=====Head & Neck=====
^ Trauma ^ [[head_and_neck#Non Trauma|Non Trauma]] ^
====Cervical spine injuries====
  *immobilisation of patient with rigid collar has inherent risk
    *delay in transport with other life threatening injuries. Those with //__penetrating__// injuries have x2 morbidity/mortality if immobilised compared with non-immobilisation
    *aspiration, pressure sores, raised intra-cranial pressure
  *hypotension and hypoxia contribute to secondary injury after any Spinal Cord Injury (SCI)
    * there is controversy regarding BP management. Usual practice is to maintain mBP>85
  *certain 'usual' neuroprotective agents should NOT be used in acute stage of traumatic spinal cord injury:
    * methylprednisolone, nimodipine, naloxone

===Cord injuries can be characterised===
  *Primary - direct cord compression, penetration, haemorrhage and traction forces
  *Secondary - haemorrhage can cause spinal cord oedema and subsequent spinal cord ischaemia
    *loss of autoregulation. Neurogenic shock with hypotension and //bradycardia*// occurs with high lesions
    *vasomotor changes (local & systemic), release of free radicals, intracellular electrolyte shifts, neurotransmitters, abnormal cell metabolism and death are all factors
    *spinal shock -  flaccid areflexia and usually with hypotension of neurogenic shock. 
[[wiki:neurology:spinalcordsyndromes|Incomplete Spinal Cord Syndromes]]

===Imaging===
Rules for limiting radiology have been developed without a clear difference. Both NEXUS and Canadian C-spine rules have been demonstrated to reduce need for imaging with low chance of missing fractures. Neither are reliably useful in children <10yo

<anno:10>NEXUS</anno><@anno:10>National Emergency X-Radiography Utilisation Study Group</@anno> criteria:
{{ :wiki:musculoskeletal:canadian_c_spine_rule.png?400|}}
if ALL are true, imaging is NOT indicated 
  *no posterior midline C spine tenderness
  *NOT intoxicated
  *alert - GCS=15
  *no focal neurological deficit
  *no painful distracting injuries

**Canadian C spine rule** - probably more diagnostic and recommended in NICE guidelines 
  *plain radiography misses fractures with some studies showing that at least 1/3 patients with identified fracture on plain XRay had a 2nd injury found on CT only
  *visualisation of C7/T1 is vital - **swimmer's view** may be required
  *CT in adults as indicated by Canadian C-spine rules:
    *if unreliable examination or patient obtunded, there is a high risk of non-contiguous injury - CT of whole spine should be undertaken
  *MRI for children <16y if strong suspicion cervical spinal cord injury per Canadian C-spine rule or signs

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|{{:wiki:musculoskeletal:lat_c_spine.png?200|}}|{{:wiki:musculoskeletal:cspine_soft_tissue.png?200|}}|{{:wiki:musculoskeletal:c1c2.png?200|}}|{{:wiki:musculoskeletal:predental_space.png?200|}}|{{:wiki:musculoskeletal:cspine_ap.png?200|}}|
|Smooth lines\\ Facet joint tiling  |**pre-vert soft tissue**\\ <7mm @ C2\\ <1/3 vert width\\ <5mm @ C3,4\\ <22mm @ C5-C7\\ <vert body width\\ <14mm in children <15y  |**dens to C1 ring**=symmetrical  |**pre-dental space**\\ ≤3mm adults\\ ≤4-5mm children  |Smooth lines  |
\\ 
The spinal column is functionally divided into 3 columns with 'instability' being described if any 2 columns are disrupted
  *Ant column - between line joining anterior longitudinal lig's and the anterior half of the intervertebral discs
  *Middle column - between the line joining the posterior longitudinal lig's and the posterior half of the intervertebral discs
  *Posterior column - ligamentum flavum, interspinous and supraspinous ligaments

