• Advanced Trauma Life-Support Protocol with emphasis on^[1]:
  • Stabilization of C-Spine via triple immobilization (hard collar, sandbags, headblocks and tape).
• Clinical assessment alone is not sufficient to identify underlying C-spine pathology.
• You cannot clear a C-spine until have neurologically intact patient (if done) with normal imaging.
• Utilize Canadian C-Spine Rule (CCR) to guide imaging requirement in adults.
  • Critical History: Adult Patient^[2]
    • Age > 65 years old.
    • Dangerous mechanism
      • Fall ≥ 1 m or 5 stairs.
      • Axial load to head (i.e., diving).
      • Motor vehicle collision (> 100 km/h), rollover or ejection.
      • Motorized recreation vehicle use.
      • Bicycle collision.
    • Paresthesia in extremities.
• Vertebral Artery Dissection^[3]:
  • Blunt trauma to head / neck.
  • Penetrating injury.
  • Utilize Denver screening criteria (following patient stabilization).

Clinical Decision Rules (CDR) for C-Spine Imaging / C-Spine Fracture Clearance ^[4] [5]:

• National emergency X-radiography utilization study (NEXUS); Sensitivity 89.9%, Specificity 39.8%.
• Canadian C-spine rule (CCR); Sensitivity 98.7%, Specificity 16.7%.

C-Spine Fracture Incidence:

• 7% of C-spine injury incidence occurs in polytrauma patients^[5].
• 10% of spinal injuries are traumatic C-spine injuries^[6].
• 40% of C-spine injuries involve the atlas (C1) and axis (C2)^[6].

Location, common mechanism, and types of C-Spine fractures ^[7] [8]:

Figure 1. Sagittal representation of spinal vertebrae showing Denis spinal column classification. Denis three column concept in spinal fracture | Radiology Case | Radiopaedia.org

C-Spine Fracture Imaging Modality Comparison^[6]:

Overview ^{[1] [5] [6]}:

• Diagnosis and management require an interprofessional team including EMS, Nurses, Emergency Physicians, Radiologists and a Spine Surgeon (Orthopedic or Neuro).
• Patients presenting with a potential C-Spine fracture should be treated as having a C-Spine injury until proven otherwise.
• Clinical assessment alone is not sufficient to identify underlying C-spine pathology.
• Utilize Canadian C-Spine Rule (CCR) to guide imaging requirement in adults.

Figure 3. Example CT of Jefferson burst fracture. File:JeffersonBurstandT2OndontCTMark.png – Wikimedia Commons

Figure 4. Sagittal view CT showing dislocation and locking of the facet joints of the sixth and seventh cervical vertebra: (A) right facet cut, (B) midsagittal cut, and (C) left facet cut Preoperative sagittal computed tomography showing dislo | Open-i (nih.gov)

Figure 5. CT scan of C-spine showing non-displaced type II odontoid fracture. (A) sagittal view (B) coronal view Pre-operative computed tomography scan of the cervical | Open-i (nih.gov)

Figure 6. (A) Axial CT image of C2 classic hangman’s fracture (arrows) (B) sagittal CT demonstrating typical fracture line location (arrows) Classical hangman’s fracture in a 74-year-old male who | Open-i (nih.gov).

Figure 7. Example flexion teardrop fracture. Sagittal CT image showing fracture of anteroinferior corner of C5 (black arrow) and horizontally directed fracture through posterior elements (white arrow). Original image cropped for content Flexion teardrop fracture. (a) Sagittal MDCT image demo | Open-i (nih.gov).

All C-Spine fractures are complex and considered unstable, management in an emergency department setting includes^[1] [7]:

• Application of triple immobilization.
• Obtain appropriate imaging.
• Consultation with spine surgeon.

All patients with C-Spine fracture to be admitted by spinal surgery service.

Current facility does not have the capability or capacity to manage a cervical spine fracture.

See Diagnostic Process and Recommended Treatment.

• Patient does not have a C-spine fracture and all other injuries have been treated, patient in stable condition with proper social supports in-place.
• Discharge by admitting surgical service.

1. Canadian C-Spine Rule (mdcalc.com)

   NEXUS Criteria for C-Spine Imaging (mdcalc.com)

   PHSA STAN CPG: Clinical Practice Guideline for the management of SUSPECTED OR CONFIRMED SPINAL INJURY in adults (16 years and older)

   
   

1. M. W. Beeharry, K. Moqeem and M. Rohilla, “Management of Cervical Spine Fractures: A Literature Review,” Cureus, pp. 1 – 5, April 2021 2021.

   
   

2. I. Stiell, G. Wells, K. Vandemheen, C. Clement, H. Lesiuk, V. De Maio, A. Laupacis, M. Schull, R. Mcknight, R. Verbeek, R. Brison, D. Cass, J. Dreyer and M. Eisenhauer, “The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients,” JAMA, vol. 286, pp. 1841 – 1848, 2001.

   
   

3. L. Simon, A. Nassar and M. Mohseni, Vertebral Artery Injury, Treasure Island, Florida: StatPearls [Internet], 2023.

   
   

4. M. Vazitizadeh-mahabadi and M. Yarahmadi, “Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis,” Archives of Academic Emergency Medicine, vol. 11, no. 1, p. e5, 2023.

   
   

5. B. Garg and K. Ahuja, “C-Spine clearance in poly-trauma patients: A narrative review.,” Journal of Clinical Orthopaedics and Trauma, pp. 66-71, 2021

   
   

6. N. Rutsch, P. Amrein, A. K. Exadaktylos, L. M. Benneker, F. Schmaranzer, M. Muller, C. E. Albers and S. F. Bigdon, “Cervical spine trauma – Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX,” Injury, vol. 54, pp. 1 – 8, May 2023

   
   

7. J. H. McMordie, V. K. Viswanathan and C. C. Gillis, Cervical Spine Fractures Overview, Treasure Island, Florida: StatPearls [Internet], 2023.

   
   

8. “Unstable Spine Fractures,” WikEM, 23 August 2017. [Online]. Available: https://wikem.org/wiki/Unstable_spine_fractures. [Accessed 13 04 2024].