This document discusses cervical spine injuries, their classification, mechanisms of injury, diagnosis, and treatment approaches. Some key points: 1. Cervical injuries can be caused by traction, direct impact, or indirect forces like flexion, compression, or rotation. Imaging helps classify injuries and assess stability. 2. Unstable injuries with neurological deficits or multiple injuries may require urgent surgical stabilization. Otherwise, treatment focuses on immobilization, reduction if needed, and rehabilitation. 3. Common injuries include fractures of C1-C2 and the odontoid process. Treatment depends on fracture type and stability but may involve traction, halo vest immobilization, or anterior/posterior fusion.

1. Cervical spine injuries and its management
Dr.Prashanth kumar
1st yr pg

2. • The cervical vertebrae are the smallest of the
moveable vertebrae, and are characterized by
a foramen in each transverse process.
• The first, second and seventh have special
features .
• The third, fourth and fifth cervical are almost
identical, and the sixth, while typical in its
general features, has minor distinguishing
differences.

5. • Readily identified by the foramen
transversarium perforating the transverse
processes. This foramen transmits the
vertebral artery, the vein,and sympathetic
nerve fibres
• Spines are small and bifid (except C1
and C7 which are single)
• Articular facets are relatively horizontal

6. • Nodding and lateral flexion movements occur
at the atlanto-occipital joint
• Rotation of the skull occurs at the atlanto-axial
joint around the dens, which acts as a pivot

7. MECHANISM OF INJURY
• Traction injury
• Direct injury: Penetrating injuries to the spine,
particularly from firearms and knives, are
becoming increasingly common

8. • Indirect injury: Most common cause. A variety of forces
may be applied to the spine (often simultaneously):
– axial compression flexion
– lateral compression
– flexion-rotation
– Shear
– flexion-distraction
– Extension
• Insufficiency fractures may occur with minimal force in
bone which is weakened by osteoporosis or a pathological
lesion

9. Mechanism of injury The spine is usually injured in
one of two ways: (a) a fall onto the head or the back of
the neck; and (b) a blow on the forehead, which forces
the neck into hyperextension

10. PRINCIPLES OF DIAGNOSIS AND
INITIAL MANAGEMENT
• Diagnosis and management go hand in hand
• Inappropriate movement and examination can
irretrievably change the outcome for the worse
• Early management
– Airway, Breathing and Circulation
– Slightest possibility of a spinal injury in a trauma
patient, the spine must be immobilized until the
patient has been resuscitated and other life-
threatening injuries have been identified and treated.

11. THREE COLUMN THEORY OF DENIS

12. • If two or three columns
injured-lesion is unstable
• Works well for C3 to T1.
• Does not work so well for
C1-2, (so consider most or
all injuries here unstable)
• Only 10 per cent of spinal
fractures are unstable
• Less than 5 per cent are
associated with cord
damage

13. • A stable injury is one in which the vertebral
components will not be displaced by normal
movements;
• In a stable injury, if the neural elements are
undamaged there is little risk of them becoming
damaged.
• An unstable injury is one in which there is a
significant risk of displacement and consequent
damage – or further damage – to the neural
tissues.

14. RADIOLOGY
Alignment
Lateral view
Top of T1 visible
Three smooth arcs
maintained
Vertebral bodies of uniform
height
Odontoid intact and closely
applied to C1

15. AP View
• The height of the cervical
vertebral bodies should be
approximately equal
• The height of each joint
space should be roughly
equal at all levels
• Spinous process should be
in midline and in good
alignment

16. Odontoid View
• An adequate film should include
the entire odontoid and the lateral
borders of C1-C2.
• Occipital condyles should line up
with the lateral masses and
superior articular facet of C1.
• The distance from the dens to the
lateral masses of C1 should be
equal bilaterally.
• The tips of lateral mass of C1
should line up with the lateral
margins of the superior articular
facet of C2.
• The odontoid should have
uninterrupted cortical margins
blending with the body of C2.

