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2022, Number 3

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Ortho-tips 2022; 18 (3)

Assessment of trauma in the subaxial cervical spine by the first contact physician

Marroquín-Herrera, Omar1; Rosales-Camargo, Santiago2; Rodríguez-Múnera, Andrés3; Alvarado-Gómez, Fernando4

Language: English
References: 29
Page: 230-238
PDF size: 401.35 Kb.


ABSTRACT

Subaxial cervical spine traumatic injuries represent a problem with high medical, social, and economic impact for health systems which is increasing with changes in the increasingly urbanized lifestyle, therefore, the use of diagnostic tools in a protocolized way, correct clinical assessment, multidisciplinary management, and adequate treatment by the spine specialist doctor have a positive impact in the short and long term. Considering the challenge of always having a spine surgeon available, a narrative review of the literature in the databases Google Academic, PubMed, with MeSH terms: Cervical spine, Spinal Injuries, ligament injury, Vertebral artery injury, Subaxial cervical spine injury classification system, is performed as an aid for the first contact physicians, allowing them to optimize resources, materials and diagnostics, to positively impact on the reduction of complications due to failure to detect traumatic injuries of the subaxial cervical spine.



INTRODUCTION

Changes in lifestyles in society and current urbanization are predisposing factors for high-energy trauma that cause bone-ligament injuries of the C3-C7 subaxial spine, occurring in 2 to 3% of general trauma; injuries can range from ligament strains to fracture-luxations, resulting in serious spinal cord injury (SCI); subaxial cervical spine is particularly vulnerable to traumatic injury due to its considerable mobility and proximity to the rigid thoracic spine, this region accounts for approximately 65% of fractures and more than 75% of all spinal dislocations, with an annual incidence of 150,000 cases in North America, of which 11,000 have SCI to some degree.1,2

The sixth and seventh cervical vertebrae together account for 39% of all cervical spine fractures. The most common causes are car accidents (41%), falls (27%), violence (15%), sports (8%), and trauma from a heavy object falling on the head (3%). SCI is seen in 1.3% of all blunt trauma; eighty percent of patients with associated SCI are men and 40% are between 18 and 44 years old. The C5-C7 region contributes 60% of all disc-ligament injuries; talking about SCI, incomplete tetraplegia is found in 40% of patients, complete paraplegia is reported in 22%, incomplete paraplegia in 22% and complete tetraplegia in 16%. Totally, the mortality rate for cervical spine injuries is approximately 6%, therefore, the timely diagnosis of these injuries is vital in the short, medium, and long term with important medical and economic repercussions.3

  • 1. Radiographic anatomy assessment. The initial evaluation of every patient with subaxial spinal trauma requires knowledge of bone structures and their anatomical relationships, which can determinate the severity of the injury. Radiographic anatomy is essential in the emergency department for making decisions (Figure 1).4
  • 2. Classification. The need to have a consensus in diagnosis, treatment and prognosis leads to the application of multiple scales, which have been improved with imaging studies advances and knowledge of trauma mechanisms. The variety in management trends by geographic regions predisposes a problem, because there was no information about the diversity of trauma mechanisms, availability of diagnostic and economic resources for treatment, therefore, AO Spine Knowledge Forum Trauma (AOSpine) validated the application of the scales;5 several studies compare the AOSpine vs Allen Ferguson scales6,7 with a kappa greater than 0.75 interobserver and intraobserver, all of them in favor of the AOSpine classification, which has presented a constant improvement adding facet components and special modifiers, which guides us in treatment and prognosis in a standardized way (Figures 2, 3 and 4).8-11
  • 3. Associated injuries assessment. Subaxial cervical fractures can be accompanied by other injuries, such as traumatic brain injury (TBI) in 18 to 40% of cases, ligament, bone, joint, vascular and nerve, for this reason we emphasize adequate emergency assessment.12
  • The facet joints by themselves are considered a vital element in deciding criteria of severity; retrospective studies average normal values of inter facet space of less than 2 mm, as well as a maximum of translation in dynamic studies of 2 mm with 11 degrees of opening between a vertebral body and de adjacent body, in case of presenting higher values, there is the possibility of hidden disc-ligament injury.13,14 The presence of facet fractures generates the need to complement with diagnostic studies like computed axial tomography (CT), magnetic resonance (MRI) or diagnostic studies for the search of associated vascular injury, according to a survey directed at orthopedists and neurosurgeons, it was reported that, in case of F1 and F2 fractures, orthopedists are more likely to request MRI and in F3 and F4 fractures, neurosurgeons and young orthopedists, request vascular studies thinking about the relationship with vertebral artery injury.15
  • Vertebral artery injuries occur in 14.7 to 17% of cervical traumas in which 33-55% are fatal injuries, mainly at the C5-C6 level in flexion-distraction trauma secondary to this level is the center gravity of the adult head in relation to the spine. In the presence of facet luxation, vertebral foramen fracture, or type C cervical lesion detected by CT, T2 axial sequence MRI image should be taken to rule out the "half-moon" sign, suggestive of arterial injury, and, if it is positive, an angiotomography should be indicated to decide treatment (Figure 5).16-18
  • 4. Biomechanics. Subaxial spine injuries are related to the movement generated by the trauma vector, having multiple mechanisms that, mostly are presented in combination for each type of fracture or ligament injury (Figure 6).4,12
  • 5. Clinical assessment. Every patient with a history of subaxial trauma implies the possibility of presenting neurological damage, which manifests with involvement of the brachial plexus, for which the correct exploration of myotomes and dermatomes of each nerve root is essential (Table 1).



