Cervical Spine Injuries

What is injury of the cervical spine & spinal cord?

This is a severe injury to the neck region in which vertebrae, intervertebral discs, ligaments, and the spinal cord are damaged simultaneously, often with fracture–dislocation.

Depending on the level and severity of injury, this may result in:

• Quadriparesis / quadriplegia (weakness or paralysis of all four limbs).
• Sensory disturbances (numbness, loss of sensation, electric-shock sensations).
• Bladder and bowel dysfunction.
• In high cervical injuries, respiratory compromise requiring ventilatory support.

These injuries constitute extreme medical emergencies and require immediate transfer to a center with expertise in spinal trauma.

How common is it & what are the most frequent causes?

Although the overall incidence is lower than that of other traumatic injuries, cervical spinal cord injury has enormous clinical and societal impact due to the severity of resulting disability.

Most common causes:

• Motor vehicle accidents (frontal/rear collisions, rollovers, motorcycles).
• Falls (particularly in the elderly or from height).
• Violent trauma (assaults, penetrating injuries, high-energy sports).
• Diving into shallow water with violent flexion/extension of the neck.

Many patients sustain multiple injuries (head, chest, abdomen) and require comprehensive polytrauma management.

Why is the neck so vulnerable? (anatomy & mechanisms of injury)

The cervical spine has a wide range of motion but is also highly vulnerable, as it houses the spinal cord and the nerve roots that innervate the limbs and diaphragm.

Physiologically, the cervical spine allows:

• significant flexion–extension,
• rotation left–right,
• lateral bending.

In high-energy trauma, such as a road traffic accident, this may result in:

• Extreme flexion with anterior subluxation/dislocation of vertebrae.
• Disruption of ligaments and discs (posterior ligament complex, anterior longitudinal ligament, annulus fibrosus), leading to instability.
• Compression fractures or translational displacement of one vertebra over another.

When spinal alignment is lost, the spinal cord is compressed, stretched, or its fibers disrupted, resulting in neurological deficit.

How does it present – which symptoms should concern you?

Any significant head or neck trauma accompanied by neck pain and neurological symptoms is considered spinal cord injury until proven otherwise.

Symptoms/signs that require immediate medical attention:

• Severe neck pain following trauma.
• Weakness or paralysis in the arms and/or legs.
• Numbness, burning, or “electric” sensations in the limbs.
• Loss of bladder or bowel control.
• Breathing difficulty, slow respiration, or the need to support the head with the hands.
• Altered consciousness when associated with traumatic brain injury.

In such cases, manipulation of the neck by non-professionals is contraindicated. The patient must be transported with a cervical collar and spinal board until diagnostic confirmation.

What are the first steps in the emergency phase (EMS, ED, ATLS)?

Initial management follows structured protocols (ATLS) with the primary aim to preserve life and protect the spinal cord from secondary injury.

Key steps:

• Airway, Breathing, Circulation (ABC) – securing the airway, adequate ventilation, and hemodynamic stability.
• Immediate cervical immobilization.
• Neurological assessment using the ASIA scale (American Spinal Injury Association) – documenting motor function, sensation, and injury level.
• Rapid access to an emergency department with CT capability and neurosurgical coverage.

In severe injuries, the patient is initially managed in an ICU or high-dependency unit for close monitoring of vital signs, respiration, and neurological status.

Which investigations are required? (CT, MRI, ASIA, SLIC)

Imaging studies are essential to define the exact pattern of fracture/dislocation, spinal instability, and degree of spinal cord compression.

• Computed tomography (CT) – the primary modality for assessing bony structures, fractures, and spinal alignment.
• Magnetic resonance imaging (MRI) – visualizes the spinal cord, discs, ligaments, and possible hematomas. Particularly valuable in occult injuries and detailed preoperative planning.
• Neurological classification (ASIA) – defines injury severity (complete vs incomplete), informs prognosis and rehabilitation.
• Classification systems such as SLIC (Subaxial Injury Classification) – assist specialists in determining the need for surgical stabilization.