17. Swimmers view

19. Key Things to Identify
• Predental space – should be 3mm or less

20. • Prevertebral soft
tissue swelling
– May be due to
hematoma from a
fracture
– Soft tissue swelling
may make fracture
diagnosis difficulty

21. • Disc spaces should be the equal and
symmetric

23. Diagnostic pitfalls in children
• Children are often distressed and difficult to
examine;
• more than usual reliance may be placed on
the x-rays.
• It is well to recall some common pitfalls.
• An increased atlanto-dental interval (up to
4.5mm)

24. • may be quite normal; this is because the skeleton
is incompletely ossified and the ligaments
relatively lax during childhood.
• There may also be apparent subluxation of C2 on
C3 (pseudosubluxation).
• An increased retropharyngeal space can be
brought about by forced expiration during crying.
• Growth plates and synchondroses can be
mistaken for fractures..

25. • The normal synchondrosis at the base of the
dens has usually fused by the age of 6 years,
but it can be mistaken for an undisplaced
fracture.
• The spinous process growth plates also
resemble fractures; and the growth plate at
the tip of the odontoid can be taken for a
fracture in older children

26. • SCIWORA is an acronym for spinal cord injury
without obvious radiographic abnormality.
• Normal radiographs in children do not
exclude the possibility of spinal cord injury
FINDING OF FRACTURE, SUBLUXATION, OR
ABNORMAL INTERSEGMENTAL MOTION AT
LEVEL OF NEUROLOGICAL INJURY EXCLUDES
SCIWORA AS A DIAGNOSIS

27. • EXPERIMENTALLY, OSTEOCARTILAGINOUS
STRUCTURES IN SPINAL COLUMN CAN
STRETCH 2 INCHES WITHOUT DISRUPTION --
SPINAL CORD RUPTURES AFTER 1/4 INCH
• ANATOMICALLY, CERVICAL SPINAL CORD IS
RELATIVELY TETHERED - SPINAL NERVES,
DURAL ATTACHMENT TO FORAMEN
MAGNUM, AND BRACHIAL PLEXUS

28. • PRESENTING NEURO EXAM CORRELATES TO
OUTCOME
• MRI FINDINGS (OR LACK OF) MAY BE MORE
PREDICTIVE OF OUTCOME
• NO CHILD HAS BEEN DOCUMENTED TO
DEVELOP SPINAL INSTABILITY AFTER DX OF
SCIWORA

29. TREATMENT
• NO CONSENSUS:
BUT HARD COLLAR IMMOBILIZATION FOR 12
WEEKS AND AVOIDANCE OF FLEX/EXT
ACTIVITIES FOR ANOTHER 12 WEEKS HAS NOT
BEEN ASSOCIATED WITH RECURRENT INJURY

30. • PRINCIPLES OF DEFINITIVE
• TREATMENT
• The objectives of treatment are:
• • to preserve neurological function;
• • to minimize a perceived threat of
neurological compression;
• • to stabilize the spine;
• • to rehabilitate the patient

31. • The indications for urgent surgical
stabilization are:
• (a) an unstable fracture with progressive
neurological deficit and MRI signs of likely
further neurological deterioration; and
• (b) controversially an unstable fracture in a
patient with multiple injuries

32. Pharmacological Management
• Methylprednisolone sodium succinate (MPSS)
– Within 3 hours 30mg/kg bolus + 5.4mg/kg/hr
infusion for 24 hours.
– During 3~8 hours  30mg/kg bolus +
5.4mg/kg/hr infusion for 48 hours.
– suppress inflammatory response and vasogenic
edema

33. Initial Treatment
Immobilization
• Rigid cervical collor (philadelphia collor)
• Poster braces
• Cervico thoracic arthrosis
• Halo device
 In unstable injury this is inadequate,cervical
traction required
– Skin (glisson’ traction)
– Skeletal
• halo traction or gardner-wells tongs
• Crutchfield tongs

34. Glisson’s Cervical Traction

35. CrutchField Traction

36. HALO TRACTION

38. UPPER CERVICAL SPINE
• Occipital condyle fracture:
• This is usually a high-energy fracture and associated
skull or cervical spine injuries must be sought.
• The diagnosis is likely to be missed on plain x-ray
examination and CT is essential.
• Impacted and undisplaced fractures can be treated
by brace immobilization for 8–12 weeks.
. Displaced fractures are best managed by using a halo-
vest or by operative fixation.

