Cervical Spine Injuries
Cervical Spine Injuries
Cervical Spine Injuries
51
52 J.P. Adams et al.
Airway
Tracheal intubation may be required for a number Manual in Line Stabilization (MILS)
of reasons:
The goal of MILS is to apply sufficient force to
1. Patient is obtunded and not protecting the the head and neck to limit the movement that
airway might result during intubation and airway
2. Airway obstruction (blood, vomit, edema, ret- control. The assistant should ideally apply equal
ropharyngeal hematoma, etc.) and counter forces to those generated by the
3. High-cord injury associated with respiratory laryngoscopist, but without the application of
failure traction. Compared with other techniques of
4. To facilitate imaging and treatment of other C-spine immobilization (collar, tape, sandbags),
injuries MILS provides better intubating conditions. The
5. Severe maxillofacial injuries (where a subse- incidence of Grade 3 and 4 Cormack and Lehane
quent early tracheostomy may be appropriate) view is 22% with MILS and 64% when immobi-
lization is provided by collar, tape, and sandbags.
Suxamethonium should not be used beyond the first 48 h after injury Although MILS is superior to other immobilizing
because of the risk of hyperkalaemia. techniques, it still impacts on the view at direct
laryngoscopy. When applied to normal patients
MRI investigations have been useful in document- with normal spines, the view at laryngoscopy
ing both the occurrence and nature of secondary deteriorates by one grade in 36% of patients, and
SCI occurring after the initial primary injury. In the by two grades in 10%.
past, deteriorations have often been ascribed to
clinical interventions such as intubation, whereas it Our recommendation is to remove the anterior portion of the cervical
now seems that most cases of secondary injury are collar and have a skilled assistant perform MILS.
probably an inevitable consequence of the primary The use of a McCoy laryngoscope and gum elastic bougie will mini-
injury. Nevertheless, all airway maneuvers will mize the force and obviate the need to achieve a Grade 1 view.
6. Cervical Spine Injuries 53
Movement During Airway Interventions The level of injury influences the effect on ventilation:
Level of
All airway maneuvers will result in some degree
injury Effect on respiration Clinical consequence
of neck movement, although the amounts are
C1–C3 Complete paralysis of all Apnea and immediate death,
small and typically within physiologic ranges.
respiratory muscles. unless mechanical ventilation
is applied. Ventilator-
dependant unless a
Role of Awake Fiber Optic Intubation diaphragm stimulator is used.
The use of a technique by practitioners not skilled C3–C5 Varied impairment of Ventilation often necessary in
the diaphragmatic the acute stages. Vast
in its use carries risk. Failed awake intubations have
contraction force. majority will wean from
been implicated in morbidity and mortality claims mechanical ventilation
by the American Society of Anesthesiologists. depending upon functional
Nevertheless, AFOI does carry theoretical advan- descent of injury level,
tages that support its use in cervical-spine-injured recovery of function in
incomplete lesions, and
patients:
improvement in respiratory
· The head and neck may be left in a neutral posi- mechanics over time.
C6–C8 Diaphragm and accessory Expiration entirely passive.
tion and collars can be left on.
cervical inspiratory Secretion retention is a
· Little spinal movement is required to achieve muscles intact. problem. Respiratory failure
laryngeal visualization. Intercostals and rarely seen unless coexistent
· Protective reflexes are left intact. abdominal muscles chest/lung injury, preexisting
· A neurological examination can be performed paralyzed. lung disease, or the need for
surgery.
post-intubation.
· Patients can be positioned awake once intu-
bated, thereby avoiding potentially injurious
positions. Lung Volumes in SCI
That AFOI requires special equipment, cannot The level of injury has a great bearing on lung
be performed on uncooperative patients, is made volumes. The FVC, FEV1 and inspiratory capacity
significantly more difficult in the presence of increase with descending SCI down to T10. It is
airway secretions and blood, and is more time- estimated that the percentage of FVC increases by
consuming than direct laryngoscopy, limits its use 9% per vertebral level as the level of injury
in the A&E setting. descends. FEV1 and FVC are maximally reduced
Aspiration is a major concern, so all obtunded immediately post-injury (up to 33% of predicted)
patients should be rapidly intubated and venti- and improve initially quite rapidly up to 5 weeks
lated with MILS and cricoid pressure and a (45% predicted), with a more gradual improve-
nasogastric or orogastric tube inserted to empty ment at 5 months (60% predicted). The reduction
the stomach. in FRC occurs at the expense of expiratory reserve
volume (ERV), with a compensatory rise in residual
volume (RV). Loss of ERV means forced exhala-
Breathing
tion, and coughing is severely impaired.