DISCUSSION

Having a complete anamnesis of the mechanism of trauma and adequate physical examination, the type of injury and its severity can be suspected, for this we need to complement our suspicion with imaging studies upon admission. Various studies protocolize and compare the use of simple radiography, CT, MRI and special studies.19

The initial radiographic management protocol, in most emergency departments, establishes that simple radiography in anteroposterior, lateral, right and left oblique positions provides low specificity and sensitivity to complex traumatic injuries, and also, dynamic radiographs entail the potential risk of neurological damage in undetected unstable injuries, therefore it is not recommended in patients with high-impact trauma.20

The positive and negative predictive value in simple radiography vs CT is compared, CT demonstrated superiority in the diagnosis of small and large bone lesions evaluated by several medical professionals in the emergency triage, therefore, it is suggested to indicate it routinely for high-impact cervical trauma, both pediatric and adult, bearing in mind that the initial emergency assessment is not performed by a spine surgeon in all trauma centers.21

Once the CT scan has been evaluated by the first contact physician and in case of a suspected fracture or indirect injury that suggests ligament involvement, complementary studies such as MRI should be indicated, up to 40% of these patients present injuries that require surgical treatment.22

Similarly, patients who do not show bone injury or indirect evidence of instability by CT scan, but who present severe neck pain without neurological deficit, MRI is suggested because it is related to hidden disc and ligament injuries in 3.5% of patients,23 paying special attention to the STIR sequences to visualize the anterior longitudinal and posterior longitudinal ligament, which may be the cause of the symptoms of pain secondary to its rupture.24

Requesting an MRI study in an asymptomatic patient, neurologically complete with normal X-rays and CT, is reported to double hospital costs and only 0.011% of these patients present evidence of ligament injury, which does not affect conservative treatment due to what is not recommended for routine use in the emergency department.25

Treatment in the first 24 hours of a subaxial injury can determinate an improvement up to two degrees in the American Spinal Cord Injury Association (ASIA) neurological assessment scale vs late management, leading to a greater socioeconomic impact.26,27 For this, we consider the following algorithm in the initial evaluation in the emergency department, from the use of a cervical collar, to the request for MRI and evaluation by a spine surgeon for definitive treatment (Figure 7).28,29



CONCLUSION

The initial evaluation of trauma patients must follow a strict protocol that ranges from prehospital care to a systematic evaluation in the emergency room; it is recommended in presence of high-impact trauma or alteration in the neurological examination, to perform a cervical CT scan and, according to the findings, to follow an imaging study protocol, such as MRI, focused on the punctual diagnostic suspicion, this reduces cost for health system and does not delay the correct care of disc-ligament, bone, neurological or vascular injuries that can be fatal.


REFERENCES

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  2. Vinícius Vital L, Chaves de Resende RL, Soares Leal J, de Melo Guimaraes R, Ribeiro Vaz de Faria A. Interobserver reproducibility assessment of the new AOSpine classification for subaxial cervical lesions. Coluna/Columna. 2021; 20 (1): 8-13.

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  5. Schroeder GD, Canseco JA, Patel PD, Divi SN, Karamian BA, Kandziora F, et al. Establishing the injury severity of subaxial cervical spine trauma: validating the hierarchical nature of the ao spine subaxial cervical spine injury classification system. Spine (Phila Pa 1976). 2021; 46 (10): 649-657.

  6. Aarabi B, Oner C, Vaccaro AR, Schroeder GD, Akhtar-Danesh N. Application of AOSpine subaxial cervical spine injury classification in simple and complex cases. J Orthop Trauma. 2017; 31 Suppl 4: S24-S32.

  7. Urrutia J, Zamora T, Campos M, Yurac R, Palma J, Mobarec S, et al. A comparative agreement evaluation of two subaxial cervical spine injury classification systems: the AOSpine and the Allen and Ferguson schemes. Eur Spine J. 2016; 25 (7): 2185-2192.

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  24. Janssen I, Sollmann N, Barz M, Baum T, Schaller K, Zimmer C, et al. Occult disco-ligamentous lesions of the subaxial c-spine-A comparison of preoperative imaging findings and intraoperative site inspection. Diagnostics (Basel). 2021; 11 (3): 447.

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AFFILIATIONS

1Spine Surgeon. ORCID: https://orcid.org/0000-0003-4159-0222. Hospital Universitario Fundación Santa Fe de Bogotá.

2Medical Research. ORCID: https://orcid.org/0000-0002-4591-0134. Hospital Universitario Fundación Santa Fe de Bogotá.

3Spine Surgeon. ORCID: https://orcid.org/0000-0002-1279-5264. Hospital Universitario Fundación Santa Fe de Bogotá.

4Chief of Spine Surgery. ORCID: https://orcid.org/0000-0002-8854-0356. Hospital Universitario Fundación Santa Fe de Bogotá.



Conflict of interests: The authors declare no conflict of interest.



CORRESPONDENCE

Omar Marroquín-Herrera. E-mail: dr.omarmhspine@gmail.com




Received: 18-10-2021. Accepted: 14-11-2021.

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