39. • Occipito-cervical dislocation:
• This high-energy injury is almost always
associated with other serious bone and/or
soft-tissue injuries, including arterial and
pharyngeal disruption, and the outcome is
often fatal.
• Patients are best dealt with by a
multidisciplinary team of surgeons and
physicians.

40. • The diagnosis can sometimes be made on the
lateral cervical radiograph:
• the tip of the odontoid should be no more
than 5mm in vertical alignment and 1mm in
horizontal alignment from the basion (anterior
rim of the foramen magnum).
• Greater distances are allowable in children.
• CT scans are more reliable.

41.  The injury is likely to be unstable and requires
immediate reduction (without traction!) and
stabilization with a halo-vest, pending surgical
treatment.
 After appropriate attention to the more serious
softtissue injuries and general resuscitation, the
dislocation should be internally fixed;
 specially designed occipito-cervical plates and screws
are available for the purpose.
 In severely unstable injuries, halo-vest stabilization
should be retained for another 6–8 weeks.

42. Occipito–cervical fusion X-ray showing one of
the devices used for internal fixation in occipito-cervical
fusion operations

43. • C1 ring fracture:
• Sudden severe load on the top of the head may cause
a ‘bursting’ force which fractures the ring of the atlas
(Jefferson’s fracture).
There is no encroachment on the neural canal and,
usually, no neurological damage.
• The fracture is seen on the open-mouth view (if the
lateral masses are spread away from the odontoid peg)
and the lateral view.
• A CT scan is particularly helpful in defining the fracture.

45. • If it is undisplaced, the injury is stable and the
patient wears a semi-rigid collar or halo-vest until
the fracture unites.
• If there is sideways spreading of the lateral
masses (more than 7 mm on the open-mouth
view), the transverse ligament has ruptured;
• this injury is unstable and should be treated by a
halo-vest for several weeks.
• If there is persisting instability on x-ray, a
posterior C1/2 fixation and fusion is needed.

46. • A hyperextension injury can fracture either
the anterior or posterior arch of the atlas.
• These injuries are usually relatively stable and
are managed with a halo-vest or semi-rigid
collar until union occurs.
• Fractures of the atlas are associated with
injury elsewhere in the cervical spine in up to
50 per cent of cases.

47. • C2 pars interarticularis fractures:
• In the true judicial ‘hangman’s fracture’ there
are bilateral fractures of the pars
interarticularis of C2 and the C2/3 disc is torn;
• the mechanism is extension with distraction.
• In civilian injuries, the mechanism is more
complex, with varying degrees of
extension,compression and flexion.

48. • This is one cause of death in motor vehicle
accidents when the forehead strikes the
dashboard.
• Neurological damage, however, is unusual
because the fracture of the posterior arch
tends to decompress the spinal cord.
• Nevertheless the fracture is potentially
unstable

50. • Undisplaced fractures which are shown to be
stable on supervised flexion–extension views
(less than 3mm of C2/3 subluxation) can be
treated in a semi-rigid orthosis until united
(usually 6–12 weeks).

51. • Fractures with more than 3mm displacement but
no kyphotic angulation may need reduction;
• however, because the mechanism of injury
usually involves distraction, traction must be
avoided.
• After reduction, the neck is held in a halo-vest
until union occurs. C2/3 fusion is sometimes
required for persistent pain and instability
(‘traumatic spondylolisthesis’).