Although mechanical ventilation may not be ini-
tially necessary, subsequent deterioration is not
uncommon. Factors that influence the need for
Diaphragm Function
ventilation include the level of the injury, aspiration Although the diaphragm may still contract in
pneumonia, worsening cord edema (i.e., functional patients with mid cervical cord injuries, its func-
ascent of the injury level) and neurogenic pulmo- tion is impaired by the loss of intercostal and
nary edema. Acute respiratory distress syndrome abdominal muscle function. Normally when the
(ARDS) may occur because of associated pulmo- diaphragm contracts, it increases the thorax
nary contusions, pneumonia, and systemic sepsis. volume by three mechanisms:
54 J.P. Adams et al.
1. As a pure piston contracting downward to increase · Close monitoring of respiratory muscle strength
intrathoracic volume. and ability to cough and clear secretions.
2. By flattening, it functions as a piston, but one · Intensive chest physiotherapy, including early use
governed by Laplace’s law. of BIPAP and cough assist devices (mechanical
3. By interacting through the zone of apposition insufflators–exsufflator devices which alternate
with the lower ribcage, the abdominal contents positive and negative airway pressures to generate
act as a fulcrum to expand the lower ribcage. a cough).
· Nurse in the supine position. Some of the physi-
Following cervical cord injury, intercostal muscle
ological changes caused by SCI can be lessened
function is lost, with consequent failure of AP
by maintaining patients in a supine position.
expansion of the ribcage. More importantly,
When supine, the weight of abdominal contents
without intercostals muscle contraction, as the dia-
pushes the diaphragm higher into the chest,
phragm contracts the chest wall is sucked in,
increasing apposition with the ribcage, reducing
reducing its efficiency and causing paradoxical
diaphragm radius of curvature and helping to
chest wall movement. Lost innervation to the lower
restore the fulcrum effect lost with higher
thoracic segments causes the diaphragm to start at
abdominal compliance. Supine values of FVC
a more caudal position. This increases the radius
and FEV1 are larger compared with values when
of curvature and, from Laplace, reduces trans-
seated, down to an injury level of T1. Binding the
diaphragmatic pressure on contraction. As the
abdomen when patients are sat upright helps
diaphragm descends, due to lost abdominal muscle
diaphragm function.
tone the abdominal contents are pushed out and
· Humidified oxygen and mucolytic therapy, for
cannot provide the fulcrum needed to expand the
example, nebulized N-acetylcysteine, oral car-
lower chest. The lower ribcage is pulled in whilst
bocisteine, and nebulized dornase alfa
the abdominal content are pushed out, resulting in
· Adequate hydration and nutrition
the “see-saw” pattern of respiration often seen.
· Prevention of pressure sores, by frequent turning,
With increased intra-abdominal compliance, the
and prophylaxis for venous thromboembolism
diaphragm is pulled down by the weight of the
(VTE).
abdominal content, especially when upright, dra-
matically reducing the zone of apposition.
Lung compliance is also reduced, mainly due to Ventilation and Weaning
a loss of gas containing alveoli secondary to
Where there is an associated lung injury for example,
atelectasis. Reduced lung volume compounds the
pulmonary contusions or an underlying lobar infec-
problem by reducing surfactant production.
tion then traditional lung protective ventilation
should be employed to prevent ventilator associated
Muscles of Expiration lung injury. Weaning from mechanical ventilation
can take weeks or months, and it is essential that
Loss of abdominal muscle activity results in a patients are prevented from becoming tired during
decrease in maximal expiratory force and a the weaning process. Normally, it should only be
reduced ability to cough, clear secretions, and embarked upon once active pulmonary pathology
protect the airway. Atelectasis increases the load has resolved (i.e. once FiO2 is less than 30%), and
placed on already compromised muscles of inspi- little progress is often made until flaccid intercostal
ration and V/Q mismatch occurs. Alveolar hypov- muscles develop some spasticity. Weaning strategies
entilation is inevitable and respiratory failure very include conventional SIMV weaning, pressure
common. support weaning and “T-piece” or “Sprint” weaning.
