RISK FACTORS: Present in 65% of CCS
* Spinal stenosis, Congenital & Acquired - prior trauma, spondylosis
* Spinal rigidity
. Klippel-Feil syndrome
. Ankylosing spondylitis
GENERAL MEASURES:
. Whiplash; depending on severity
. Activity restriction with increases after patient improvement
. Soft to rigid collar
. Medicines - analgesics, muscle relaxants, anti-inflammatory
. Post resolution of spasms, repeat flexion/extension lateral c-spine to confirm stability
. CCS
. See Medications
. If no instability, bed rest with soft collar for 4-6 weeks followed by mobilization with collar for another 4-6 weeks
. Fractures; stability determined by usual radiologic criteria; surgical decompression and stabilization is
indicated:
. In patients with incomplete spinal cord injuries and spinal canal compromise from bone, disc, subluxation,
or hematoma
. In those who deteriorate or do not improve on conservative therapy
. Hangmanยfs fracture - traumatic spondylolisthesis of the axis with bilateral fractures through the C2 pedicles,
often with anterior subluxation of C2 over C3
. Usually stable, managed with orthosis, SOMI (sternal-occipital-mental orthosis)
. Unstable if C2 subluxation over C3 is greater than 50% of vertebral body of C3 in anteroposterior diameter
. Unstable if excessive angulation of C2 over C3
. Then treated with halo vest immobilization for 8-14 weeks until repeat flexion/extension films
. If stable, rigid collar for additional 8-12 weeks
. Odontoid fracture - treated according to type
. I - through apex, may be unstable and require surgical fusion
. II - most common type, at base of dens, usually unstable; nonunion rates of about 30% with immobilization
alone, especially with increased dens displacement more than 6 mm in patients more than 7 years old
. III - through C2 body, usually stable; immobilized in halo for 8-14 weeks, rigid collar for 8-14 weeks, then
mobilization
. C3-C7 hyperextension fractures
. If stable, rigid collar for 8-14 weeks then mobilization
. If unstable, halo brace; serial lateral c-spine films from supine to upright; if still unstable, surgical stabilization
. Post-op, followup x-rays until trabeculation across fracture site or interbody fusion achieved
SURGICAL MEASURES:
. CCS
. In acute cases, surgery is associated with deterioration and increased complications, and therefore
contraindicated
. Surgery may be indicated in patient who is improving and then deteriorates
. Otherwise, surgical decompression and stabilization performed only when neurologic function has reached a plateau or maximum recovery
. Fractures: See General Measures
ACTIVITY : Rest and immobilization until pain is controlled; followed by gradual mobilization, and rehabilitation exercises if needed
DRUG(S) OF CHOICE CCS - methylprednisolone 30 mg/kg IV over one hour followed by 5.4 mg/kg IV per hour for 23 hours (continue for 47 hours if started more than eight hours after injury). It improves neurological outcome, motor and sensory function at 6 weeks, 6 months, and 1 year after incomplete spinal cord injury.
PATIENT MONITORING:
. Patients seen and checked with x-rays every 3-4 weeks for about 3 months, when bone healing is usually
adequate
. Halo then replaced with rigid collar for next 3 months or rigid collar replaced with soft collar for comfort
PREVENTION/AVOIDANCE: Wearing seat belts; using proper equipment when participating in sports activities
POSSIBLE COMPLICATIONS:
. Persistent symptoms
. Nonunion of fractures
. Persistent instability requiring another procedure
. Reactions and infection related to orthosis
EXPECTED COURSE/PROGNOSIS:
Most important prognostic factor is the initial neurologic status
. Whiplash - most patients recover well, mild symptoms resolving within 6 months
. On the average, more severe injuries without disc involvement resolve in 21 months
. 30 months for those with degenerative changes
. At 2 years, 42% complete recovery, 15% mild discomfort, 43% signifi cant discomfort affecting work
. CCS
. Most patients recover motor strength within 2 weeks
. Younger patients have better prognosis
. Leg, bowel, and bladder function return first
. Return of arm strength follows, then that of hand
. However, upper extremities recover less well, and fine finger movements is usually not regained completely
. With cord contusion but no hematomyelia, 50% recover enough strength and sensation to ambulate
independently although usually with spasticity
. Fracture-dislocation
. Hangmanยfs fracture - 93-100% fusion rate after 8-14 weeks external immobilization
. Odontoid fracture - type III, 90% fusion with immobilization
AGE-RELATED FACTORS:
Pediatric: Consider spinal cord injury without radiographic abnormality (SCIWORA), which has a high
incidence at < 9 years. MRI may help detect the injury.
Geriatric: Degenerative disease of cervical spine may be confused with acute traumatic change on
imaging