Eduovisual
Emergency & Toxicology
Cervical spine clearance in trauma
— Cervical spine injury (CSI) occurs in 2–5% of blunt trauma patients presenting to US emergency departments
— Missed CSI carries catastrophic risk: secondary cord injury, quadriplegia, and medicolegal liability
— Goal of "clearance" is to safely remove cervical immobilization (collar) once injury is reasonably excluded, balancing the morbidity of prolonged collar use (pressure ulcers, aspiration, raised ICP, agitation in TBI) against missed fracture
— High-speed MVC (>35 mph, rollover, ejection, death of occupant)
— Falls >3 feet or 5 stairs (any height in elderly)
— Axial load injury (diving, helmet-to-helmet)
— Bicycle/motorcycle collision, pedestrian struck
— Penetrating trauma near the neck
— EMS applies rigid collar + spinal motion restriction for any suspicious mechanism or symptoms
— On ED arrival: maintain immobilization until clinical or radiographic clearance protocol is completed
— ATLS primary survey first — airway, breathing, circulation, disability — manage life threats before formal C-spine workup
— All blunt trauma patients with possible cervical injury
— Penetrating neck trauma does NOT require routine collar (collar can obscure vascular injury and delay airway); only immobilize if focal neurologic deficit
— NEXUS criteria (sensitivity ~99%)
— Canadian C-Spine Rule (CCR) (sensitivity ~99–100%, higher specificity)
Board pearl: A cervical collar in a combative TBI patient raises ICP and worsens outcomes — clear the C-spine early or use clinical clearance pathways aggressively rather than leaving the collar on "just in case." If imaging is needed, get CT promptly rather than deferring.
— Midline posterior neck pain (the single most sensitive symptom)
— Paresthesias, weakness, electric "Lhermitte-like" shocks
— Urinary retention or incontinence (cord involvement)
— Priapism in males (complete cord injury)
— Central cord syndrome: elderly patient, hyperextension (often a fall forward onto face), upper-extremity weakness > lower-extremity weakness, often with cervical spondylosis
— Anterior cord syndrome: flexion injury or vascular insult, bilateral motor + pain/temp loss, preserved proprioception/vibration
— Brown-Séquard: penetrating/hemisection, ipsilateral motor + proprioception loss, contralateral pain/temp loss
— Complete cord injury: flaccid paralysis, areflexia, loss of all sensation below level, spinal shock
— Age ≥65: cannot use NEXUS reliably; CCR mandates imaging
— Dangerous mechanism (as defined by CCR)
— Paresthesias in extremities at any point — disqualifies low-risk clinical clearance
— Prior cervical surgery, ankylosing spondylitis, RA, DISH — predispose to unstable fractures from minor trauma
— Long-bone fracture, large laceration, burn, or any painful injury that may mask neck pain
— Considered a NEXUS exclusion (cannot clinically clear)
— Alcohol, drugs, head injury → cannot reliably assess; require imaging
— GCS <15 typically mandates CT
Step 3 management: In a 72-year-old who fell down 4 stairs and now has neck pain — even if exam is normal and she is alert — proceed directly to CT cervical spine. Age ≥65 alone meets a "dangerous" CCR criterion and removes the option of clinical clearance, regardless of how reassuring the bedside exam appears at triage.
