Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected c-spine injury: at initial presentation

1st line – spinal motion restriction (SMR) and urgent assessment

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INITIAL
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suspected c-spine injury: at initial presentation
1st line – 

spinal motion restriction (SMR) and urgent assessment

All trauma patients should be evaluated based on the principles of Advanced Trauma Life Support®, independent of whether a spinal cord fracture or spinal cord injury (SCI) is suspected or confirmed.[14] The primary survey should focus on hemorrhage control, airway, breathing, circulation, disability, and exposure; the <C>ABCDE approach.[26]

If there is evidence of any of the following in a patient, after an incident thought to be compatible with a possible cervical spine injury, the clinician should apply SMR including a rigid cervical collar.[14][25]  Acutely altered level of consciousness (Glasgow Coma Scale [GCS] <15, evidence of intoxication); focal neurological signs and/or symptoms, anatomic deformity of the spine; distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc) or any similar injury that impairs the patient's ability to contribute to a reliable examination).

When SMR is indicated in adults, it should be applied to the entire spine due to the risk of noncontiguous injuries. The head, neck, and torso should be kept in alignment by placing the patient on a long backboard, a scoop stretcher, a vacuum mattress, or an ambulance cot.[14][25]

Urgent cervical spine imaging is warranted in the following situations: altered mental status (GCS<15), neurological deficit, high-risk injury mechanism, neck tenderness; decreased range of motion of the cervical spine.[14]

Following initial assessment, the patient's management will be determined by the findings on examination and imaging, and the injury will be managed either as for uncomplicated neck injuries, with a low probability of neurological injury, or as for injuries requiring urgent neurosurgical and/or orthopedic intervention.

ACUTE

low probability of neurological injury: following initial assessment

1st line – nonsteroidal anti-inflammatory drug (NSAID) and follow-up

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ACUTE
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low probability of neurological injury: following initial assessment
1st line – 

nonsteroidal anti-inflammatory drug (NSAID) and follow-up

Injuries to the cervical spine with a low probability of neurological sequelae are most often associated with minimal- to moderate-severity vehicle crashes and do not involve neurological signs or symptoms. They are generally injuries without fracture, dislocation, disk herniation, or other bony or soft-tissue injuries. These injuries most often resolve spontaneously or with minimal conservative therapy, typically within 3 months.

Restoration of normal motion to the spine is of great importance, and to this end cervical collars are largely counterproductive and typically contraindicated, as is bed rest.

Referral for physical therapy should be considered, and should be done 3 times a week for 4 weeks. Physical modalities include home range-of-motion exercises to tolerance (should not cause pain). The patient should be reevaluated within 4 weeks.

NSAIDs can be prescribed.[14]​ There are no studies that support the use of muscle relaxants in the acute phase.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 3200 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

Consider – short-term opioid analgesia

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ACUTE
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low probability of neurological injury: following initial assessment
Consider – 

short-term opioid analgesia

Treatment recommended for SOME patients in selected patient group

May be helpful for patients with moderate- to high-intensity pain, although imaging studies, including flexion/extension x-ray views, should be performed to rule out ligament injury or fracture prior to starting any treatment in these patients.

Moderate pain can be treated with tramadol, and severe pain with hydrocodone or oxycodone plus acetaminophen.

Treatment course: 1-2 weeks only. If pain persists, referral to a pain specialist should be considered.

Primary options

tramadol: 50 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

Secondary options

hydrocodone/acetaminophen: 5-10 mg orally every 4-6 hours when required

More

OR

oxycodone/acetaminophen: 5-10 mg orally (immediate-release) every 4-6 hours when required

More

Plus – physical therapy

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ACUTE
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low probability of neurological injury: following initial assessment
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with persistent musculoskeletal symptoms
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

Patients with musculoskeletal symptoms (including lower back pain, upper-extremity joint pain, and temporomandibular joint pain, each of which are associated with a traffic crash mechanism of rear-impact collision with whole-body accelerations) that persist beyond the first 4 to 6 weeks after a mild-to-moderate injury should be encouraged to undertake a physical therapy program. One study has suggested that the efficacy of intense physical therapy is similar to simply receiving advice from a physical therapist in a single session.[70] Patients should consult with their physicians about the details of any program to ensure it is appropriate.

Consider – specialist referral

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ACUTE
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low probability of neurological injury: following initial assessment
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with persistent headache
Consider – 

specialist referral

Treatment recommended for SOME patients in selected patient group

Persistent headache can be associated with a closed head injury, irritation of the greater occipital nerve, cervical facet injury (C2-4 most typically), or cervical muscle tension.

If headache persists beyond the initial 4 to 6 weeks of injury, referral to a headache neurologist should be considered.

Plus – conservative measures and/or surgery

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ACUTE
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low probability of neurological injury: following initial assessment
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older adults (>65 years old)
Plus – 

conservative measures and/or surgery

Treatment recommended for ALL patients in selected patient group

Unique challenges exist in managing spine trauma in older adults. Central cord syndrome (CCS) is the most common subtype of incomplete traumatic SCI defined by cruciate weakness (upper extremities worse than lower extremities) and a variable pattern of sensory loss and bowel/bladder dysfunction.

