Chapter 9

Prompt diagnosis of cervical spine injuries is imperative to provide early treatment and prevent secondary spinal cord injury. The cervical spine is the most common location in the spine to be injured, accounting for more than 60% of cases.1 Unfortunately, there is a delay in diagnosis in one-quarter of cases. Approximately 3% of malpractice claims are related to fractures of the spine, and these claims account for almost 10% of dollars paid.

The upper cervical spine consisting of the occiput, C1 (atlas), and C2 (axis) is unique from the remainder of the cervical spine. It is designed to allow for rotation of the head. The C1 vertebra is a ring structure that articulates with the occiput. The C2 vertebra is composed of a body with a bony projection (dens) that goes through the anterior portion of the ring of C1. The dens is stabilized by the very important transverse and alar ligaments (Fig. 9–1). The transverse ligament is located along the posterior surface of the dens, attaching on either side of C1. Injury to this ligament may be catastrophic to the patient in the form of atlantoaxial instability and a high cervical cord lesion.

###### Figure 9–1.

The transverse and alar ligaments and their importance in stabilizing the C1 and C2 vertebrae.

The lower cervical spine can be divided into two columns, where disruption of an entire column is required to alter stability.2 The anterior column consists of the anterior and posterior longitudinal ligaments and the vertebral body. The posterior column comprises the pedicle, lamina, articular facet joints, and ligamentum flavum.

### Imaging

Not all patients with a traumatic source of neck pain will require imaging. Two groups have attempted to safely reduce the rate of imaging of the cervical spine in the setting of trauma based on the absence of high-risk criteria.3,4 The National Emergency X-Radiography Utilization Study (NEXUS) group identified five criteria that were 99.6% sensitive in excluding a clinically significant cervical spine injury (Table 9–1). The Canadian C-spine rule detected 100% of 151 clinically significant C-spine injuries in 8,924 patients (Fig. 9–2).

Table 9–1. Nexus Criteria to Clinically Exclude a Cervical Spine Fracture
###### Figure 9–2.

The Canadian C-spine rule. (Reprinted, with permission, from Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1846. Copyright 2010 American Medical Association. ...

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