Surgery chapters
Neck and spine trauma
Protecting and clearing the cervical spine, imaging, common spinal fractures, neurogenic and spinal shock, incomplete cord syndromes, and the assessment of penetrating and blunt neck injuries.
- Assume a spinal injury in every blunt multisystem trauma patient and restrict spinal motion until it is cleared clinically (NEXUS or Canadian rule) or by CT.
- Neurogenic shock (cord injury at T6 or above) gives hypotension with bradycardia and warm skin; spinal shock is loss of tone and reflexes below the lesion.
- A penetrating neck wound through the platysma is left for a surgeon; active bleeding, expanding haematoma, bruit or airway compromise means operation.
On this page
Overview
Spinal injury is easy to miss and devastating if made worse. ATLS stresses that 5% of brain-injured patients have a spinal injury and a quarter of spinal injury patients have at least a mild brain injury. Any patient with significant head or maxillofacial injury is treated as having a cervical spine injury.
The neck also contains the airway, great vessels, oesophagus and nerves in a small space, so a small wound can hide a large injury.
Anatomy you need
- The cord runs from the foramen magnum to about L1/L2 (conus medullaris); below is the cauda equina. So lumbar fractures below L2 rarely cause complete deficits.
- Mobile–fixed junctions are injured most: cervicothoracic and thoracolumbar (T11–L1).
- The thoracic canal is narrow, so a thoracic fracture-dislocation usually causes a complete cord injury, although the rib cage makes thoracic fractures less common.
| Tract | Carries | Crosses |
|---|---|---|
| Lateral corticospinal | Motor | In the medulla (so loss is same side) |
| Dorsal columns | Position, vibration, fine touch | In the medulla (same side) |
| Lateral spinothalamic | Pain and temperature | Within 1–2 segments of entry (opposite side) |
Three-column model: anterior, middle and posterior columns. Injury to two or more columns means the spine is unstable.
Distribution of spinal injury (ATLS)
- About 55% cervical, 15% thoracic, 15% thoracolumbar junction, 15% lumbosacral.
As many as 1 in 10 people with a broken cervical vertebra also have a second, non-adjacent spinal fracture, so image the whole spine once one fracture is found.
Initial management
- Primary survey first. Airway with cervical spine motion restriction: manual in-line stabilisation during intubation, then a rigid collar with blocks.
- Log-roll with enough people to inspect and palpate the whole spine; look for step, gap, tenderness and bruising.
- Long spine boards are for transport only; insensate skin breaks down into pressure sores quickly. A firm flat surface with careful handling is enough.
- Rectal examination: anal tone, voluntary contraction and perianal sensation.
- Treat hypotension: exclude bleeding first, then think of neurogenic shock.
- Insert a urinary catheter (retention) and a gastric tube (ileus).
- Breathing: cord injury at C3–C5 paralyses the diaphragm; lower cervical or upper thoracic injury paralyses the intercostals, giving abdominal (diaphragmatic) breathing.
In ankylosing spondylitis the stiff spine fractures easily, and forcing a standard collar onto a fixed kyphotic neck can harm. Immobilise in the patient's usual position.
Clinical clearance of the cervical spine: NEXUS
No imaging is needed if all five are present:
- No midline posterior cervical tenderness
- No intoxication
- Normal alertness
- No focal neurological deficit
- No painful distracting injury
NEXUS: Neuro deficit, Ethanol/intoxication, eXtreme distracting injury, Unable to give a history, Spinal tenderness.
The Canadian C-Spine Rule is the other validated tool (high-risk factors such as older age, dangerous mechanism or limb paraesthesia mean imaging; low-risk patients are asked to rotate the neck).
Imaging
- CT (multidetector) from occiput to T1 with reconstructions is the investigation of choice and the gold standard for bony injury.
- Without CT: lateral, AP and open-mouth (odontoid) views. The lateral film must show the skull base down to the top of T1; if not, pull the shoulders down or take a swimmer's view.
- On the lateral film check prevertebral soft tissue swelling and the anterior, posterior and spinolaminar lines. Bailey & Love describes instability as more than 3.5 mm translation or more than 11° angulation compared with the next level.
- MRI for neurological deficit, ligament injury and cord or disc lesions; also for clearing the obtunded patient.
- Flexion–extension films are not done acutely.
Children can have SCIWORA (spinal cord injury without radiographic abnormality), so a normal X-ray does not exclude cord injury; MRI is needed.