52. • Occasionally, the ‘hangman’s fracture’ is
associated with a C2/3 facet dislocation.
• This is a severely unstable injury; open
reduction and stabilization is required

53. C2 Odontoid process fracture
• Odontoid fractures are uncommon.
• They usually Occur as flexion injuries in
young adults after highvelocity injuries.
• However, they also occur in elderly,
osteoporotic people as a result of low-energy
trauma in which the neck is forced into
hyperextension, e.g. a fall onto the face or
forehead

54. • A displaced fracture is really a fracture-
dislocation of the atlanto-axial joint in which the
atlas is shifted forwards or backwards, taking the
odontoid process with it.
• At this level about a third of the internal
diameter of the atlas is free space, a third filled
with the odontoid and a third with the cord;
• thus there is room for displacement without
neurological injury.
• However,cord damage is not uncommon and in
old people there is a considerable mortality rate

55. Classification
• • Type I – An avulsion fracture of the tip of
the odontoid process due to traction by the
alar ligaments.
• The fracture is stable (above the transverse
ligament) and unites without difficulty.
• .

56. • • Type II – A fracture at the junction of the
odontoid process and the body of the axis.
• This is the most common (and potentially the
most dangerous) type.
• The fracture is unstable and prone to non-
union

57. • • Type III – A fracture through the body of
the axis.
• The fracture is stable and almost always unites
with immobilization.

58. Fractured odontoid process (a) Anteroposterior
‘open-mouth’ x-ray showing a Type II odontoid fracture.
(b) Lateral x-ray of the same patient.

59. • Clinical features
• The history is usually that of a severe neck strain
followed by pain and stiffness due to muscle spasm.
• The diagnosis is confirmed by high quality x-ray
examination;
• it is important to rule out an associated occipito-
cervical injury which commands immediate attention.
In some cases the clinical features are mild and
continue to be overlooked for weeks on end.
• Neurological symptoms occur in a significant number
of cases.

60. • Imaging
• Plain x-rays usually show the fracture, although
the extent of the injury is not always obvious –
e.g. there may be an associated fracture of the
atlas or displacement at the occipito-atlanto
level.
• Tomography is helpful but MRI has the advantage
that it may reveal rupture of the transverse
ligament; this can cause instability in the absence
of a fracture.

61. • Treatment
• Type I fractures Isolated fractures of the
odontoid tip are uncommon.
• They need no more than immobilization in a
rigid collar until discomfort subsides.

62. • Type II fractures These are often unstable and
prone to non-union, especially if displaced more
than 5 mm.
• Undisplaced fractures can be held by fitting a
halo-vest or – in elderly patients – a rigid collar.
• Displaced fractures should be reduced by traction
and can then be held by operative posterior C1/2
fusion; a drawback is that neck rotation will be
restricted.

63. • Anterior screw fixation is suitable for Type II
fractures that run from anterior-superior to
posterior-inferior,provided the fracture is not
comminuted, that the transverse ligament is not
ruptured, that the fracture is fully reduced and
the bone solid enough to hold a screw; in that
case neck rotation is retained.
• If full operative facilities are not available,
immobilization can be applied by using a halo-
vest with repeated x-ray monitoring to check for
stability.

64. Fractured odontoid – treatment (a) A severely displaced Type II odontoid fracture. (b)
The fracture was reduced
by skull traction and held by fixing the spinous process of C1 to that of C2 with wires. (c)
An undisplaced Type II fracture,
which was suitable for (d) anterior screw fixation.

65. • Type III fractures If undisplaced, these are treated in a
halo-vest for 8–12 weeks.
• If displaced, attempts should be made at reducing the
fracture by halo traction, which will allow positioning in
either flexion or extension, depending on whether the
displacement is forward or backward;
• the neck is then immobilized in a halo-vest for 8–12
weeks.
• For elderly patients with poor bone a collar may
suffice, though this carries a higher risk of non-union.