Tracheostomies are usually essential in weaning
patients, but thought should be given to facilitating
Principles of Respiratory Care speech – using fenestrated tubes, having periods
Spontaneously breathing patients with SCI require where cuffs are left down to allow air to pass upward
close observation and aggressive management through the vocal cords, or using a one- way speaking
including: valve (for example, a Passy-Muir valve).
6. Cervical Spine Injuries 55
The stimulus must be removed promptly (e.g., such as flexion–extension fluoroscopy should not
bladder catheterization or bowel evacuation) and be done without expert advice, and only when
occasionally the condition will warrant drug treat- other imaging has been negative (see Fig. 6.1).
ment with a rapidly acting vasodilator (e.g., sub-
lingual nifedipine or GTN).
Other Injuries
Patients with cervical spine trauma are likely to
Radiology have other injuries and a thorough assessment is
Traditionally, all patients with suspected cervical required. High spinal injuries may mask intra-
spine trauma will have the three standard plain abdominal injury, and further imaging or a diag-
X-rays consisting of lateral, anterior–posterior nostic peritoneal lavage should be performed if
and open-mouth odontoid peg views. In the intu- this is suspected.
bated patient the latter will be replaced by a sub-
mental projection. When stable, the patient will
also have thin CT cuts of the occipito–atlanto-axial
Types of Cervical Spine Fractures
region and the C7/T1 region. Modern radiological Injuries to the C1–2 complex are associated with
techniques allow for very rapid helical CT scans a lower incidence of serious neurological injury
of the cervical spine which, increasingly is removing than injuries lower down (C3–7), possibly as a
the need for the three plain views. result of increased space for the cord at the higher
level. Atlanto–occipital disruption, however, is
The combination of good-quality plain films and focused CT slices associated with a higher risk of immediate fatal-
excludes over 99% of significant cervical spine trauma in adults. ity due to disruption of brainstem function.
Those who survive will need stabilization by
If pathology is discovered, the patient will probably either nonsurgical or surgical techniques (see
require an MRI scan to plan further treatment Fig. 6.2).
and further imaging of the whole spine to look Cervical spine fractures are often described by
for additional damage. Other imaging modalities their mechanism of injury:
Figure 6.1. The diagnosis of acute injury can be difficult in the presence of the degenerative spine. Flexion-extension views demonstrate
stability. This X-ray shows what looks like an acute slip at C4/5 but the flexion-extension views demonstrate that this is old and stable.
6. Cervical Spine Injuries 57
Figure 6.3. (a) Flexion injury after diving in to a shallow pool. Lateral view shows a burst fracture of C6 (red arrow). (b) Unifacetal fractures
are potentially unstable and the management varies substantially. They are characterized by < 50% of vertebral body slip. (c) Bifacetal fracture
of C5/6 where > 50% of the vertebral body has slipped forward. This is a highly unstable fracture that requires urgent stabilization.
58 J.P. Adams et al.
Steroids are not universally used in the treatment of acute SCI, and
administration is dictated by local policy.
Following the NASCIS II (1990) and NASCIS III boards or transfer trolleys. Patients who develop
(1997) studies, high-dose methylprednisolone was pressure sores will require early referral to the
routinely used in acute SCI. However, in both tissue viability team and possible input from the
studies the drug only had an impact when given plastic surgeons.
early (<8 h after injury) and was associated with Occipital pressure sores are commonly seen,
an increase in infectious complications. Serious especially in patients with poorly fitting hard collars
concerns subsequently arose about the methodol- and scalp lacerations. Some spinal units advocate
ogy of both studies, and the current consensus in shaving off the hair in ventilated SCI patients.
the United Kingdom is that corticosteroids are not
recommended after traumatic SCI. Elsewhere they
continue to be used in selected patient groups and Temperature Regulation
their use is dictated by local policy.
Impaired temperature regulation and vasodilata-
tion leads to a drop in core temperature. Preven-
Thromboprophylaxis tion of heat loss and the usual rewarming methods
should be employed.