In high cervical injuries, angiography or CT angiography may be indicated to assess the vertebral artery, particularly when vascular injury is suspected.

What are the treatment options in summary?

Management is individualized and depends on spinal stability, neurological impairment, age, and overall patient condition.

General objectives:

• Prevention of secondary spinal cord injury (e.g., avoidance of hypotension).
• Reduction & realignment of the spinal column.
• Stabilization (conservative or surgical) to allow sitting and mobilization.
• Prevention and management of complications (thrombosis, infection, pressure ulcers).
• Early initiation of rehabilitation (physiotherapy, occupational therapy).

A combination of methods is often required: closed reduction with traction, surgical stabilization, external orthoses (e.g., halo vest), ICU care, and rehabilitation.

What is closed reduction with cranio-cervical traction?

Closed reduction is a technique in which, without open surgery, we attempt to realign the spine by applying carefully controlled traction through a cranial device.

Basic principles:

• A halo ring or Gardner–Wells tongs are applied and progressive weight is added via a pulley system.
• The patient should be awake to report any neurological deterioration, allowing close monitoring during traction.
• Frequent radiographic assessments are performed to confirm whether reduction is achieved.

If closed reduction is successful, surgical stabilization usually follows. If it fails or is contraindicated, we proceed to open surgical reduction.

When is surgery required and which techniques are used?

In most severe injuries with instability, vertebral displacement, or spinal cord compression, surgical intervention is necessary.

Indications for surgery include:

• Severe kyphosis/angulation/translation (fracture–dislocation).
• Instability not amenable to conservative treatment.
• Spinal cord compression by bone fragments, disc material, or hematoma.
• Failure or contraindication of closed reduction.

Surgical approaches:

• Posterior approach – placement of screws and rods across multiple levels (multilevel posterior fusion), particularly at the cervicothoracic junction where mechanical loads are high.
• Anterior approach – disc or vertebral body removal (discectomy/corpectomy) with plate and cage reconstruction, commonly used for anterior cervical pathology.
• Combined anterior–posterior stabilization – in particularly severe injuries to achieve maximal stability.

Technique selection is individualized based on imaging findings, general condition, and the primary objective: durable stabilization with the lowest possible surgical risk.

Role of ICU, hemodynamic stabilization & prevention of complications

Care does not end in the operating room. ICU management, blood pressure optimization, and complication prevention are critical determinants of outcome.

Key points:

• Avoidance of hypotension – in complete or incomplete spinal cord injury, hypotension (neurogenic shock or hemorrhage) can exacerbate neurological damage. The goal is to maintain adequate mean arterial pressure (MAP) using intravenous fluids and, if necessary, vasopressors.
• Respiratory support – high cervical injuries (C3–C5) may require intubation and mechanical ventilation.
• Prevention of venous thromboembolism – anticoagulation (when safe), compression stockings, pneumatic devices.
• Prevention of pressure ulcers and infections, meticulous bladder and bowel care.

The use of high-dose corticosteroids (methylprednisolone) is now controversial and in many international guidelines is not recommended due to the risk of complications.

What is the prognosis & the role of rehabilitation?

Prognosis depends on the level of injury, whether the lesion is complete or incomplete, as well as patient age and overall health.

In general:

• Incomplete injuries (preserved sensation and/or movement below the level of injury) have a better likelihood of partial neurological recovery.
• Complete injuries have less potential for motor or sensory recovery, but modern rehabilitation can significantly improve independence and quality of life.

Rehabilitation includes:

• Specialized physiotherapy to maintain range of motion, prevent contractures, and strengthen preserved muscles.
• Occupational therapy for training in activities of daily living with or without assistive devices.
• Psychological support for the patient and family.
• Orthotic and assistive technologies (wheelchairs, braces, customized seating).

Rehabilitation is a long-term process requiring continuous adaptation to each patient’s evolving capabilities, with the goal of maximizing independence.