66. LOWER CERVICAL SPINE
• Fractures of the cervical spine from C3 to C7
tend to produce characteristic fracture
patterns, depending on the mechanism of
injury:
• flexion,
• axial compression,
• flexion–rotation or
• hyperextension

67. Posterior ligament injury
• Sudden flexion of the mid-cervical spine can
result in damage to the posterior ligament
complex (the interspinous ligament, facet
capsule and supraspinous ligament).
• The upper vertebra tilts forward on the one
below, opening up the interspinous space
posteriorly

68. Cervical spine – posterior ligament injury
(a) The film taken in extension shows no displacement of
the vertebral bodies, but there is an unduly large gap
between the spinous processes of C4 and 5. (b) With the
neck slightly flexed the subluxation is obvious.
NB: flexion–extension views are potentially dangerous and
should be used only in specific situations under direct
supervision of an experienced surgeon.

69. • The patient complains of pain and there may
be localized tenderness posteriorly.
• X-ray may reveal a slightly increased gap
between the adjacent spines;
• however, if the neck is held in extension this
sign can be missed, so it is always advisable to
obtain a lateral view with the neck in the
neutral position

70. • . A flexion view would, of course, show the
widened interspinous space more clearly, but
flexion should not be permitted in the early
post-injury period.
• This is why the diagnosis is often made only
some weeks after the injury,when the patient
goes on complaining of pain.

71. • The assessment of stability is essential in these
cases.
• If the angulation of the vertebral body with its
neighbour exceeds 11 degrees, if there is anterior
translation of one vertebral body upon the other
of more than 3.5 mm or if the facets are fractured
or displaced, then the injury is unstable and it
should be treated as a subluxation or dislocation.
•

72. • If it is certain that the injury is stable, a semi-
rigid collar for 6 weeks is adequate;
• if the injury is unstable then posterior fixation
and fusion is advisable

73. Wedge compression fracture
• A pure flexion injury results in a wedge
compression fracture of the vertebral body
• The middle and posterior elements remain
intact and the injury is stable.
• All that is needed is a comfortable collar for 6–
12 weeks.

74. • A note of warning: The x-ray should be
carefully examined to exclude damage to the
middle column and posterior displacement of
the vertebral body fragment, i.e. features of a
burst fracture (see below)which is potentially
dangerous. If there is the least doubt, an axial
CT or MRI should be obtained

75. Cervical compression fracture A wedge
compression
fracture of a single cervical vertebral body. This
is
a stable injury because the middle and
posterior elements
are intact.

76. Burst and compression-flexion (‘teardrop’)
fractures
• These severe injuries are due to axial compression of
the cervical spine, usually in diving or athletic accidents
• If the vertebral body is crushed in neutral position of
the neck the result is a ‘burst fracture’.
• With combined axial compression and flexion,an
antero-inferior fragment of the vertebral body is
sheared off, producing the eponymous ‘tear-drop’ on
the lateral x-ray.
• In both types of fracture there is a risk of posterior
displacement of the vertebral body fragment and
spinal cord injury.

77. • Plain x-rays show either a crushed vertebral body
(burst fracture) or a flexion deformity with a triangular
fragment separated from the antero-inferior edge of
the fractured vertebra (the innocent-looking
‘teardrop’).
• The x-ray images should be carefully examined for
evidence of middle column damage and posterior
displacement (even very slight displacement) of the
main body fragment.
• Traction must be applied immediately
• and CT or MRI should be performed to look for
retropulsion of bone fragments into the spinal canal.

78. • TREATMENT
• If there is no neurological deficit, the patient
can be treated surgically or by confinement to
bed and traction for 2–4 weeks, followed by a
further period of immobilization in a halo-vest
for 6–8 weeks. (The halo-vest is unsuitable for
initial treatment because it does not provide
axial traction).

79. • If there is any deterioration of neurological
status while the fracture is believed to be
unstable, and the MRI shows that there is a
threat of cord compression,then urgent
anterior decompression is considered anterior
corpectomy, bone grafting and plate fixation,
and sometimes also posterior stabilization.