====Cervical spine fractures====
^Occipital condyle fracture  |• Class I -comminuted fracture of the condyle\\ • Class II -related basilar skull fracture\\  • Class III - avulsion fracture at attachment of alar ligament.  |
^Occipito-cervical dislocation  |• Type I - ventral subluxation of condyles relative to C1\\ • Type II -vertical dislocation of the occipital condyles\\ • Type III -rare & involve dorsal dislocations of the condyles  |
^C1 fracture\\  //(atlas)//  |• Type I - limited to ant or post arch\\ • Type II - unilateral lateral mass injury\\ • Type III - //**‘Jefferson fractures’**// = burst-type fractures with ≥3 fracture sites through ventral & dorsal aspects of the C1 ring\\ • C1 fractures may be associated with disruption of the transverse atlantal ligament causing instability  |
^C2 fracture\\  //(axis)//  ^Dens  |
|  |• Type I - occur at the superior tip of the dens\\  • Type II - junction of base of dens and body of axis\\  • Type III - extend into body of axis  |
|  ^Pars Interarticularis -// Hangman's fractures//  |
|  |• Type I - <3 mm of translation of C2 on C3 and lack significant angulation at the fracture site.\\  • Type II - >3 mm of translation & significant angulation\\  • Type III - involve pars fractures plus bilateral C2/3 facet dislocations  |
^Subaxial  | • C3–C7 = similar in anatomy and biomechanics & therefore similar # patterns.\\   • 6 common patterns - compressive flexion, compressive extension, distractive flexion, vertical compression, distractive extension and lateral flexion  |

===Management===
  *Usual principles of resuscitation with particular attention to avoiding hypoxia to prevent secondary cord injury
  *80% of all cervical cord injuries require ventilation at some point - usually ≤48/24
  *when relevant RSI with manual inline cervical immobilisation (*NB - succinylcholine should not be used after 72/24 as can precipitate life threatening //**hyperkalaemia**//
  *Hypotension due to sympathetic paralysis (after the initial phase when there is massive catecholamine release) - may need vasopressors as less responsive to fluid
  *bradycardia (due to unopposed vagal tone) - may need intermittent atropine or glycopyrrolate
  *therapeutic hypothermia used in some places
  *debate still around the use of steroids but generally NOT used
  *other supportive measures including VTE prophylaxis, gastric protection, nutritional support and pressure area management etc


==== Non Trauma ====
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====Cervical Radiculopathy====
  *typically present with neck pain, arm pain, or both.
  *Unilateral symptoms more common
  *Generally speaking, the incidence of trauma preceding the onset of cervical radiculopathy is relatively low
  *C7 (C6-7 herniation) most commonly affected, followed by the C6 (C5-6 herniation) and C8 (C7-T1 herniation) nerve roots but cervical spondylosis is more common cause
  *mechanical compression leads to irritation, localised ischaemia and nerve damage
  *chemical irritation also accompanies leading to TNF and interleukin release leading to increased sensitisation and pain
  ***Spurling test** is helpful - passive cervical extension with rotation to the affected side and axial compression. +ve if radicular pain is reproduced.
  *//**Differentials**// - peripheral nerve compression syndromes, [[wiki:neurology:nentrapments#brachial_neuritis|Parsonage-Turner syndrome]], cardiac pain, herpes zoster (shingles), postmedian sternotomy lesion, intra and extraspinal tumours, and thoracic outlet syndrome

==References include:== 
[[https://www.nice.org.uk/guidance/ng41/resources/spinal-injury-assessment-and-initial-management-pdf-1837447790533|NICE 2016 spinal injury]]\\ 
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994619/#bibr16-2058-5241.3.170076|NCBI safe management of C spine injuries 2018]]\\ 
[[https://pn.bmj.com/content/15/4/266| Acute Mx C Spine cord injury 2015]]\\ 
https://radiologykey.com/imaging-the-cervical-thoracic-and-lumbar-spine/\\ 
https://emedicine.medscape.com/article/824380-overview\\ 
https://radiologykey.com/imaging-the-cervical-thoracic-and-lumbar-spine/\\ 
[[https://iem-student.org/how-to-read-c-spine-x-ray/|pictures from IEM]]\\ 
[[https://academic.oup.com/bjaed/article/13/6/224/246947|Initial Mx - anaesthesia and Critical care 2013 ]]\\ 
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958381/|Cervical radiculopathy review 2016]]\\