Injury to the Cervical Spine

The majority of spine injuries occur at the level of the cervical spine, the most mobile portion of the vertebral column. Motor vehicle accidents account for most of these injuries. Fractures and fracture-dislocations are the most common injury patterns, although subluxations and injuries without radiographic abnormalities (SCIWORA), although altogether uncommon, occur more frequently in younger patients [13]. About 60% of patients who have sustained cervical spine trauma have suffered an injury to another organ system which can exacerbate the effects of secondary injury to the spinal cord, such as hypoxia or hypotension.

It is estimated that 15% of patients with trauma to the spine sustain a neurological injury. With the cervical spine being the most commonly affected segment, it is estimated that 40-60% of all trauma to the cervical spine will result in some kind of neurological morbidity and/or mortality. As an example, studies have shown that the mortality, in the field, for patients with occiput-C3 lesions is approximately 25-40%. This is probably due to respiratory compromise secondary to high spinal cord injury.

After clinical and radiographic assessment has been completed, unstable or displaced injuries should be promptly treated with cervical traction by applying Gardner-Wells (GW) skull tongs. The ready availability of MRI-compatible tongs of different sizes in emergency departments and ICUs cannot be overemphasized.

Application of these tongs requires a local anesthetic and skin preparation. The pins are applied 1 cm cephalad to the pinna in line with the external auditory meatus, after careful cleansing of the skin in the area and infiltration of a local anesthetic. The pins are tightened until the spring-loaded pin protrudes 1 mm. This indicates a 30-lb compressive force against the skull. The pins are rechecked and, if necessary, re-tightened only once more, at 24 hours.

Closed reduction can then continue with the patient supine on a stretcher, with caudal traction on both upper extremities. This can be accomplished with a combination of straps and/or surgical tape attached to the shoulders. The use of intravenous analgesics, muscle relaxants and oxygen by nasal cannula is invaluable in accomplishing reduction in responsive patients. The use of portable monitors to assess heart rate, blood pressure and oxygen saturation is helpful when titrating sedatives and muscle relaxants to the desired effect. It is important to keep the patient comfortable but awake enough to co-operate with serial neurological evaluations.

The amount of weight applied at first is always small, to avoid overdistraction. Depending on the level of the injury and the amount of suspected ligamentous damage, to start with 5 lb per vertebral level above the injury is the standard in our institution. Five-pound increments are added until approximately two-thirds of the patient's body weight or about 100 lbs are reached. If these attempts are unsuccessful, open reduction can be indicated.

Cervical traction is associated with complications, such as pin dislodgement, site infections and skull penetration. Contraindications to this procedure include purely distractive injuries, skull fractures and unstable upper cervical spine injuries. In patients with distractive injuries, gentle compression after positioning of a halo ring or the placement of sandbags to secure the head and placing the patient in the Trendelenburg position might provide temporary relief.

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