— Log-roll patient maintaining inline stabilization
— Palpate each spinous process from occiput to T1 looking for midline tenderness, step-off, boggy hematoma, or crepitus
— Inspect for ecphymosis, abrasions ("seatbelt sign"), or penetrating wounds
— Active rotation 45° left and right while seated
— If the patient cannot achieve full painless rotation, clearance fails → imaging
— C5 deltoid/biceps, C6 wrist extensors, C7 triceps, C8 finger flexors, T1 finger abductors
— Grade 0–5 bilaterally; document asymmetry
— C4 shoulder cap, C6 thumb, C7 middle finger, C8 little finger, T1 medial forearm
— Test light touch and pinprick — dissociation suggests cord syndrome
— Biceps (C5–6), brachioradialis (C6), triceps (C7)
— Hoffman sign: flick distal middle finger → flexion of thumb/index suggests UMN/cord pathology
— Bulbocavernosus reflex: absence indicates spinal shock; return marks end of spinal shock and allows prognostication
— Neurogenic shock: hypotension + bradycardia + warm dry skin from loss of sympathetic tone (T6 and above)
— Distinguish from hypovolemic shock (tachycardia, cool extremities) — and remember both can coexist in polytrauma
— Tone, voluntary contraction, sensation, bulbocavernosus
Key distinction: Neurogenic shock is hemodynamic (vasodilation, bradycardia) and treated with fluids then vasopressors (norepinephrine, phenylephrine). Spinal shock is a transient neurologic phenomenon — flaccidity and areflexia below the lesion — and is not a shock state at all.
— No midline cervical tenderness
— No focal neurologic deficit
— Normal alertness (GCS 15, oriented)
— No intoxication
— No painful distracting injury
— Sensitivity ~99%, specificity ~13% (over-images)
— Step 1 — High-risk factors mandating imaging:
— Age ≥65
— Dangerous mechanism (fall ≥3 ft/5 stairs, axial load, MVC >100 km/h, rollover, ejection, motorized recreational vehicle, bicycle collision)
— Paresthesias in extremities
— Step 2 — Low-risk factors allowing safe ROM assessment:
— Simple rear-end MVC (not pushed into traffic, not struck by high-speed vehicle, not rollover)
— Sitting position in ED
— Ambulatory at any time
— Delayed onset of neck pain
— Absence of midline tenderness
— Step 3 — Able to actively rotate neck 45° left and right? If yes → clinically clear, no imaging
— CT cervical spine without contrast is first-line in all adults requiring imaging
— Plain radiographs (3-view: AP, lateral, odontoid) are inadequate in adults and are no longer recommended when CT is available
— Lateral plain film must show C7–T1 junction to be considered adequate (often requires swimmer's view)
— CT sensitivity for clinically significant fracture ~98%
— Adds detection of facet fractures, transverse process fractures, and incidental vascular concerns
Board pearl: Plain films are essentially obsolete for adult C-spine clearance in the US trauma bay — choose CT every time on a Step 3 stem. The exception is pediatrics, where plain films remain first-line to minimize radiation exposure.
— Indicated when:
— Persistent neurologic deficit despite normal CT
— Suspected ligamentous injury (e.g., increased prevertebral soft tissue on CT, widened interspinous distance, listhesis without fracture)
— Obtunded patient with negative CT and ongoing need for clearance
— Suspected cord contusion, epidural hematoma, or disc herniation
— Best modality for ligaments, discs, cord, and epidural collections
— High-quality CT alone is sufficient to remove the collar in obtunded blunt trauma patients with negative CT (EAST, Western Trauma Association guidelines)
— MRI is no longer routinely required; reserved for those with neurologic findings or abnormal CT
— This shift reduces collar-related complications in ICU patients
— Screen for blunt cerebrovascular injury (BCVI) using modified Denver criteria:
— C-spine fracture involving foramen transversarium, subluxation, or any fracture C1–C3
— Basilar skull fracture into carotid canal
— Le Fort II/III facial fractures
— Severe TBI with GCS <6
— Cervical seatbelt sign with significant swelling/pain
— Near-hanging with anoxia
— Largely obsolete; high false-negative rate in acute setting due to muscle spasm
— Some centers use delayed (7–10 day) flex-ex if persistent pain after negative CT/MRI
Step 3 management: For a polytrauma patient with a C2 fracture, do not stop at CT spine — order CTA neck to evaluate for vertebral artery injury. A missed BCVI can lead to delayed stroke days later, and treatment (antiplatelet or anticoagulation) is initiated based on grade once intracranial hemorrhage is excluded.
— Step 1: Is the patient alert (GCS 15), non-intoxicated, without distracting injury, and without focal neuro deficit?