Specific spinal injuries
| Injury | Level / mechanism | Key points |
|---|---|---|
| Jefferson fracture | C1 ring burst from axial loading (diving, weight on head) | Lateral masses spread; best on open-mouth view and CT; usually no cord injury (wide canal) but unstable; collar or halo |
| Atlanto-axial rotatory subluxation | C1 on C2; children, minor trauma, infection, rheumatoid arthritis | Fixed torticollis; do not force the head straight |
| Odontoid (dens) fractures | C2 | Type I tip (uncommon); type II base of dens (commonest, prone to non-union); type III extends into the C2 body |
| Hangman fracture | C2 pars interarticularis (posterior elements), hyperextension | Traumatic spondylolisthesis of C2 on C3; rigid collar then specialist care |
| Subaxial (C3–C7) injuries | Flexion, extension, rotation | C5 commonest fracture level; C5 on C6 commonest subluxation; unilateral or bilateral facet dislocation (bilateral is worse) |
| Thoracic wedge compression | Flexion with axial load | Anterior height rarely reduced by more than a quarter; usually stable |
| Burst fracture | Vertical axial load | Widened interpedicular distance, fragments pushed into canal; unstable |
| Chance fracture | Flexion–distraction across a lap belt | Transverse split through body and posterior elements; associated duodenal, pancreatic, bowel and aortic injury |
| Fracture-dislocation | High energy, rotation | Thoracic: usually complete cord injury |
Axial loading → Jefferson (C1). Hyperextension → hangman (C2) and central cord syndrome. Lap belt flexion–distraction → Chance (thoracolumbar).
Bailey & Love notes that corticosteroids are no longer indicated for acute spinal cord injury; ATLS also finds insufficient evidence for them. The only absolute indication for urgent spinal surgery is deteriorating neurology.
Neurogenic shock vs spinal shock
| Feature | Neurogenic shock | Spinal shock | Haemorrhagic shock |
|---|---|---|---|
| Cause | Loss of sympathetic outflow (cord injury T6 or above, mostly cervical) | Temporary loss of all cord function below the lesion | Blood loss |
| Blood pressure | Low | May be normal | Low |
| Heart rate | Normal or slow | Variable | Fast |
| Skin | Warm, dry, pink | Variable | Cold, clammy |
| Tone and reflexes | — | Flaccid, areflexic | Normal |
| Treatment | Cautious fluids, vasopressors, atropine for bradycardia | Supportive; resolves over days to weeks | Stop bleeding, blood |
- Spinal shock ends when the bulbocavernosus reflex returns; spasticity and brisk reflexes follow.
- Bailey & Love says spinal shock can last 6 weeks or longer.
Haemorrhage is still the commonest cause of shock in trauma, even with a cord injury. Rule out bleeding before blaming neurogenic shock. Large fluid volumes in neurogenic shock cause pulmonary oedema.
Classifying the cord injury
- Neurological level: the most caudal segment at which both feeling and power are still intact on right and left.
- Complete vs incomplete: any sacral sparing (perianal sensation, deep anal pressure or voluntary anal contraction) means incomplete, with a better outlook. Sacral reflexes (bulbocavernosus, anal wink) do not count as sparing.
- ASIA impairment scale (based on Frankel): A complete; B sensory only; C motor present but most key muscles below grade 3; D most key muscles grade 3 or more; E normal.
Useful sensory landmarks
| Level | Area |
|---|---|
| C5 | Lateral shoulder (skin over deltoid) |
| C6 | Tip of the thumb |
| C7 | Pulp of the middle finger |
| C8 | Tip of the little finger |
| T4 | Nipple line |
| T10 | Umbilicus |
| L5 | First web space of the foot |
| S1 | Lateral border of the foot |
Incomplete cord syndromes
| Syndrome | Mechanism | Picture | Prognosis |
|---|---|---|---|
| Central cord | Hyperextension in an older patient with cervical spondylosis/stenosis (forward fall on the face) | Arms weaker than legs, variable sensory loss | Best of the incomplete syndromes |
| Anterior cord | Flexion injury or anterior spinal artery ischaemia | Paraplegia and bilateral loss of pain and temperature; dorsal columns preserved | Worst |
| Brown-Séquard | Hemisection, usually penetrating (stab) | Same-side weakness and loss of position/vibration; opposite-side loss of pain and temperature 1–2 levels below | Good recovery usual |
| Posterior cord | Rare | Loss of position and vibration only | Variable |
| Cauda equina | Lumbar/sacral root compression | Lower motor neurone weakness, saddle anaesthesia, sphincter loss | Depends on early decompression |
In the cord, the arm fibres lie centrally, so a central lesion hits the arms most.
