Urgent considerations

See Differentials for more details

Cervical fracture or dislocation

This possibility should be considered with any dangerous mechanism of injury; for example:

  • Fall from height 90 cm (3 feet) or more, or 5 stairs

  • Axial loading of head (e.g., diving)

  • Motor vehicle collision at high speed (>100 km/h or >60 mph) or with rollover or ejection

  • Collision involving a motorised recreational vehicle

  • Bicycle collision.

In all of these circumstances, cervical spine immobilisation should be done. Additionally, cervical spine immobilisation should be performed for a distracting injury, such as a femur fracture, or if the patient is obtunded, either through traumatic brain injury or an intoxicating substance. Cervical spine computed tomography (CT) scan without contrast with sagittal and coronal reformat should be ordered.[34] The patient should be evaluated for any soft tissue, vascular, or neurological injury to the neck while the assessment for fracture is being completed.

Meningitis

Bacterial meningitis is a life-threatening disease that needs urgent assessment. Patients usually have fairly rapid onset of fever, headache, nuchal rigidity, and mental status changes. They may develop a petechial rash or palpable purpura on the lower extremities. Patients should undergo a lumbar puncture with assessment of opening pressure and spinal fluid. Antibiotics should be started as soon as possible. Early antibiotic therapy decreases morbidity and mortality in patients with acute bacterial meningitis.​[26][27][35]

There are certain cases in which a CT scan should be done prior to a lumbar puncture.[36] These are: immunocompromised state, history of central nervous system disease (mass, stroke, or focal infection), new-onset seizure, papilloedema, abnormal level of consciousness, and focal neurological deficit.

Epidural abscess

Patients with epidural abscess usually present with fever and spinal pain. Some patients may present without fever, especially immunocompromised or diabetic patients, or intravenous drug users. A magnetic resonance imaging (MRI) of the spine (without and with contrast) at the area of interest should be performed as the initial imaging study.[37]

For all patients, treatment includes empirical and subsequent culture-directed definitive antibiotic therapy. For patients with neurological deficit, decompressive surgery is essential. In these patients, the single most important predictor of the final neurological outcome is the patient's neurological status immediately before decompressive surgery. Prognosis is most closely related to the patient's neurological status at presentation.

Cervical radiculopathy

The treatment approach for patients with cervical radiculopathy starts with conservative therapy and may include consideration of epidural steroid injections, for which there is weak supporting evidence.[38][39]​ Surgery is typically recommended when all of the following are present:[40]

  • Signs and symptoms of cervical radiculopathy, and

  • Cervical radiculopathy with unremitting radicular pain despite 6 to 12 weeks of conservative treatments or progressive motor weakness, and

  • MRI that shows nerve root compression.

If patients undergo surgery, they should continue to use stretching and strengthening exercises postoperatively as directed in order to regain function.

Acute whiplash

Consider imaging studies where fracture/serious injury is suspected.[34][41][42]​ Otherwise, treat much like other forms of acute neck pain. The most important therapy to improve long-term outcome in patients with acute whiplash is early mobilisation and early return to normal activity.[43] Soft collars are not recommended.[44]

Analgesic treatment with or without muscle relaxants can be helpful to enable the patient to begin early mobilisation. Once the patients' pain is tolerable, they can begin stretching and strengthening exercises, which can be done with a therapist or at home.

Atlantoaxial subluxation associated with rheumatoid arthritis

Elderly patients and those with more severe rheumatoid arthritis are at higher risk for developing disease in the cervical spine. Osteochondral destruction of C1 and C2 may result, and lead to atlantoaxial subluxation and instability. The development of signs or symptoms of spinal cord compression is concerning and patients generally need surgery urgently. Without surgery the patient will likely develop progressive neurological deterioration and there is a risk of death.[45]

Cervical artery dissection

CT imaging, CT angiography, MRI, and magnetic resonance angiography (MRA) can identify cervical artery dissection. MRI/MRA better identify small intramural haematomas; however, CT is usually easier to access in the emergency setting.[29][46] Anticoagulation or antiplatelet treatment should be started after confirming the diagnosis, and should be continued for 3-6 months to reduce the risk of thrombosis at the dissection site.[29][47][48]​​​ Intravascular therapy is available in some centres. A combination of techniques is used, including thrombolysis, thrombectomy, stenting, and angioplasty.[29][49]​​

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