• 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

• 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.

Incomplete Spinal Cord Syndromes

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

NEXUSclose National Emergency X-Radiography Utilisation Study Group criteria: 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

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

• 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

• 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, Parsonage-Turner syndrome, cardiac pain, herpes zoster (shingles), postmedian sternotomy lesion, intra and extraspinal tumours, and thoracic outlet syndrome

NICE 2016 spinal injury
NCBI safe management of C spine injuries 2018
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/
pictures from IEM
Initial Mx - anaesthesia and Critical care 2013
Cervical radiculopathy review 2016