— If NO → CT cervical spine
— If YES → proceed to Step 2
— Step 2: Apply Canadian C-Spine Rule
— Any high-risk factor → CT
— No high-risk factor + low-risk factor present + able to rotate 45° → clinically clear, remove collar
— Otherwise → CT
— Maintain collar
— Obtain CT cervical spine immediately
— If CT negative and no focal deficit on best available exam → remove collar per modern consensus
— If CT shows fracture or persistent neuro deficit → MRI and spine surgery consult
— Considers morphology (compression, burst, distraction, rotational), discoligamentous complex integrity, and neurologic status
— Score ≥5 → operative; ≤3 → nonoperative; 4 → surgeon discretion
— Jefferson burst (C1)
— Hangman's fracture (C2 pedicle/pars)
— Type II odontoid fracture (high nonunion)
— Bilateral facet dislocation
— Flexion teardrop fracture
— Any distraction injury, especially in ankylosing spondylitis
CCS pearl: In a CCS case of high-energy trauma, your sequence is: cervical collar on arrival → ATLS primary survey → CT head + CT cervical spine (often as part of pan-CT) → consult neurosurgery/orthopedic spine if positive → CTA neck if Denver criteria met → admit ICU for spinal precautions. Advancing the clock without imaging in a high-risk patient is a common deduction.
— IV acetaminophen and short-course opioids (fentanyl or morphine, titrated)
— Avoid NSAIDs acutely if surgery anticipated or fracture confirmed (bone healing concerns) and in head-injured patients (bleeding risk)
— Muscle relaxants (cyclobenzaprine, methocarbamol) for muscular strain after fracture excluded
— IV crystalloid bolus first (avoid over-resuscitation — can worsen cord edema)
— Maintain MAP 85–90 mmHg for first 7 days post cord injury to optimize cord perfusion
— Vasopressor of choice: norepinephrine (alpha + beta — counters both vasodilation and bradycardia)
— Phenylephrine acceptable but may worsen reflex bradycardia
— Atropine or glycopyrrolate for symptomatic bradycardia
— No longer recommended as standard of care by AANS/CNS, AAOS, or ATLS
— Evidence does not support meaningful neurologic recovery; increased rates of infection, GI bleeding, and pneumonia
— May still be administered at some institutions within 8 hours, but Step 3 answer is: steroids are not standard
— Spinal cord injury patients are extremely high risk for DVT/PE
— Mechanical prophylaxis (SCDs) starts immediately
— Pharmacologic prophylaxis (LMWH preferred) starts within 72 hours once hemorrhagic risk cleared with surgical team
— PPI for stress ulcer prevention
— Foley catheter; bowel regimen to prevent ileus and autonomic dysreflexia later
Board pearl: If a Step 3 stem asks whether to give high-dose methylprednisolone to a patient with acute cervical cord injury, the answer is no. Choose supportive care, MAP goal 85–90, and early neurosurgical consultation.
— Rigid Philadelphia or Aspen collar applied at scene
— Avoid the cumbersome long backboard beyond transport — increases pressure injury and respiratory restriction; remove on ED arrival
— Maintain in-line cervical stabilization during intubation
— Front of collar may be opened to allow jaw movement while assistant holds head
— Video laryngoscopy preferred — less cervical motion than direct
— Avoid nasotracheal intubation in midface/basilar skull fracture
— For facet dislocations, awake closed reduction with traction (Gardner-Wells tongs) can be considered by spine service before MRI in select centers
— MRI before reduction is required if patient is obtunded (rule out disc herniation that could worsen with reduction)
— Unstable fracture pattern (SLIC ≥5)
— Cord compression with neurologic deficit
— Failure of closed reduction
— Progressive deformity or pain
— Open or penetrating injury
— Anterior cervical discectomy and fusion (ACDF) for anterior compression, disc herniation, burst fractures
— Posterior fusion for posterior ligamentous disruption, multilevel injuries, facet dislocations
— Combined approaches for highly unstable injuries
— Used for type II odontoid fractures in young patients, some Jefferson and hangman's fractures
— Avoid in elderly (high morbidity: pneumonia, mortality up to 40%) — favor surgical fixation or rigid collar
— Early decompression (<24 hours) in incomplete cord injury improves neurologic outcomes (STASCIS trial)
Step 3 management: Spinal cord injury with incomplete deficit and cord compression on MRI → urgent (within 24 hours) decompression by neurosurgery or orthopedic spine. Delay is a wrong-answer choice; admit to ICU, maintain MAP 85–90, and operate early.