Depending on the existing comorbidities, for less severe deficits (ASIA grade D), an initial conservative approach with close clinical follow-up is appropriate, while reserving the option to surgically decompress depending on the extent and temporality of recovery.

Odontoid fractures are often caused by low-energy falls. Type I (tip of the dens) fractures are rare and typically treated with a collar after ruling out associated transverse atlantal ligament (TAL) injuries or atlantooccipital dislocation. Type III fractures may be treated with either a halo vest (TAL intact, not significantly displaced and stable in a halo) or surgery (anterior odontoid screw or posterior fusion). Type II fractures are the most common type and are treated similarly to type III fractures with a halo or surgery; however, halo vests are associated with substantial morbidity and mortality in older adult patients.

Upfront surgical intervention is now considered a reasonable approach in older adults who would otherwise be treated in a halo. If the surgical risk is too high, a rigid collar and close clinical and radiographic follow-up may be a reasonable approach to achieve a fibrous nonunion across the fracture site while sparing the morbidity of a halo.

high probability of neurological injury: following initial assessment

1st line – spinal motion restriction + emergency neurosurgical referral

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ACUTE
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high probability of neurological injury: following initial assessment
1st line – 

spinal motion restriction + emergency neurosurgical referral

Potentially urgent cervical injuries include fracture, dislocation, disk herniation, and other bony and soft-tissue injuries that are associated with a high probability of neurological injury. They are more likely to be associated with a history of a higher-energy injury mechanism, often including a head or face strike. These patients may present similarly to those with uncomplicated neck injuries, but will typically have a neurological deficit. If there is evidence of any of the following in a patient, after an incident thought to be compatible with a possible cervical spine injury, the clinician should apply SMR including a rigid cervical collar.[14][25] Acutely altered level of consciousness (Glasgow Coma Scale [GCS] <15, evidence of intoxication); focal neurological signs and/or symptoms, anatomic deformity of the spine; distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc) or any similar injury that impairs the patient's ability to contribute to a reliable examination).

When SMR is indicated in adults, it should be applied to the entire spine due to the risk of noncontiguous injuries. The head, neck, and torso should be kept in alignment by placing the patient on a long backboard, a scoop stretcher, a vacuum mattress, or an ambulance cot.[14][25]

Patients who have sustained an injury requiring surgical treatment and who are also taking anticoagulant medications may require reversal of their anticoagulant status. An urgent discussion should be held between the treating physician and the surgeon to decide on a management plan.

Ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis are associated with unique fracture patterns and management paradigms after spinal trauma. Hyperextension-distraction fractures resulting from minor trauma can produce severe spinal cord injuries requiring urgent decompression and long-segment instrumented fusions. Key to early management is application of spinal motion restriction to prevent further injury, followed by urgent surgical consultation.

Patients with fractures and central cord syndrome (CCS) should be definitively treated through internal and/or external immobilization in consultation with a surgical service. AOSpine 2017 guidelines concluded that early decompression (≤24 hours after injury) for adult patients presenting with SCI irrespective of level should be offered, although the quality of evidence for the recommendation was low.[64] In one meta-analysis, patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury, as measured by an improvement in total motor scores, light touch scores, and pinprick scores. Patients who had early decompression also had better ASIA Impairment Scale (AIS) grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery.[65]

Consider – intravenous methylprednisolone

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ACUTE
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high probability of neurological injury: following initial assessment
Consider – 

intravenous methylprednisolone

Treatment recommended for SOME patients in selected patient group

If there is a rapid onset of paresis and a potential delay in specialist consultation, treatment with intravenous methylprednisolone should be considered. High-dose methylprednisolone has been shown to be the only efficacious pharmacologic option when administered within 8 hours of injury in the context of acute SCI.[61][62]​​​​​​ Although studies have identified a subgroup of patients who demonstrated better motor scores after receiving methylprednisolone within 8 hours of injury compared with placebo, side effects included infection, gastrointestinal bleeding, hyperglycemia and death.[61]​​ The American College of Surgeons state that the use of methylprednisolone within 8 hours following SCI cannot be definitively recommended.[14]

Where is it used, there is variability in the decision to administer methylprednisolone and which specific protocol to use.[14][63] In the context of the controversial role of corticosteroids in SCI, the use of methylprednisolone should be considered on an individual basis. It remains an option for patients presenting within 8 hours of nonpenetrating SCI in the young, nondiabetic, and immunocompetent patient population. If there is a penetrating SCI, then methylprednisolone should not be administered.[14] The infusion of methylprednisolone should not exceed the 24-hour period given the increased risk of adverse events such as pneumonia and sepsis.[62] Specialist consultation should be sought before commencing treatment with methylprednisolone.​

Primary options

methylprednisolone sodium succinate: 30 mg/kg intravenously as a loading dose, followed by 5.4 mg/kg/hour intravenous infusion for 23 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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