Definition

Cervical trauma refers to an injury to the cervical vertebrae, commonly known as neck bones, typically resulting from mechanical energy. Such injuries may also involve damage to the spinal cord and surrounding cervical tissues. Though infrequent, this condition can lead to long-term paralysis.

The cervical vertebrae form the uppermost segment of the spine located posterior to the neck. There are seven cervical vertebrae, which function to protect the enclosed spinal cord. Due to their anatomical location and flexibility, these vertebrae are the spine's most vulnerable segment. The frequently injured areas include cervical vertebrae 2, 5, 6, and 7.

Causes

Motor vehicle accidents and falls are the primary causes of cervical spine injuries, accounting for 50% and 20% of cases, respectively. Recent studies indicate that factors such as collision force, driver age of 65 or older, and rollover accidents significantly elevate the risk of cervical spine injuries.

Sports-related activities account for 15% of these injuries, while other cases are linked to interpersonal violence. Injuries from sharp objects rarely cause fractures of the cervical vertebrae but can result in significant nerve damage if they do occur.

It is crucial to recognize that initially minor injuries can evolve into more severe conditions. Various processes, including the generation of free radicals, vasogenic edema (tissue swelling), and alterations in blood flow, influence the progression of spinal cord injuries.

Risk factor

While spinal injuries, including those to the cervical region, typically result from accidents and can affect anyone, certain factors can heighten the risk:

• Male Gender: In the United States, women account for only about 20% of traumatic spinal injuries.
• Ages 16 to 30: More than half of spinal injuries occur within this age range.
• Age 65 or Older: Increased risk of falls in the elderly.
• Children: Cervical injuries in children range from 0.2% to 1.6% due to factors such as underdeveloped neck muscles, larger head-to-body ratio, higher spinal pivot points, incomplete ossification, and weaker joint capsules.
• Alcohol Consumption: Involved in 25% of traumatic spinal injuries.
• High-risk activities: Such as diving into shallow water and engaging in sports without proper equipment.
• Preexisting Conditions: Minor injuries can cause significant spinal damage if there are underlying bone or joint conditions, such as osteoporosis.

Symptoms

Common symptoms of cervical trauma include:

• Pain in the back of the neck, especially upon palpation
• Limited neck movement due to pain
• Weakness or numbness in areas innervated by the affected nerve

Physical examination findings in patients with cervical injury may include:

• Spinal shock (due to spinal cord concussion)
• Paralysis
• Loss of tendon reflexes
• Loss of anal muscle tone
• Inability to control urination
• Priapism (prolonged, unwanted erection)
• Loss of bulbocavernosus reflex (anal muscle reflex)
• Neurogenic shock (blood flow disorder due to nerve damage)
• Hypotension (decreased blood pressure)
• Bradycardia (weak heartbeat)
• Red, dry, and warm skin
• Autonomic dysfunction, affecting internal organ functions
• Reduced bowel movements
• Urinary retention or difficulty urinating
• Poikilothermia (impaired body temperature regulation)

Diagnosis

Diagnosis of spinal injuries relies heavily on patient interviews and physical examinations. Manifestations such as neck stiffness or pain can indicate bone fractures and dislocations.

The physician will inquire about the injury mechanism and monitor the patient's condition. Spinal cord injuries should be suspected in unconscious patients, those with neck pain, or those exhibiting signs of nerve injury. However, the absence of neurological symptoms does not exclude the possibility of spinal injuries.

A detailed neurological examination should include the assessment of muscle strength, sensation, and tendon reflexes in the upper and lower limbs. Additionally, the physician will evaluate tenderness, joint movement, and crepitus (crackling sound during joint movement). Examining the cervical nerves can help determine the injury's extent and location:

• C1 to C3: Control head movement.
• C2: Responsible for head sensation.
• C3: Controls sensation on the side of the face and back of the head.
• C3 to C4: Involved in breathing by controlling the diaphragm muscles, leading to respiratory difficulties in injuries at these levels.
• C5 to C7: Responsible for deep tendon reflexes in the biceps, brachioradialis, and triceps.
• C5: Controls shoulder abduction and elbow flexion.
• C6 to C7: Responsible for elbow extension, wrist extension, and flexion.
• C8: Controls finger extension and abduction.

Neurological disorders at any of these levels can present as muscle weakness or paralysis, reduced or absent reflexes, and loss of sensation or proprioception.

Initial evaluation focuses on patient stabilization and advanced life support protocols. Once stable, the patient undergoes neck X-rays from various angles, with a lateral view encompassing all seven cervical vertebrae.

CT scan

CT scans, due to higher radiation exposure, are reserved for high-risk patients, such as those with altered mental status. If initial X-rays are normal and there are no neurological deficits, flexion and extension X-rays are recommended. A CT scan is warranted if:

• Initial X-rays are inadequate
• Further examination is necessary based on X-ray findings
• Bone fractures or dislocations are visible on X-rays
• High-risk injury mechanisms are present

Magnetic Resonance Imaging (MRI)

An MRI is considered when there are neurological signs or symptoms despite normal X-rays or CT scans. MRI can evaluate nerve compression locations.

Management

If a neck injury is suspected:

• Avoid moving the person without proper procedures to prevent serious complications.
• Contact emergency medical services immediately.
• Keep the patient still until help arrives.
• Use thick towels or hold the head and neck to prevent movement until medical help arrives.
• Provide basic first aid, such as stopping bleeding and making the patient comfortable without moving the head or neck.

Minor cervical fractures without neurological deficits may be treated with pain medication, neck braces, and periodic monitoring. Surgery might be necessary for unstable conditions, with the type of surgery dependent on the injury.

The patient's prognosis also depends on associated injuries, such as head trauma, neurological deficits, Glasgow Coma Scale (GCS) score, and age. Many patients may experience persistent movement disorders characterized by chronic pain or limited joint movement range.

Complications

Complications of cervical trauma include:

• Spinal Shock
• Neurogenic Shock
• Anterior Spinal Cord Syndrome: Damage to the front of the spinal cord causing limb paralysis and loss of temperature and pain sensitivity below the injured nerve.
• Central Spinal Cord Syndrome: Marked by weakness, particularly more severe in the upper extremities.
• Brown-Séquard Syndrome: Results from injury to one side of the spinal cord, causing paralysis, loss of vibration sensation, and proprioception on the affected side, along with loss of pain and temperature sensation on the contralateral side.

Prevention

To mitigate the risk of cervical injuries:

• Drive Safely: Motor vehicle crashes are a leading cause of cervical injuries. Always wear seat belts, use helmets when riding motorcycles, and ensure children use appropriate safety restraints. Children under 12 should sit in the back seat to avoid airbag injuries.
• Check Water Depth Before Diving: Do not dive into water unless it is at least 3.7 meters deep and avoid diving into unknown depths.
• Prevent Falls: Use handrails on stairs, and non-slip mats in bathrooms, and ensure ladders are stable. Install safety gates for children and window guards.
• Take Precautions During Sports: Warm up before exercising and use recommended safety equipment. Employ spotters for new gymnastics moves.
• Avoid Driving Under the Influence: Do not drive under the influence of alcohol or drugs, and avoid riding with intoxicated drivers.

When to see a doctor?

Immediate medical evaluation is necessary for anyone who has sustained a head or neck injury to determine if a cervical injury is present. It is prudent to assume the presence of a cervical injury until proven otherwise because:

• Serious cervical injuries are not always immediately apparent.
• Undetected injuries can worsen.
• Numbness or paralysis can occur immediately or develop gradually.
• The timing of treatment significantly impacts severity, complications, and recovery potential.