the head with the spine in-line using the following stepwise approach.[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41

• Fit an appropriately sized, semi-rigid collar unless contraindicated by:

  • A compromised airway

  • Known spinal deformities, such as ankylosing spondylitis (in these patients keep the spine in the patient's current position)

• Reassess the airway after applying the collar

• Secure the patient with head blocks and tape.

For patients with suspected thoracic or lumbosacral spine injury see our topic Thoracolumbar spine trauma.

Treatment recommended for ALL patients in selected patient group

Offer medications to control pain in the acute phase in patients with a suspected spinal injury:[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41

• Use intravenous morphine as the first-line analgesic, adjusting the dose as needed to maintain adequate pain relief

• If intravenous access has not been established, consider diamorphine or ketamine via the intranasal route (follow local protocols)

• Consider intravenous ketamine, given in analgesic doses, as a second-line option.

Seek urgent advice from a neurosurgeon or spinal surgeon for any patient with a cervical spine injury confirmed on imaging.[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41 ​​[27]British Orthopaedic Association Standards for Trauma (BOAST). Cervical spine clearance in the trauma patient. May 2021 [internet publication]. https://www.boa.ac.uk/resource/boast-cervical-spine-clearance-in-the-trauma-patient.html

Treatment recommended for ALL patients in selected patient group

Offer medications to control pain in the acute stage:[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41

• Use intravenous morphine as the first-line analgesic, adjusting the dose as needed to maintain adequate pain relief

• If intravenous access has not been established, consider diamorphine or ketamine via the intranasal route (follow local protocols)

• Consider intravenous ketamine, given in analgesic doses, as a second-line option.

Offer oral analgesics to patients with a simple neck sprain injury (i.e., injury to the neck where there has been no demonstrable bony injury or unstable ligamentous injury) or whiplash.

• Start with paracetamol. If pain relief is inadequate, replace paracetamol with a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen.

• Give a weak opioid (e.g., codeine, tramadol) to patients who cannot take an NSAID.

  • The UK Medicines and Healthcare products Regulatory Agency (MHRA) advises that opioids should be used with caution as there is an increased risk of tolerance, dependence, and addiction, especially with prolonged use (longer than 3 months). The dose should be tapered slowly at the end of treatment to minimise the risk of withdrawal reactions.[35]Medicines and Healthcare products Regulatory Agency. Opioids: risk of dependence and addiction. September 2020 [internet publication]. https://www.gov.uk/drug-safety-update/opioids-risk-of-dependence-and-addiction

Treatment recommended for ALL patients in selected patient group

Discharge patients who have either no indications for a CT scan (as identified by the Canadian C-spine rule) or a normal CT scan, if they are able to rotate their neck 45 degrees to both left and right and do not have severe neck pain (≥7/10 severity).​[13]National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. Feb 2016 [internet publication]. https://www.nice.org.uk/guidance/ng41

• Advise patients to immediately return to the accident and emergency department if they develop any new neurological symptoms or signs.[33]Royal College of Emergency Medicine. Exclusion of significant cervical spine injury in alert, adult patients with potential blunt neck trauma in the emergency department. November 2010 [internet publication]. https://www.rcem.ac.uk/docs/College%20Guidelines/5z18.%20Practical%20guide%20-%20a%20short%20summary%20of%20the%20above%20c-spine%20guideline.pdf