— Cervical spondylosis, osteoporosis, kyphosis reduce spinal canal reserve
— Low-energy mechanisms (ground-level fall) commonly cause fractures
— Odontoid type II fractures are the most common C-spine fracture in patients >70
— Central cord syndrome from hyperextension is classic
— Age ≥65 → automatic CT per Canadian rule
— NEXUS performs poorly in elderly; many recommend imaging regardless of NEXUS in age ≥65
— Dementia or baseline cognitive impairment removes ability to clinically clear
— Halo vest associated with high morbidity/mortality in elderly — avoid
— Surgical fixation (odontoid screw or C1–C2 fusion) often preferred over prolonged rigid collar
— Conservative management with hard collar for 12 weeks acceptable if poor surgical candidates
— Many elderly are on DOACs, warfarin, antiplatelets
— Reverse coagulopathy if intracranial or cord hemorrhage present
— Warfarin → 4-factor PCC + vitamin K
— Dabigatran → idarucizumab
— Apixaban/rivaroxaban → andexanet alfa or 4-factor PCC
— Hold anticoagulation; resume timing coordinated with spine and trauma teams
— Adjust opioids: morphine accumulates in renal failure → use hydromorphone or fentanyl
— LMWH requires dose reduction at CrCl <30; consider unfractionated heparin
— Avoid NSAIDs in CKD
— "Brittle" fused spine — minor trauma causes highly unstable transverse fractures
— Always image with CT, low threshold for MRI; high rate of epidural hematoma
Board pearl: A 78-year-old with neck pain after a ground-level fall on warfarin — image with CT cervical spine and CT head, reverse INR if any bleed, and consider hospital admission for observation even if imaging is initially negative.
— Large head relative to body → fulcrum at C2–C3 in children <8
— More cartilaginous, ligamentous laxity
— Higher incidence of upper cervical (occiput–C2) injuries and SCIWORA (spinal cord injury without radiographic abnormality)
— Pseudosubluxation of C2 on C3 is normal in children <8 (Swischuk line corrects for this)
— NEXUS is validated down to age 2 but performs less reliably <8
— PECARN identified risk factors: altered mental status, focal neuro findings, neck pain, torticollis, substantial torso injury, high-risk MVC, predisposing condition (Down, Klippel-Feil)
— Imaging modality: plain radiographs first-line in children to minimize radiation; CT only if abnormal films or high suspicion
— MRI for SCIWORA suspicion
— Atlantoaxial instability — screen with flexion-extension films before contact sports; any trauma warrants imaging
— Trauma is leading non-obstetric cause of maternal mortality
— Tilt backboard 15° to left to displace gravid uterus off IVC
— Imaging: CT cervical spine has minimal fetal radiation exposure (uterus shielded; scatter <1 mGy) — do not withhold indicated imaging
— Fetal monitoring for ≥4 hours if ≥20 weeks after trauma
— MRI safe in pregnancy without gadolinium
— Inform pregnant patients that benefit of cervical imaging far outweighs negligible fetal risk
— Document shared decision-making
Key distinction: SCIWORA — pediatric phenomenon where the child has neurologic deficits but normal plain films and CT; MRI is the test of choice and may show cord edema or ligamentous injury. Adults with negative CT but persistent deficits also get MRI but the entity is named for pediatrics.