Complications of spinal cord injury
- Pressure sores (turn regularly, proper mattress)
- DVT and PE (Bailey & Love: DVT in about 30%; give stockings and low molecular weight heparin when safe)
- Autonomic dysreflexia in lesions above about T6: sudden hypertension, headache, flushing and sweating above the lesion, bradycardia; usually triggered by a full bladder or loaded rectum. Treat by sitting up and removing the trigger.
- Neurogenic bladder and bowel, urinary infection and stones
- Spasticity, contractures, heterotopic ossification, osteoporosis
- Post-traumatic syringomyelia (late rising level of deficit)
- Respiratory failure and pneumonia in high lesions
Penetrating neck injury
- Do not probe or explore a wound that breaches the platysma in the emergency room; call a surgeon.
- Airway first: early intubation if there is an expanding haematoma, stridor or voice change; a surgical airway may be needed.
- Hard signs needing operative exploration (ATLS): active arterial bleeding, an expanding haematoma, a bruit, or airway compromise. Other signs: subcutaneous emphysema, haemoptysis, haematemesis, dysphagia, voice change, neurological deficit.
- Stable patients without hard signs: CT angiography, with contrast swallow, endoscopy or bronchoscopy as needed.
- Unexplained weakness of one arm suggests a brachial plexus or root injury.
Anatomical zones of the neck (traditional)
| Zone | Boundaries | Concern |
|---|---|---|
| I | Clavicles/sternal notch to the cricoid cartilage | Great vessels, thoracic outlet; hard to reach, needs imaging and possibly sternotomy |
| II | Cricoid to the angle of the mandible | Carotid, jugular, larynx; most accessible |
| III | Angle of mandible to the skull base | Distal carotid; difficult exposure; often angiography |
Many centres now decide on physiology and CT angiography rather than zone alone.
Blunt neck injury
- Laryngeal fracture: triad of hoarseness, subcutaneous emphysema and palpable fracture crepitus. Secure the airway early; a surgical airway (tracheostomy, or cricothyroidotomy as a lifesaving option) may be needed.
- Blunt carotid and vertebral artery injury: seat-belt across the neck, hanging, hyperextension. May present late with stroke. Screen with CT angiography when there are C1–C3 fractures, cervical fracture with subluxation, or fractures through the foramen transversarium.
Expect: who needs c-spine imaging (NEXUS), the standard plain film series and the need to see C7–T1, the fracture from axial loading (Jefferson) and hyperextension (hangman), commonest odontoid type, Chance fracture and associated visceral injury, neurogenic vs hypovolaemic vs spinal shock, the definition of incomplete injury, the four cord syndromes and their prognosis, steroids in cord injury, autonomic dysreflexia triggers, and what to do with a neck wound breaching the platysma.
Quick revision
- Treat every major blunt trauma patient as having a spinal injury until cleared.
- NEXUS: no midline tenderness, not intoxicated, alert, no deficit, no distracting injury.
- CT occiput–T1 is the standard; X-ray series is lateral, AP, open-mouth; must see C7–T1.
- C1 Jefferson (axial load); C2 hangman (extension); odontoid type II commonest; C5 commonest level.
- Chance = lap belt flexion–distraction + bowel/pancreas injury.
- Neurogenic shock: low BP, slow pulse, warm; vasopressors and atropine.
- Spinal shock ends with return of the bulbocavernosus reflex.
- Incomplete = sacral sparing. Central cord best, anterior cord worst.
- No steroids for acute cord injury.
- Neck wound through platysma: no probing; hard signs → theatre.
Written by The House Job from standard references (ATLS Student Course Manual, 10th edition; Bailey & Love's Short Practice of Surgery, 27th edition).
FAQ
How do I tell neurogenic shock from bleeding in a patient with a neck injury?
Neurogenic shock gives low blood pressure with a normal or slow pulse and warm skin, while bleeding gives a fast pulse and cold, clammy skin; always exclude bleeding first because both can coexist.
What makes a spinal cord injury incomplete?
Any preserved function in the lowest sacral segments, such as perianal sensation, deep anal pressure or voluntary anal contraction.
Which cervical X-ray view shows a Jefferson fracture best?
The open-mouth odontoid view, which shows the lateral masses of C1 spreading outwards; CT confirms it.
Should a stab wound of the neck be probed in the emergency room?
No. If it goes through the platysma it should be assessed by a surgeon, with immediate operation for hard signs and CT angiography for stable patients.