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Key Points

  • Use the NEXUS criteria and/or Canadian C-Spine rules to determine which patients require radiographic imaging.

  • Forego plain films and proceed directly to computed tomography imaging of the cervical spine for all patients with a moderate to high risk of injury.

  • Consider spinal cord injury without radiologic abnormality in pediatric patients with neurologic findings despite negative initial imaging.

  • The use of high-dose corticosteroids to improve long-term neurologic outcomes in patients with blunt spinal cord injury is no longer recommended.


There are currently more than 200,000 patients living with spinal cord injury (SCI) in the United States, and between 12,000 and 20,000 new cases occur on an annual basis. The majority of patients are between 16 and 30 years of age, with motor vehicle collisions, falls, violence, and sporting injuries accounting for the bulk of cases. Fewer than 1% of patients experience complete neurologic recovery before hospital discharge, and the associated economical, physical, and emotional tolls are astronomical.

The cervical spine is composed of 7 cervical vertebrae, the first 2 of which are unique, whereas the remaining 5 (C3 through C7) are functionally similar. The anatomy of the axis (C1) is that of a bony ring without a true vertebral body. It consists of an anterior and posterior arch joined together by 2 lateral masses that articulate with the occipital condyles above and C2 below. The Atlas (C2) has a unique anterior body that extends superiorly to form the odontoid process. This structure articulates with the internal surface of the anterior ring of C1 and is held in place by the transverse ligament. The unique design of these 2 vertebrae allow for the increased flexibility and axial rotation of the upper cervical spine. The remaining cervical vertebrae are functionally similar and composed of an anterior body and a posterior arch.

The vertebrae are separated by flexible intervertebral disks and linked together by an intricate system of ligaments that allows the spine to function as a single unit. Anterior and posterior longitudinal ligaments run along the entire length of the vertebral bodies, whereas the posterior rings are linked together by the ligamentum flavum and interspinous ligaments (Figure 86-1). This network enables significant spinal column mobility while still providing adequate spinal cord protection as it courses within the spinal canal between the body and arch of each vertebra. External forces that exceed the normal physiologic range of motion can result in fractures, dislocations, and spinal cord injuries. Children and the elderly are especially prone to injury of the upper cervical spine (C1 through C3), whereas young and middle-aged adults are more likely to injure the lower cervical spine (C6 through T1). Of the cervical vertebrae, the atlas (C2) is the most frequently fractured.

Figure 86-1.

Bony and ligamentous anatomyof the spine. Reprinted with permission from Tintinalli JE, Kelen GD, Stapczynski JS. Tintinalli's Emergency Medicine: A ...

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