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Prompt diagnosis of cervical spine (C-spine) injuries is imperative to provide early treatment and prevent secondary spinal cord injury. Motor vehicle collisions account for the majority of spinal cord injuries followed by falls and acts of violence (i.e., gunshot wounds).1 Cervical spine injuries are found in 2% to 3% of blunt trauma patients that undergo imaging.2 The cervical spine is the most common location in the spine to be injured, accounting for upward of 60% of cases.1,3 Unfortunately, a delay in diagnosis occurs 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 both the 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.4 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.


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.5,6 The National Emergency X-Radiography Utilization Study (NEXUS) group consisting of 34,069 patients 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 8924 patients. In this rule, to be considered for exclusion from needing C-spine radiographs, patients must have a Glasgow Coma Scale of 15 and have no high risk features (age greater than 65, dangerous mechanism, or extremity paresthesias). Next, low risk factors are assessed. In patients with a low risk factor (simple rear-end MVC, sitting in ED, ambulatory at any time, delayed onset of neck pain, or absence of midline C-spine tenderness) ...

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