— Complete cord injury → quadriplegia, ventilator dependence (lesions above C5)
— Phrenic nerve (C3–C5) injury → diaphragmatic paralysis
— Incomplete syndromes with variable recovery
— Neurogenic shock: hypotension, bradycardia, vasodilation
— Spinal shock: flaccid areflexia, returning bulbocavernosus signals resolution
— In injuries above T6, noxious stimulus below the lesion (full bladder, fecal impaction) triggers severe hypertension, headache, flushing above lesion, pallor below
— Treatment: sit upright, remove stimulus, short-acting antihypertensive (nitroglycerin, nifedipine)
— Atelectasis, pneumonia, ventilator-associated complications
— High cervical injuries require tracheostomy planning
— Highest risk in immobilized SCI patients; PE is a major cause of late mortality
— Occipital, sacral, heel ulcers from collar and immobility — reposition every 2 hours, remove backboard early
— Pressure ulcers (occiput, mandible, chin)
— Aspiration from limited swallowing/airway access
— Increased ICP in TBI patients
— Agitation and increased sedation needs
— Missed BCVI → delayed stroke days to weeks later
— Missed unstable ligamentous injury → progressive deformity, late cord injury
— Inadequate CT (motion, suboptimal reconstruction) → repeat imaging
— Neurogenic bladder/bowel, sexual dysfunction, chronic pain, spasticity, depression
Board pearl: A patient with C6 quadriplegia and sudden severe headache + BP 220/120 → autonomic dysreflexia. First action: sit the patient upright (not lying flat) and check for a kinked Foley or fecal impaction before reaching for antihypertensives.
— Any spinal cord injury with neurologic deficit (MAP goals, frequent neuro checks)
— High cervical injury (C5 and above) — risk of respiratory failure
— Neurogenic shock requiring vasopressors
— Unstable fracture pending surgical fixation
— Polytrauma with associated TBI or thoracic injury
— Stable fractures cleared for nonoperative management with rigid collar can go to surgical floor
— Step-down if at risk for delayed neuro decline but not requiring vasopressors
— Neurosurgery or orthopedic spine for any fracture, dislocation, ligamentous injury, or neurologic deficit
— Trauma surgery as primary admitting team for polytrauma
— Vascular surgery / neuro-interventional radiology for grade III–V BCVI
— PM&R early for SCI rehab planning
— Pulmonary / critical care for high cervical injuries
— If at a non-trauma center: transfer all confirmed unstable C-spine injuries to Level I or II trauma center
— EMTALA-compliant transfer with collar in place, documented neuro exam, copies of imaging
— Use ground vs air based on hemodynamic stability and distance
— Use structured handoff (SBAR/I-PASS)
— Explicitly communicate: cervical clearance status, presence of collar, neuro exam, anticoagulation status, MAP goal, surgical plan
CCS pearl: In a CCS case, after diagnosis of unstable C-spine fracture, your orders should include: consult neurosurgery, ICU admission, MAP goal 85–90, SCD prophylaxis now / LMWH in 48–72 h, Foley, NPO pending surgery, type and screen, and serial neuro checks q1h. Forgetting any one of these — especially the MAP goal or VTE plan — costs points.
— Most common diagnosis after low-speed rear-end MVC
— Diagnosis of exclusion after imaging clears bony and ligamentous injury
— Soft collar (≤72 h), early mobilization, NSAIDs, physical therapy
— Counsel that 80% recover within 6 weeks; persistent symptoms warrant re-evaluation
— Acute disc may occur with trauma; presents with radicular pain, sensory/motor findings in dermatome
— MRI is diagnostic
— Initial management nonoperative unless progressive deficit or myelopathy
— Hyperextension in elderly with spondylosis; UE > LE weakness
— MRI shows cord edema; CT often normal aside from spondylosis
— Management nonoperative initially; surgery for failure to improve or persistent compression
— May present with posterior circulation stroke, neck pain, Horner syndrome
— CTA neck diagnostic
— Treat with antiplatelet (aspirin) or anticoagulation depending on grade and bleeding risk
— Rapid neurologic decline after trauma or with anticoagulation
— MRI; emergent surgical decompression
— Even minor trauma → unstable transverse fracture, high rate of epidural hematoma
— Image liberally; admit for observation
— Pannus erosion or congenital laxity; risk of cord compression
— Flexion-extension imaging in stable patients; CT/MRI if acute
Key distinction: Whiplash and cervical strain are diagnoses you assign only after the structural workup is complete and negative. Naming a strain too early on a stem is a common trap; if the patient is elderly, intoxicated, or had a dangerous mechanism, the answer is imaging first.