80. Tear-drop fracture (a) This comminuted vertebral body fracture has produced a large
anterior fragment and obvious
posterior displacement of the posterior fragment. (b) In this case the anterior ‘tear-
drop’ was noted but the severity of
the injury was underestimated; careful examination shows that the main body fragment
is displaced slightly posteriorly.
The patient was treated in a collar; 3 weeks later (c) the fracture had collapsed and the
large body fragment was now
very obviously tilted and displaced posteriorly. By then he was complaining of tingling
and weakness in his right arm.
Beware the innocent tear-drop!

81. Hyperextension injury
• Hyperextension strains of soft-tissue
structures are common and may be caused by
comparatively mild acceleration forces. Bone
and joint disruptions, however,are rare.
• The more severe injuries are suggested by the
history and the presence of facial bruising or
lacerations.
• The posterior bone elements are compressed
and may fracture;

82. • the anterior structures fail in tension, with
tearing of the anterior longitudinal ligament
or an avulsion fracture of the anterosuperior
or anteroinferior edge of the vertebral body,
opening up of the anterior part of the disc
space, fracture of the back of the vertebral
body and/or damage to the intervertebral disc

83. • . In patients with pre-existing cervical
spondylosis, the cord can be pinched between
the bony spurs or disc and the posterior
ligamentum flavum;
• oedema and haematomyelia may cause an
acute central cord syndrome (quadriplegia,
sacral sparing and more upper limb than
lower limb deficit,a flaccid upper limb
paralysis and spastic lower limb paralysis).

84. • These injuries are stable in the neutral
position, in which they should be held by a
collar for 6–8 weeks.
• Healing may lead to spontaneous fusion
between adjacent vertebral bodies

85. Hyperextension injuries (a) The anterior longitudinal ligament has been torn; in the
neutral position the gap will
close and reduction will be stable, but a collar or brace will be needed until the soft
tissues are healed. (b) X-ray in this
case showed a barely visible flake of bone anteriorly at the C6/7 disc space. (c) 1
month later the traction fracture at C6/7
was more obvious, as was the disc lesion at C5/6. (d) A year later C6/7 has fused
anteriorly; the patient still has neck pain
due to the C5/6 disc degeneration.

86. Avulsion injury of the spinous process
• Fracture of the C7 spinous process may occur
with severe voluntary contraction of the
muscles at the back of the neck; it is known as
the clay-shoveller’s fracture.
• The injury is painful but harmless.
• No treatment is required;
• as soon as symptoms permit, neck exercises
are encouraged.

87. Avulsions (a) The clay-shoveller’s fracture.
Jerking the neck backwards has resulted
in avulsion of one of the spinous processes – a
benign injury. (b) This patient might be
thought to have a similar fracture, but a subsequent
flexion film (c) shows the serious nature
of the injury – a severe fracture-dislocation

88. SPRAINED NECK (WHIPLASH INJURY)
• Soft-tissue sprains of the neck are so common
aftermotor vehicle accidents that they now constitute
a veritable epidemic.
• There is usually a history of a lowvelocity rear-end
collision in which the occupant’s body is forced against
the car seat while his or her head flips backwards and
then recoils in flexion.
• This mechanism has generated the imaginative term
whiplash injury, which has served effectively to
enhance public apprehension at its occurrence.
• .

89. • However, similar symptoms are often reported
with flexion and rotation injuries.
• Women are affected more often than men,
perhaps because their neck muscles are more
gracile

90. • There is disagreement about the exact pathology
but it has been suggested that the anterior
longitudinal ligament of the spine and the
capsular fibres of the facet joints are strained and
in some cases the intervertebral discs may be
damaged in some unspecified manner.
• There is no correlation between the amount of
damage to the vehicle and the severity of
complaints.

