History and exam
Key diagnostic factors
common
concordant mechanism of injury
Recognizing local variation depending on the center, the most common mechanisms include motor vehicle accidents (MVAs), pedestrian trauma, violence, falls, and sports injuries.[4][51]
High-velocity injuries (e.g., MVAs) tend to be associated with more severe cervical spine injuries and a higher likelihood of spinal cord injury than low-velocity injuries (e.g., falls).[51]
neck pain
Neck pain is the most common symptom associated with cervical injuries. Specific characteristics of pain should be determined, including location (e.g., level, midline versus lateral), severity, quality (sharp or shooting into extremities versus dull and aching), and radiation to shoulders or elsewhere.
The presence of associated injuries causing pain may mask or distract from the severity of the patient's neck pain.
sacral sparing
Shown by preservation of perianal sensation (light touch and pinprick sensation at S4-S5 level) and voluntary rectal motor function. This indicates an incomplete spinal cord injury. Assessment may be inaccurate if spinal shock is present.
uncommon
associated traumatic injury
Approximately one third of cervical spine injuries are accompanied by an extraspinal fracture; around 20% have an associated abdominal/pelvic, thoracic or extremity injury, and about 16% have an associated head injury.[19][52] Thoracic trauma, including multiple rib fractures, sternal, scapular and clavicular fractures, increase the risk for associated cervical and thoracic spinal injuries.[53][54]
These can confound the accuracy of history and physical exam and are an indication for imaging studies.
posterior cervical tenderness
The physician should examine the neck and gently palpate the posterior midline of the neck, observing for any point tenderness or overt deformity.[14]
Cervical tenderness lateral to the midline is more suggestive of muscular or soft-tissue injury, which should not impact cervical spine stability.
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.
numbness, tingling, or weakness of extremities
These symptoms are highly suspicious for potential neurologic injury from spinal cord or nerve root compression or compromise.
motor weakness
Should be evaluated for all myotomes. Motor evaluation should be completed following the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) documentation tool.[14] ASIA: International standards for neurological classification of SCI (ISNCSCI) worksheet Opens in new window
Motor weakness confined to one myotome in a single limb is suggestive of a nerve root injury. Bilateral or larger segments of weakness are more suggestive of injury to the spinal cord itself.
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
Should be evaluated for all dermatomes. Sensory evaluation should be completed following the ISNCSCI documentation tool.[14] ASIA: International standards for neurological classification of SCI (ISNCSCI) worksheet Opens in new window
bowel or bladder dysfunction
priapism
Priapism, a state of sustained penile erection in males, occurs in some cases of traumatic SCI, but can also be seen in a wide variety of spinal cord compressive pathologies. This is commonly associated with complete motor and sensory (American Spinal Injury Association Impairment Scale grade A) injury and resolves without any specific treatment required.
uncommon
reduced or painful cervical range of motion (ROM)
Active ROM (whereby the patient alone attempts to move the neck) should only be attempted if there is a low suspicion of bony fracture, as per the low-risk criteria using the Canadian C-spine rule. If a fracture is suspected, imaging should be obtained prior to active ROM evaluation.
Evaluation should include forward flexion, extension, lateral flexion, rotation.
Reduced or painful active ROM could signify muscle/soft-tissue injury as well as possible dynamic cervical spine instability.
loss of anorectal tone and perianal sensation
Absence of rectal tone is observed only with evidence of a conus lesion or compression of the conus. Loss of perianal sensation defines a complete spinal cord transection.
stroke
Patients with stroke may have had an associated fall and a cervical spine injury may go undetected; bilateral signs and symptoms are an indicator of potential cervical spine injury in a patient with stroke.
cranial nerve deficit
Injury at the occipital-cervical junction may lead to lower brainstem or cranial nerve injury.
hyperreflexia
May be absent in acute spinal cord injury but is a typical sign of spinal cord injury or upper motor neuron injury.
Babinski sign
An upgoing plantar response indicates presence of an upper motor neuron lesion.
Hoffman 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.
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, hypovolemic) 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 to 3 days but it may persist for several weeks, which can confound the clinical exam until return of reflexes.[55]
A 4-phase model of spinal shock has been proposed: 0 to 1 days, areflexia/hyporeflexia due to loss of supraspinal excitation, increased spinal inhibition, and resultant motor neuron hyperpolarization; 1 to 3 days, return of reflexes due to neurotransmitter receptor upregulation and denervation supersensitivity; 1 to 4 weeks, hyperreflexia due to synapse growth, particularly short-axoned interneurons; 1 to 12 months, hyperreflexia due to long-axon synapse growth.[55] The return of bulbocavernosus reflex heralds the end of spinal shock.
respiratory change
May manifest as hypoventilation, tachypnea, or diaphragmatic breathing.
Usually associated with high cervical spinal cord injury compromising phrenic nerve or thoracic intercostal nerve function, or with neck soft-tissue injury compromising the airway.
Risk factors
strong
age 18 to 25 or >65 years old
Cervical spine injuries are encountered at all ages, but approximately 80% of injuries occur in patients ages 18 to 25 years. This age group is generally associated with higher-velocity injuries consequent to motor vehicle accidents, while older people may experience cervical spine injuries from relatively minor mechanisms of injury (e.g., falling from standing).
a dangerous mechanism of injury
A fall from a height >1 meter or 5 steps, or an axial load to the head (e.g., diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorized recreational vehicles, bicycle collision, and horse riding accident) are considered dangerous mechanisms of injury.[11]
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.[19] See Assessment of traumatic brain injury, acute.
intoxication
Around 30% of patients with spinal cord injury are intoxicated at the time of injury.[20] This should be ascertained at the time of the initial assessment because it may confound the accuracy of initial history and physical exam.
lack of preparation or awareness of collision
A more relaxed occupant is more likely to be injured in a collision.[21]
head rotated at time of collision
The greater the rotation, the greater the unilateral loading force on the cervical facet joints.[22]
previous cervical spine trauma or surgery
Prior whiplash injury predisposes a person to a poorer prognosis following a second injury.[23]
weak
pre-existing spinal, cranial, or other abnormality
Any biomechanical risk factor for injury is likely to lead to greater injury risk. Risk factors associated with increased risk of cervical spine fracture or cord injury after trauma include ankylosing spondylitis, degenerative cervical spine disease (cervical spondylosis), osteoporosis, osteopenia, and diffuse idiopathic skeletal hyperostosis.[14] Chiari malformation, os odontoideum (failed fusion at the base of the odontoid), and other conditions have been reportedly made symptomatic or aggravated by cervical spine trauma.[24] Thus the evidence for causation varies from relatively strong and irrefutable to anecdotal and hypothetical.
stroke
Patients with stroke may have had an associated fall and a cervical spine injury may go undetected; bilateral signs and symptoms are an indicator of potential cervical spine injury in a patient with stroke.
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