Blunt neck trauma: Difference between revisions

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==Pearls==
==Background==
*Suspect vascular damage to cord, if discrepancy between [[Focal neurologic deficits|neuro deficit]] and level of spinal column injury
*[[Spinal cord injury]] is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted


==Clinical Features==
*Signs of life-threatening neck or upper thoracic injury (look for ''TWELVE''):
:'''T'''racheal deviation'',
:'''W'''ounds,
:'''E'''xternal markings,
:'''L'''aryngeal disruption,
:'''V'''enous distention,
:'''E'''mphysema (surgical)
*Features may include signs and symptoms of:
**[[Spinal cord injury]]
**[[Vertebral and Carotid Artery Dissection]]
**Laryngeal or [[tracheal injury]]


* Suspect vascular damage to the cord if discrepancy between neuro deficit and level of spinal column injury
===Pediatrics===
* Down syndome predisposes to atlanto-occipital dislocation; RA predisposes to C2 transverse ligament rupture
*In a small study of 42 patients with a cervical seatbelt sign there were no isolated  cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. <ref>Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.</ref>
* Cord injury is more likely if both the anterior (vertebral bodies) and posterior (spinal canal) columns are disrupted


===Atlanto-occipital dislocation===
==Differential Diagnosis==
{{Blunt neck trauma DDX}}


===Other===
*[[Head trauma]]
*[[Thoracic trauma]]


* Evaluate with the Powers ratio
==Evaluation==
* Ratio of BC:OA > 1 suggests anterior subluxation
===Workup===
* BC = distance between basion and midpoint of C2 post laminar line
*Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below)
* OA = Distance between opisthion and ant arch of C2
**May later consider cervical MRI to further evaluate for cord injury
*Consider CTA neck with contrast to evaluate for vascular injury (see below)


===Atlanto-axial dislocation===
===General Approach===
[[File:Vertebral lines.png|thumb|Plain films lines]]
*If concern for cervical spine injury, use a [[cervical spine clearance]] decision rule to determine need for imaging
*Perform a neuro exam, to determine concern for [[spinal cord injury]]
*If concern for vascular injury, use the [[Denver screening criteria]]


==Management==
*Prehospital
**See the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]]
*Hospital
**Secure ABCs
**See [[cervical spine clearance]]
**See specific diagnosis


==Disposition==
 
*Based on specific diagnosis
===C1 Fractures===
 
 
* Burst (Jefferson)
* Highly unstable
* Axial loading transmitted through occipital condyles to the lateral masses
* Results in fx of the ant and post arches
* Stability is determined by whether or not the transverse ligament is disrupted
* Suspect if:
* Lateral xray: Increase in the predental space between C1 and the dens
* Predental space greater than 3 mm in adults or 5 mm in children is abnormal
* Odontoid xray: Masses of C1 to lie lateral to the outer margins of the articular pillars of C2
* If either of the above findings on xray then obtain CT c-spine
* Posterior Arch
* Must ensure that you are not confusing this with a burst fx!
* Odontoid view must be normal
* Due to forced neck extension
* Vertical fx line through posterior arch seen on lateral xray
* Stable (b/c anterior arch and transverse ligament are unaffected)
===C2 Fractures===
 
 
* Traumatic spondylolysis ("Hangman's Fx")
* Unstable
* Forced extension of an already extended neck
* Spinal cord damage is often minimal (the AP diamter of the neural canal is greatest at C2)
* Odontoid Fracture
* Type I
* Above the transverse ligament
* Stable
* Type II
* At the base where it attaches to C2
* Unstable
* Most common
* Type III
* Extension of the fracture through the upper portion of C2
===Cervical Fractures===
 
 
* Anterior Wedge Fracture
* Unstable if:
* Loss of over half of vertebral height OR
* Multiple adjacent wedge fractures
* Flexion Teardrop Fracture
* Unstable
* Associated with acute anterior cervical cord syndrome
* Displacement of a teardrop shaped fragment of the antero-interior portion of the superior vertebra
* Severe flexion > vertebral body collides with the one below
* Extension Teardrop Fracture
* Unstable
* Abrupt neck extension > anterior longitudinal ligament avulses anteroinferior corner
* Avulsed fragment is greater in height than width (contrast with flexion teardrop)
* Often occurs at C5-C7 associated with diving accidents
* Associated with central cord syndrome
* Spinous Process Fracture (Clay Shoveler's)
* Stable
* Isolated fracture of one of the spinous processes of the lower cervical vertebrae
* Burst Fracture
* Posteriorly displaced fracture fragment may impinge on the cord
* Axial compression > nucleus pulposus forced into vertebral body
* Imaging
* Lateral xray - Comminuted body and loss of vertebral height
* AP xray - Vertical fracture of the body
===Facet Dislocations===
 
 
* Bilateral
* Unstable
* Complete spinal cord injury most often results
* Disruption of the annulus fibrosus and the ant longitudinal ligament > ant displacement of the spine
* Unilateral
* Stable
* Spinal cord injury rarely occurs
 
==Source==
 
 
UpToDate


==See Also==
*[[Penetrating neck trauma]]
*[[Cervical spine clearance]]
*[[Canadian cervical spine rule]]
*[[NEXUS cervical spine rule]]
*[[Strangulation]]
*[[Vertebral and carotid artery dissection]]


==External Links==
*[https://coreem.net/podcast/episode-173-0-blunt-neck-trauma/ Blunt Neck Trauma from CoreEM]


==References==
<references/>


[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Orthopedics]]

Latest revision as of 19:45, 9 October 2024

Background

  • Suspect vascular damage to cord, if discrepancy between neuro deficit and level of spinal column injury
  • Spinal cord injury is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted

Clinical Features

  • Signs of life-threatening neck or upper thoracic injury (look for TWELVE):
Tracheal deviation,
Wounds,
External markings,
Laryngeal disruption,
Venous distention,
Emphysema (surgical)

Pediatrics

  • In a small study of 42 patients with a cervical seatbelt sign there were no isolated cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. [1]

Differential Diagnosis

Neck Trauma

Other

Evaluation

Workup

  • Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below)
    • May later consider cervical MRI to further evaluate for cord injury
  • Consider CTA neck with contrast to evaluate for vascular injury (see below)

General Approach

Plain films lines

Management

Disposition

  • Based on specific diagnosis

See Also

External Links

References

  1. ↑ Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.
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