93. Clinical features
• Often the victim is unaware of any abnormality
immediately after the collision.
• Pain and stiffness of the neck usually appear within the
next 12–48 hours, or occasionally only several days later.
• Pain sometimes radiates to the shoulders or interscapular
area and may be accompanied by other, more ill-defined,
symptoms such as headache, dizziness, blurring of vision,
paraesthesia in the arms, temporomandibular discomfort
and tinnitus.
• Neck muscles are tender and movements often restricted;
the occasional patient may present with a ‘skew neck’.
Other physical signs – including neurological defects – are
uncommon.

94. • X-ray examination may show straightening out
of the normal cervical lordosis, a sign of
muscle spasm; in other respects the
appearances are usually normal.
• In some cases, however, there are features of
longstanding intervertebral disc degeneration
or degenerative changes in the uncovertebral
joints; it may be that these patients suffer
more, and for longer spells,than others.

95. • Proposed grading of whiplash-associated
• injuries
• Grade Clinical pattern
• 0 No neck symptoms or signs
• 1 Neck pain, stiffness and tenderness No physical
signs
• 2 Neck symptoms and musculoskeletal signs
• 3 Neck symptoms and neurological signs
• 4 Neck symptoms and fracture or dislocation

96. Differential diagnosis
• The diagnosis of sprained neck is reached largely
by a process of exclusion, i.e. the inability to
demonstrate any other credible explanation for
the patient’s symptoms.
• X-rays should be carefully scrutinized to avoid
missing a vertebral fracture or a mid-cervical
subluxation.
• The presence of neurological signs such as muscle
weakness and wasting, a depressed reflex or
definite loss of sensibility should suggest an acute
disc lesion and is an indication for MRI.

97. • Seat-belt injuries often accompany neck sprains.
• They do not always cause bruising of the chest,
but they can produce pressure or traction injuries
of the suprascapular nerve or the brachial plexus,
either of which may cause symptoms resembling
those of a whiplash injury.
• The examining doctor should be familiar with the
clinical features of these conditions.

98. Treatment
• Collars are more likely to hinder than help recovery.
• Simple pain-relieving measures, including analgesic
medication, may be needed during the first few weeks.
• However, the emphasis should be on graded exercises,
• beginning with isometric muscle contractions and
postural adjustments, then going on gradually to active
movements and lastly movements against resistance.
• The range of movement in each direction is slowly
increased without subjecting the patient to
unnecessary pain. Many patients find osteopathy and
chiropractic treatment to be helpful.

99. • 1-5% OF CSI ARE MISSED - MAINTAIN
APPROPRIATE LEVEL OF SUSPICION IF SEEING A
PATIENT WITH CONTINUED NECK PAIN AFTER
BEING “CLEARED” -- KNOW THE BASIC
MANAGEMENT GUIDELINES FOR CLEARING THE
C-SPINE
• If a spinal fracture is identified at any level, the
entire spine should be examined with antero-
posterior and lateral views to document the
presence or absence of spinal fractures at other
levels
TAKE HOME MESSAGE

100. • MISSED/DELAYED CSI OCCURS DUE TO
LACK OF AN APPROPRIATE INDEX OF
SUSPICION, INADEQUATE PLAIN FILMS, AND
MISREAD STUDIES
• IF HAVE HIGH ENOUGH INDEX OF SUSPICION
TO GET XRAYS, THEN DO NOT ACCEPT
INADEQUATE ONES

101. • IN “CLEARING” THE C-SPINE, DO NOT FORGET
NONSKELETAL INJURIES: LIGAMENTOUS
INSTABILITY, CERVICAL STENOSIS, AND
SCIOWRA
• KNOW YOUR PEDIATRIC ANATOMICAL
VARIATIONS
• DON’T BE IN A HURRY TO CLEAR THE
CERVICAL SPINE - CAN ALWAYS LEAVE IN A
HARD COLLAR

102. • Progressive neurological deficit in cord
compression needs early surgical
decompression.
• Anterior decompression is better.
• Early surgical intervention for instability
prevents deterioration