— Penetrating neck trauma or severe blunt mechanism
— Subcutaneous emphysema, odynophagia, hematemesis
— CT neck with contrast, esophagography, endoscopy
— Hoarseness, stridor, subcutaneous emphysema, neck crepitus
— Secure airway early (may require surgical airway)
— CT neck and laryngoscopy
— Expanding hematoma, bruit, neurologic deficit, Horner syndrome
— CTA neck; vascular surgery
— Referred neck pain; check brachial plexus and distal pulses
— Increased prevertebral soft tissue on lateral CT
— May rapidly compromise airway → secure early
— Blunt aortic injury can refer pain to interscapular/neck area; widened mediastinum on CXR → CTA chest
— In atraumatic Step 3 vignette: aortic dissection can present with neck/jaw pain
— Especially in IV drug users with neck pain after minor trauma; fever, leukocytosis
— MRI with contrast
— Coincidental finding in low-energy trauma; tender lymph nodes, fever
— Severe occipital pain; trauma history may be incidental
Step 3 management: A patient with penetrating neck trauma and expanding hematoma — even without obvious neurologic findings — needs immediate operative exploration or CTA depending on stability and zone of injury, not just a cervical collar. Do not let "neck trauma" funnel you only into a C-spine answer when vascular or airway threats coexist.
— Soft collar optional for comfort (no proven benefit beyond 72 hours)
— Acetaminophen and short-course NSAIDs
— Early gentle ROM and physical therapy referral
— Return precautions: new weakness, numbness, bowel/bladder dysfunction, severe progressive pain
— Rigid cervical collar (Aspen, Miami J) typically for 6–12 weeks
— Follow-up CT at 6 and 12 weeks to confirm healing
— Activity restriction: no driving while in rigid collar (impaired visual field), no heavy lifting
— Wound care; watch for infection, dysphagia (ACDF)
— Cervical collar 4–6 weeks
— Smoking cessation strongly counseled — nicotine impairs fusion
— Acute inpatient rehab transfer once medically stable
— Bowel/bladder programs, transfer training, adaptive equipment
— Mental health screening — high incidence of depression and suicide
— Continue VTE prophylaxis (LMWH) for typically 8–12 weeks after SCI per ACCP
— Bowel regimen (docusate, senna, ± bisphosphonate suppository)
— Bladder management (intermittent cath preferred over indwelling)
— Spasticity: baclofen, tizanidine
— Neuropathic pain: gabapentin or pregabalin (first-line in SCI pain)
— Cleared by spine surgeon once stable healing; rigid collar generally precludes driving
— Vocational rehab for SCI patients
Board pearl: First-line agent for neuropathic pain after spinal cord injury is gabapentin or pregabalin, not opioids or tricyclics. Step 3 may also ask about baclofen for spasticity and intermittent catheterization rather than indwelling Foley to reduce UTI risk long-term.
