Blunt neck trauma: Difference between revisions

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==Background==
==Background==
*Suspect vascular damage to cord if discrepancy between [[Focal neurologic deficits|neuro deficit]] and level of spinal column injury
*[[Spinal cord injury]] is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted
[[File:Three-column-concept-2.jpg|thumb|Three column concept of spinal fracture stability]]
[[File:Three-column-concept-2.jpg|thumb|Three column concept of spinal fracture stability]]
*Suspect vascular damage to cord if discrepancy between neuro deficit and level of spinal column injury
*RA predisposes to C2 transverse ligament rupture
*Cord injury is more likely if ant (vertebral bodies) AND post (spinal canal) columns are disrupted
*Penetrating injury rarely results in unstable fx


==Fractures and Related==
==Clinical Features==
{{Cervical spine injuries}}
*Signs of life-threatening neck or upper thoracic injury (look for ''TWELVE'')
''T''racheal deviation'',
''W''ounds,
''E''xternal markings,
''L''aryngeal disruption,
''V''enous distention,
''E''mphysema (surgical)
*Features may include signs and symptoms of:
**[[Spinal cord injury]]
**[[Vertebral and Carotid Artery Dissection]]
**Laryngeal or [[tracheal injury]]
 
==Differential Diagnosis==
{{Blunt neck trauma DDX}}
 
===Other===
*[[Head trauma]]
*[[Thoracic trauma]]
 
==Evaluation==
 
===Fracture===
{{C-spine NEXUS}}
:^If find injury consider CT C-spine, x-ray rest of spine
 
===[[Spinal cord trauma]]===
*Neuro exam
 
===[[Vertebral and Carotid Artery Dissection]]===
{{Denver Screening Criteria}}


== Vascular Injuries ==
===Pediatrics===
*Carotid and vertebral artery injuries can occur with blunt c-spine trauma
*In a small study of 42 patients with a cervical seatbelt sign there were no isolated  cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. <ref>Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.</ref>
**Half of patients present with initially normal neuro exam
**OR for carotid/vertebral artery injury of 8.6 with c-spine fracture
**OR for vertebral artery injury of 30.6 with transverse process fracture
**Vertebral angiography for transverse process fractures extending into transverse foramen or evidence of vertebral-basilar insufficiency(90% show dissection or occlusion of vertebral artery)
*Indications for screening (CTA or MRA) for vascular injury
**Unexplained neuro deficit with hyperflexion or extension injury
**Blunt trauma to neck or seatbelt injury
**C-spine or skull base fractures involving vascular foramina
**[[Le Fort]] II or III facial fractures


==Management==
==Management==
*Prehospital: see the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]]
*Prehospital
**See the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]]
*Hospital
**Secure ABCs
**See specific diagnosis
 
==Disposition==
*Based on specific diagnosis


==See Also==
==See Also==
*[[Spinal Cord Trauma]]
*[[Penetrating neck trauma]]
*[[Spinal Cord Compression (Non-Traumatic)]]
*[[Cervical spine clearance]]
*[[Neurogenic Shock]]
*[[Canadian cervical spine rule]]
*[[C-spine (NEXUS)]]
*[[NEXUS cervical spine rule]]
*[[C-Spine X-Ray]]
*[[Fractures (Main)]]
*[[Unstable spine fractures‎]]


==Source==
==References==
*National Spinal Cord Injury Statistical Center (NSCISC). Spinal Cord Injury. Facts and Figures at a Glance. Birmingham, Ala: NSCISC; July 1996
<references/>
*Ivy ME, Cohn SM. Addressing the myths of cervical spine injury management. Am J Emerg Med. Oct 1997;15(6):591-5
*Woodring JH, Lee C, Duncan V. Transverse process fractures of the cervical vertebrae: are they insignificant? J Trauma. June 1993; 34(6):797-802.
*Tintinalli's


[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Revision as of 16:11, 13 April 2017

Background

  • Suspect vascular damage to cord if discrepancy between neuro deficit and level of spinal column injury
  • Spinal cord injury is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted
Three column concept of spinal fracture stability

Clinical Features

  • Signs of life-threatening neck or upper thoracic injury (look for TWELVE)

Tracheal deviation, Wounds, External markings, Laryngeal disruption, Venous distention, Emphysema (surgical)

Differential Diagnosis

Neck Trauma

Other

Evaluation

Fracture

NEXUS Cervical Spine Rule

Radiography is not necessary if the patient satisfies ALL of the following low risk criteria:

  • No midline cervical tenderness
  • No focal neuro deficits
  • Normal alertness
  • No intoxication
  • No painful distracting injury

C-spine imaging should be considered unless the patient meets all of the above low risk criteria[1] [2]

^If find injury consider CT C-spine, x-ray rest of spine

Spinal cord trauma

  • Neuro exam

Vertebral and Carotid Artery Dissection

Denver screening criteria for blunt cerebrovascular injury

The Denver Screening Criteria are divided into risk factors and signs and symptoms

Signs and Symptoms

  • Arterial hemorrhage
  • Cervical bruit
  • Expanding neck hematoma
  • Focal neurologic deficit
  • Neuro exam inconsistent with head CT
  • Stroke on head CT

Risk Factors

  • Midface Fractures (Le Fort II or III)
  • Basilar Skull Fracture with carotid canal involvement
  • Diffuse axonal injury with GCS<6
  • Cervical spine fracture
  • Hanging with anoxic brain injury
  • Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status
    • Isolated seatbelt sign without other neurologic symptoms has not been identified as a risk factor[3][4][5]

Pediatrics

  • In a small study of 42 patients with a cervical seatbelt sign there were no isolated cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. [6]

Management

Disposition

  • Based on specific diagnosis

See Also

References

  1. 27. Hoffman JR, et al. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 1992;21:1454-60.
  2. Mahadevan, et al. Interrater reliability of cervical spine injury criteria inpatients with blunt trauma. Ann Emerg Med1998;31:197-201
  3. DiPerna CA, Rowe VL, Terramani TT, et al. Clinical importance of the “seat belt sign” in blunt trauma to the neck. Am Surg. 2002;68:441–445
  4. Rozycki GS, Tremblay L, Feliciano DV, et al. A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma. 2002;52:618–623; discussion 623–624
  5. Sherbaf FG, Chen B, Pomeranz T, et al. Value of emergent neurovascular imaging for “Seat belt injury”: A multi-institutional study. American Journal of Neuroradiology. 2021;42(4):743-748
  6. Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.