Guideline sources The following summarized guidelines for the evaluation and management of cervical spinal cord injury are prepared by our editorial team based on guidelines from the American Association of Neurological Surgeons (AANS/CNS 2013). 1 2 3 4 5 6 6 6 7 Definition Cervical spinal cord injury refers to a complete or partial loss of motor and/or sensory function due to an acute trauma to the cervical spinal cord. 6 Epidemiology Cervical spinal cord injury is mainly due to accidental falls and motor vehicle accidents/transport injuries. 7 Disease course Clinical manifestations include complete or incomplete loss of all movements and/or sensation and may result in respiratory failure, cardiovascular complications, multiple organ failure, and death. 6 Prognosis and risk of recurrence https://web.pathway.md/diseases/recMpt3HakCslyHPO 1/5 6/29/23, 3:49 AM Cervical spinal cord injury Pathway Prognosis and risk of recurrence Cervical spinal cord injury is associated with a 30-day mortality of 9.4%. 6 Calculator NEXUS criteria for cervical spine Guidelines 1. Screening and diagnosis Indications for testing: triage patients with potential spinal injury at the scene to determine the need for immobilization during transport. B 2. Classification and risk stratification Severity grading: use the American Spinal Injury Association (ASIA) international standards for neurological and functional classification of spinal cord injury as the preferred neurological examination tool for the assessment and care of patients with acute spinal cord injury. B 3. Diagnostic investigations Evaluation of asymptomatic patients: avoid radiographic evaluation of the cervical spine in the awake, asymptomatic patient who is without neck pain or tenderness, who has a normal neurological examination, is without an injury detracting from an accurate evaluation, and who is able to complete a functional ROM examination. D Evaluation of symptomatic patients: Obtain a high-quality CT imaging of the cervical spine in awake patients with symptoms of suspected cervical spinal cord injury. A Obtain 3-view cervical spine XRs (anteroposterior, lateral, and odontoid views) in awake patients with symptoms of suspected cervical spinal cord injury when CT is unavailable. Obtain a follow-up CT study if necessary, when it becomes available, to further define areas that are suspicious or not well visualized on plain cervical XRs. A Evaluation of obtunded patients: obtain a high-quality cervical spine CT as the initial imaging modality of choice in obtunded or unevaluable patients. Avoid routine 3-view cervical spine XRs if CT imaging is available. A Magnetic resonance imaging: obtain MRI in patients with cervical spinal fracture-dislocation injuries who cannot be examined during closed reduction because of altered mental status, or https://web.pathway.md/diseases/recMpt3HakCslyHPO 2/5 6/29/23, 3:49 AM Cervical spinal cord injury Pathway before either anterior or posterior surgical procedures when closed reduction has failed. B 4. Medical management Indications for cervical spine immobilization: Implement spinal immobilization in all trauma patients with a cervical spine or spinal cord injury or with a mechanism of injury having the potential to cause cervical spinal injury. B Avoid spinal immobilization in trauma patients who are awake, alert, are not intoxicated; who are without neck pain or tenderness; who do not have an abnormal motor or sensory examination; and who do not have any significant associated injury that might detract from their general evaluation. D Choice of cervical immobilization device: Employ a combination of a rigid cervical collar and supportive blocks on a backboard with straps to limit motion of the cervical spine. B Avoid the longstanding practice of attempted spinal immobilization with sandbags and tape. D Management of awake patients with normal imaging: Consider any of the following alternative strategies in awake patients with neck pain or tenderness and normal high-quality CT imaging or normal 3-view cervical spine series: continue cervical immobilization until asymptomatic discontinue cervical immobilization following normal and adequate dynamic flexion/extension radiographs discontinue cervical immobilization following a normal MRI obtained within 48 hours of injury discontinue cervical immobilization at the discretion of the treating physician. C Management of obtunded patients with normal imaging: Consider one of the following alternative strategies in obtunded or unevaluable patients with a normal high-quality CT or normal 3-view cervical spine series: continue cervical immobilization until asymptomatic, discontinue cervical immobilization following a normal MRI study obtained within 48 hours of injury discontinue cervical immobilization at the discretion of the treating physician. C Expeditious transport to specialized centers: transport patients with acute cervical spine or spinal cord injuries expeditiously and carefully to the nearest medical facility with capacities for definitive treatment, using the most appropriate mode of transportation available. B 5. Surgical interventions Early closed reduction: Perform early closed reduction of cervical spinal fracture/dislocation injuries with craniocervical traction for the restoration of anatomic alignment of the cervical spine in awake patients. B https://web.pathway.md/diseases/recMpt3HakCslyHPO 3/5 6/29/23, 3:49 AM Cervical spinal cord injury Pathway Avoid closed reduction in patients with an additional rostral injury. D 6. Specific circumstances Patients with penetrating trauma: avoid implementing spinal immobilization in patients with penetrating cervical trauma because of increased mortality from delayed resuscitation. D 7. Follow-up and surveillance Indications for specialist referral: involve physicians trained in the diagnosis and management of spinal injuries to decide on further management in patients in whom there is a high clinical suspicion of injury yet have a normal high-quality CT imaging studies. B Clinical findings Symptoms Past medical history Dysarthria Cancer Fecal incontinence Inflammation Inability to groom or dress oneself Traumatic injury Musculoskeletal exam Numbness Urinary incontinence Arthritis Neurological exam Paralysis References 1. Ryken TC, Hadley MN, Walters BC et al. Radiographic assessment for cervical spine injuries. Neurosurgery. 2013 Mar;72 Suppl 2 54 72. Open 2. Theodore N, Aarabi B, Dhall SS et al. Transportation of patients with acute traumatic cervical spine injuries. Neurosurgery. 2013 Mar;72 Suppl 2 35 9. Open 3. Gelb DE, Hadley MN, Aarabi B et al. Initial closed reduction of cervical spinal fracture-dislocation injuries. Neurosurgery. 2013 Mar;72 Suppl 2 73 83. Open 4. Theodore N, Hadley MN, Aarabi B et al. Prehospital cervical spinal immobilization after trauma. Neurosurgery. 2013 Mar;72 Suppl 2 22 34. Open 5. Hadley MN, Walters BC, Aarabi B et al. Clinical assessment following acute cervical spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2 40 53. Open https://web.pathway.md/diseases/recMpt3HakCslyHPO 4/5 6/29/23, 3:49 AM Cervical spinal cord injury Pathway 6. Jiang Shao, Wei Zhu, Xiongsheng Chen et al. Factors associated with early mortality after cervical spinal cord injury. J Spinal Cord Med. 2011 Nov; 34 6 555 562. Open 7. Joel A Torretti and Dilip K Sengupta. Cervical spine trauma. Indian J Orthop. 2007 Oct-Dec; 41 4 255 267. Open 8. Jiang Shao, Wei Zhu, Xiongsheng Chen et al. Factors associated with early mortality after cervical spinal cord injury. J Spinal Cord Med. 2011 Nov;34 6 555 62.2011 Nov;34 6 555 62. Open 9. Joel A Torretti, Dilip K Sengupta. Cervical spine trauma. Indian J Orthop. 2007 Oct;41 4 255 67.2007 Oct;41 4 255 67. Open https://web.pathway.md/diseases/recMpt3HakCslyHPO 5/5