Cervical Spine Injury

1. Introduction to Cervical Spine Injury (CSI)

🔹 Cervical spine injuries occur in ~2-5% of blunt trauma cases, with C5-C7 being the most commonly injured levels.

🔹 High cervical spine injuries (C1-C4) can cause diaphragmatic paralysis due to phrenic nerve involvement (C3-C5).

🔹 Patients with unstable CSI require immediate spinal immobilization and a precise airway management strategy to prevent secondary spinal cord injury (SCI).

📌 Key Point: Airway management is the most critical step in acute cervical spine trauma.

2. Emergency Department (ED) Management of Cervical Spine Injury

🔹 A. Initial Trauma Assessment (ATLS Protocols)

• Airway (A), Breathing (B),Circulation (C)

🔹 B. Cervical Spine Immobilization

• Rigid cervical collar (Philadelphia collar) is applied immediately.

• Head immobilization with sandbags and tape for suspected CSI.

• Log-roll maneuver for patient transfers.

🔹 C. Neurological Examination (ASIA Score)

• American Spinal Injury Association (ASIA) classification determines neurological impairment.

• Complete spinal cord injury (SCI): No motor or sensory function below the injury level.

• Incomplete SCI: Partial preservation of function.

🔹 D. Imaging in Cervical Spine Injury

• Canadian C-Spine Rule (CCR) and NEXUS Criteria guide imaging decisions.

• CT cervical spine (Gold Standard) – detects fractures.

• MRI cervical spine – detects ligamentous injury and cord compression.

📌 Key Point: All trauma patients are assumed to have an unstable cervical spine injury until proven otherwise.

3. Anesthesia Considerations in Cervical Spine Injury

🔹 A. Airway Management in CSI

• Avoid excessive neck movement during laryngoscopy.

• Preferred techniques:

• Video laryngoscopy (1st choice)

• Fiberoptic intubation (awake, if stable)

• Intubation with manual inline stabilization (MILS)

• Avoid head tilt–chin lift; use jaw thrust instead.

🔹 B. Induction of Anesthesia

• Rapid Sequence Intubation (RSI) with in-line stabilization is standard.

• Drugs of choice: Etomidate (minimal hemodynamic effect) or Ketamine (if hypotensive),Succinylcholine or Rocuronium for muscle relaxation.

🔹 C. Hemodynamic Considerations

• Spinal shock (seen in high cervical injuries) can cause bradycardia and hypotension.

• Fluids and vasopressors (e.g., norepinephrine, dopamine) are needed to maintain MAP > 85 mmHg for spinal cord perfusion.

🔹 D. Intraoperative Monitoring

• Invasive BP monitoring (arterial line) is required.

• Neuromonitoring (SSEP, MEP) is used in spinal surgery cases.

📌 Key Point: Minimizing movement during intubation is the most important anesthetic concern in CSI.

4. ICU Management of Cervical Spine Injury

🔹 A. Ventilation Management

• High cervical injuries (C1-C4) may require prolonged mechanical ventilation.

• Protective lung ventilation strategy (6 mL/kg tidal volume) is recommended.

• Diaphragmatic pacing can be considered in C3-C5 injuries.

🔹 B. Hemodynamic Management

• Neurogenic shock (hypotension + bradycardia) requires vasopressors (e.g., norepinephrine, dopamine).

• Maintain MAP > 85 mmHg to optimize spinal cord perfusion.

🔹 C. DVT Prophylaxis

• Spinal cord injury patients are at high risk for DVT/PE.

• Low-molecular-weight heparin (LMWH) is recommended.

🔹 D. Early Rehabilitation

• Physiotherapy and early mobilization prevent complications.

• Spinal stabilization surgery (if indicated) should be performed early.

📌 Key Point: Ventilatory support and MAP optimization are critical ICU management goals in CSI.

5. MCQs on Cervical Spine Injury

Question 1:What is the gold standard imaging modality for diagnosing cervical spine fractures?

A. X-ray (Lateral View)

B. CT Cervical Spine

C. MRI Cervical Spine

D. Ultrasound

✅ Answer: B. CT Cervical Spine

Question 2:Which of the following is the most appropriate intubation technique in a patient with an unstable cervical spine fracture?

A. Direct laryngoscopy with head tilt

B. Video laryngoscopy with manual inline stabilization

C. Nasal intubation with blind technique

D. Cricothyrotomy as first-line airway management

✅ Answer: B. Video laryngoscopy with manual inline stabilization

Question 3:Which maneuver should be avoided in airway management of a cervical spine injury patient?

A. Jaw thrust

B. Head tilt–chin lift

C. Video laryngoscopy

D. Fiberoptic intubation

✅ Answer: B. Head tilt–chin lift