— 1–2 weeks: wound check if applicable, collar fit, neuro exam, pain assessment
— 6 weeks: CT to assess interim healing; may transition to soft collar if healing well
— 12 weeks: CT confirming union; collar weaning; begin formal physical therapy
— 6 months: functional assessment, ROM, return to sport/work clearance
— 2-week wound check
— 6-week and 3-month X-rays for hardware position and fusion
— 6-month and 1-year CT for fusion confirmation
— Watch for adjacent-segment disease at later years
— ASIA exam at admission, discharge, and follow-up to track recovery
— Urodynamics at 3 and 6 months
— DEXA — disuse osteoporosis develops rapidly; baseline at 6–12 months
— Annual ultrasound or limb assessments for DVT in chronic phase
— Screen for depression at each visit (PHQ-9)
— Smoking cessation (fusion success, overall outcomes)
— Fall prevention in elderly (home safety, vision check, medication review)
— Helmet use — bicycle, motorcycle, skiing — for primary prevention
— Seatbelts and proper headrest position to reduce whiplash
— Pool safety: never dive into shallow water
— Refer for therapy and peer-support groups (e.g., Christopher & Dana Reeve Foundation)
— Address vocational, financial, and caregiver burden
— Use bundled trauma care pathways; reduce readmissions through structured outpatient follow-up
Step 3 management: A patient discharged after C2 fracture in a rigid collar should be told explicitly: no driving while wearing the collar, no smoking, return for any new neurologic symptom, and follow up at 2 and 6 weeks with imaging. Document each element for both quality metrics and medicolegal clarity.
— Intubated or obtunded trauma patient cannot consent to imaging or surgery — use implied emergency consent for life- or limb-threatening interventions
— Notify next of kin as soon as feasible; document attempts
— For non-emergent procedures (delayed elective fusion), wait for capacity or surrogate
— Intoxicated patients cannot refuse cervical immobilization or imaging if injury possible
— Document inability to consent and proceed under emergency doctrine
— Suspected non-accidental trauma in children with C-spine injury → mandatory child protective services report
— Elder abuse or neglect when mechanism doesn't match injury → adult protective services
— Gunshot/stab wounds → law enforcement notification per state law
— Motor vehicle crash with impairment may have reporting obligations to DMV (varies by state)
— Failure to communicate cervical clearance status during handoff is a leading source of preventable harm
— Collar should not be removed by receiving team without documentation of formal clearance
— Use checklists: "Collar status: in place / cleared by [name, date, time, modality]"
— Document NEXUS or CCR criteria explicitly — "patient meets all five NEXUS low-risk criteria; cervical collar removed"
— Document neuro exam before AND after collar removal and after any procedure
— Document discussion of risks/benefits of imaging vs clinical clearance
— Backboard removal within 30 min of arrival to prevent pressure injury
— Collar audit programs reduce unnecessary collar days in ICU
— Missed C-spine injury is one of the highest-payout malpractice claims in EM — defensible practice is following validated rules and documenting them
Board pearl: An intoxicated, combative patient who tries to refuse imaging after a high-speed MVC does not have capacity to refuse. Maintain immobilization, obtain imaging under emergency doctrine, document carefully, and use chemical restraint as needed to facilitate safe care.
— Jefferson fracture: C1 burst fracture from axial load (diving)
— Hangman's fracture: bilateral C2 pars/pedicle fracture from hyperextension
— Odontoid type II: across the base — highest nonunion rate
— Flexion teardrop: anteroinferior C-body fragment, highly unstable
— Clay shoveler's: C7 spinous process avulsion, stable
— Chance fracture: thoracolumbar, seatbelt mechanism, not cervical but commonly confused
— Central cord — UE>LE, elderly, hyperextension
— Anterior cord — motor + pain/temp loss, proprioception spared
— Brown-Séquard — hemisection; ipsi motor/proprio, contra pain/temp
— Posterior cord — rare; proprioception/vibration loss
— Conus medullaris — bowel/bladder, mixed UMN/LMN at sacral
— Cauda equina — flaccid, saddle anesthesia, surgical emergency
— NEXUS sensitivity ~99%, specificity ~13%
— CCR sensitivity ~99–100%, specificity ~45% (better)
— CT sensitivity ~98% for clinically significant fracture
— MAP goal 85–90 mmHg × 7 days post SCI
— Early decompression <24 hours for incomplete SCI
— Pediatric pseudosubluxation C2–C3 normal <8 years
— High-dose methylprednisolone — not standard
— Succinylcholine — avoid after 48 hours post SCI (hyperkalemia risk)
— NSAIDs — caution if fusion planned
— NEXUS = NSAID? No: Neuro deficit, Spinal tenderness, Altered mental status, Intoxication, Distracting injury
— Denver criteria screen for BCVI in C-spine fractures with foramen transversarium involvement
Key distinction: Type II odontoid in young adults can sometimes be treated with anterior odontoid screw fixation; in elderly, the same fracture is treated with rigid collar or posterior C1–C2 fusion because halo vest carries unacceptable mortality.