· Patients with SCI are at high risk for throm-
boembolic complications.
· All patients should be fitted with graded com- Surgical Management
pression stockings or intermittent pneumatic
calf-compression devices. Surgical intervention aims to realign the spine,
· Low molecular weight heparin (LMWH) should provide mechanical stability, decompress neural
be started within 72 h of injury, unless there is tissue, and prevent further SCI. The options are:
a specific contraindication. · Mechanical traction: halo jacket or cranial tongs
· Warfarin can replace LMWH once the acute · Operative intervention: reduction of the fracture
phase of injury is over, provided there are no and fixation
plans for additional surgery (aim for INR ~ 2.0).
· Where anticoagulation has failed or is contrain- In patients with cord compression but stable neu-
dicated, a vena cava filter should be considered. rology, there remains debate about the optimal
· Prophylaxis should continue at least until dis- timing of surgery. However, emergency surgery is
charge from rehabilitation. required in patients with rapidly deteriorating
neurology.
Patients who require surgical intervention are
at high risk of needing mechanical ventilation post-
Infection operatively. Preoperative optimization of the chest
(e.g., aggressive physiotherapy, prophylactic BIPAP,
Infective complications are common in patients and use of a cough assist device) is advised. Post-
with SCI, with sepsis being the leading cause of operatively, patients should be monitored in a
death in this patient group. Chest and urinary- High-Dependency environment and non-invasive
tract infections are the most common infections, ventilation used to maintain alveolar recruitment
although occult peritonitis should always be con- and hopefully avoid the need for invasive ventilation.
sidered as the usual characteristic signs and
symptoms may be absent.
Longer-Term Management
Pressure Sores Patients with cervical spine injuries may require
prolonged intensive care and early involvement
It is vital that all efforts are made to prevent pressure from the Regional Spinal Team is recommended.
sores. This includes pressure-relieving mattresses, Ideally the patient should be managed in a unit
regular turning, rotating beds, and ensuring the with dedicated physiotherapy input and a proto-
patient spends as little time as possible on spinal colized weaning program. Attention during acute
60 J.P. Adams et al.
treatment and rehabilitation must be directed to all acute spinal cord injury. Results of the third national
facets of care including prevention of complica- acute spinal cord injury randomized controlled
tions, pain management, nutrition, occupational trial. national acute spinal cord injury study. JAMA
therapy, and psychosocial needs. 277(20):1597–1604
Crosby ET (2006) Airway management in adults after cervi-
Acknowledgments Images kindly supplied by Dr.Dominic cal spine trauma. Anesthesiology 104:1293–1318
Denis F (1983) The three column spine and its signifi-
Barron and Mr. Jake Timothy, Leeds Teaching Hospitals.
cance in the classification of acute thoracolumbar
spine injuries. Spine 8:817–831
Further Reading Fraser M (2005) Management of acute spinal injury.
In: Galley H (ed) Critical Care Focus 11, Trauma.
Baxendale BR, Yeoman PM (1997) Spinal injury. In: Blackwell Publishing, UK, pp 36–51
Goldhill D, Withington PS (eds) Textbook of inten- Heath K, Erskine R (2000) The anaesthetic manage-
sive care. Chapman & Hall, London, pp 639–651 ment of spinal injuries and surgery to the cervical
Bracken MB, Shepard MJ, Collins WF et al (1990) A spine. In: Matta B, Menon D, Turner J (eds) Textbook
randomized, controlled trial of methylprednisolone of neuroanaesthesia and critical care. Greenwich
or naloxone in the treatment of acute spinal-cord Medical Media, London, pp 241–252
injury. Results of the second national acute spinal Stevens RD (2004) Spinal cord injury. In: Bhardwaj A,
cord injury study. N Engl J Med 322(20):1405–1411 Mirski M, Ulatowski J (eds) Handbook of neurocritical
Bracken MB, Shepard MJ, Holford TR et al (1997) Admin- care. Humana Press, New Jersey, pp 165–181
istration of methylprednisolone for 24 or 48 hours Timothy J, Towns G, Girns HS (2004) Cervical spine
or tirilazad mesylate for 48 hours in the treatment of injuries. Curr Orthop 18:1–16