— 22-year-old, rear-ended at low speed, alert, no midline tenderness, no neuro deficit, sober, no distracting injury, able to rotate neck 45°
— Best next step: remove collar, discharge with PT referral — meets NEXUS and CCR low-risk criteria
— 70-year-old fell down 4 stairs, alert, no midline tenderness
— Best next step: CT cervical spine — age ≥65 disqualifies clinical clearance
— Trauma patient, BP 80/40, HR 55, warm extremities, no obvious bleeding
— Diagnosis: neurogenic shock → fluids + norepinephrine, MAP 85–90
— Elderly man, fell forward striking forehead, weak hands more than legs, "burning" in hands, normal CT but cervical stenosis
— Diagnosis: central cord; next step MRI cervical spine
— C2 fracture through foramen transversarium → next step CTA neck
— Intubated TBI patient, CT C-spine negative, no obvious deficit
— Best next step (modern guideline): remove collar (CT alone sufficient per EAST)
— C5 SCI patient at month 3 with BP 210/110, headache
— First action: sit up, check Foley/bowel, then short-acting antihypertensive
— Acute cervical SCI within 6 hours; should we start methylprednisolone?
— Answer: No — not standard of care
— 6-year-old with transient leg weakness post-MVC, normal CT
— Next step: MRI cervical spine
CCS pearl: When a stem describes a high-risk mechanism in any elderly patient, the trap answer is "examine and clinically clear." The correct answer is essentially always CT cervical spine, often paired with CT head and CTA neck depending on findings.
Cervical spine clearance is the structured process of safely removing immobilization in blunt trauma patients by applying validated tools (NEXUS or Canadian C-Spine Rule) for clinical clearance, defaulting to CT for any high-risk feature, and reserving MRI for persistent neurologic findings, suspected ligamentous injury, or unresolved obtundation.
— Apply CCR or NEXUS to the alert, unimpaired patient; both have ~99% sensitivity
— Any high-risk feature (age ≥65, dangerous mechanism, paresthesias, intoxication, distracting injury, altered mental status, midline tenderness, focal deficit) → CT cervical spine
— MRI for persistent deficit, suspected ligamentous injury, or to evaluate cord pathology
— CTA neck if Denver criteria met (e.g., fracture through foramen transversarium, C1–C3 fracture)
— Maintain collar until cleared; remove backboard within 30 minutes
— Cord injury: MAP goal 85–90 × 7 days, norepinephrine for neurogenic shock, no high-dose steroids
— Early (<24 h) decompression for incomplete cord injury
— VTE prophylaxis: SCDs immediately, LMWH within 72 hours
— Elderly: image liberally; avoid halo vest
— Pediatrics: plain films first; remember SCIWORA and pseudosubluxation
— Pregnancy: do not withhold indicated imaging; tilt left 15°
— Ankylosing spondylitis: highly unstable from minor trauma — low threshold for MRI
— Explicitly chart NEXUS/CCR application and clearance decision
— Communicate collar status clearly at every handoff
— Missed C-spine injury is among the most consequential — and litigated — emergency-medicine misses
Board pearl: When in doubt, keep the collar on and scan. The cost of a CT is trivial compared to a missed unstable fracture, and modern Step 3 answer choices reward image-then-clear over clinical bravado in any patient who is elderly, intoxicated, altered, or injured by a high-energy mechanism.