Cervical Spine Injuries: Part I
Authors:
Janine D. Grayson, MD, MPH, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey New Jersey Medical School, Newark, NJ.
Karma B. Warren, MD, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey New Jersey Medical School, Newark, NJ.
Tiffany Murano, MD, FACEP, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey New Jersey Medical School, Newark, NJ.
Peer Reviewer:
Jonathan Glauser, MD, FACEP, Associate Professor of Emergency Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH.
I see many patients brought by EMS from motor vehicle collisions and ground level falls. The majority arrive with a rigid cervical collar placed by the EMTs or paramedics because of neck pain or a concern about possible cervical spine injury based on the mechanism of injury. If the patient did not have initial pain, most will have developed pain by the time of arrival because of their placement in a rigid cervical collar and on a hard backboard. Thus, we often cannot clear many of these patients using clinical decision tools and we therefore obtain radiographic studies. Our knowledge of the patterns of cervical spine injuries has dramatically increased because of CT scans. We now identify injuries that heretofore would not have been seen with plain radiographs. It is important for the emergency physician to have knowledge about these injuries and an understanding of their potential for spinal cord damage. This issue of EM Reports is the first of a two-part series on cervical spine fractures.
J. Stephan Stapczynski, MD, Editor
Introduction
The incidence of cervical spine injuries in blunt trauma is between 2-3%, and significant morbidity and disability accompany those injuries.1,2 Motor vehicle crashes and falls are the leading mechanisms of spinal cord injury in the United States. They are also the leading causes of emergency department (ED) visits due to unintentional trauma, accounting for approximately 14 million visits in 2008.3-5 Associated traumatic brain injury with cervical spine injuries is common, owing to the mechanism of injury. Historically, studies have shown the incidence of cervical spine injury to be up to 8% when there is intracranial injury.6,7 One study showed that in blunt trauma patients with a Glasgow Coma Scale (GCS) of 8 or less, there was an increased risk of injury to the bony structures of the cervical spine of more than two-fold, with the risk of spinal cord injury increased five-fold.6 It is important for the emergency physician to understand which patients are at risk for cervical spine injury given demographic factors, mechanism of injury, and clinical presentation. This article focuses on evaluation and management of cervical spine injuries for patients who present to the ED.
Epidemiology
Cervical spine injuries are more prevalent in white males who are older than 65 years of age.1,8 The most commonly injured cervical vertebra is C2. Fractures of the odontoid are notably prevalent in the elderly population.1,9,10 The next most commonly fractured levels of the cervical spine are C6 and C7, which account for approximately one-third of all injuries.1 Fractures of C3 and C4 are uncommon. Recent trends have shown that the percentage of persons with high cervical injuries (C1-C4) has more than doubled from 12.3% in the 1970s to 27.2% since 2005, likely due to an increase in the elderly population.11
Figure 1: Illustration of the Atlas
Reproduced from the 20th U.S. edition of Gray's Anatomy of the Human Body.
Anatomy
The bony cervical spine consists of seven vertebrae. The first, second, and seventh cervical vertebrae have structures that are unique. The first cervical vertebra is called the atlas and supports the base of the skull. It is distinctive for its ring-like structure that has no vertebral body or spinous process. (See Figure 1.) The circular configuration allows for a large central spinal canal with anterior and posterior arches separated by lateral masses on either side. The atlanto-occipital joint is formed by the articulation of the superior aspects of the lateral masses with the occipital condyles of the skull. This union functionally allows for half of the flexion and extension motions of the neck. The second cervical vertebra is called the axis and is uniquely characterized by the odontoid process, also called the dens. (See Figure 2.) The dens projects cranially from the body of C2 into the anterior third of the atlas and articulates with the posterior surface forming a pivotal point, which allows lateral rotation of the head. (See Figure 3.) The atlantoaxial joint is stabilized by the transverse ligament and is the point at which half of the rotation of the neck occurs. The feature that distinguishes the seventh cervical vertebra from the others is the fact that it has the longest spinous process, making it more susceptible to injury. (See Figure 4.)
Figure 2: Illustration of the Axis
Reproduced from the 20th U.S. edition of Gray's Anatomy of the Human Body.
Figure 3: Illustration of the Articulation Between the Atlas and the Axis
Reproduced from the 20th U.S. edition of Gray's Anatomy of the Human Body.
Figure 4: Illustration of the Seventh Cervical Vertebra
Reproduced from the 20th U.S. edition of Gray's Anatomy of the Human Body.
There are intervertebral discs that start at the C2-3 interspace and act to support and cushion the bony surfaces of the vertebrae.
The structures of the cervical spine are supported by a network of ligaments. (See Figure 5.) The anterior longitudinal ligament, the posterior longitudinal ligament, and the ligamentum flavum are three of the major supporting ligaments. The anterior longitudinal ligament extends down the entire length of the vertebral column and connects the anterior regions of the vertebral bodies. As the spine extends, this ligament becomes taut and, therefore, acts to prevent hyperextension. Like the anterior longitudinal ligament, the posterior longitudinal ligament also runs the length of the vertebral column, but it connects the posterior elements of the vertebral bodies and forms the anterior surface of the spinal canal. The posterior longitudinal ligament acts to limit hyperflexion. The ligamentum flavum forms the posterior aspect of the spinal canal and joins the vertebral laminae. Other ligaments include the interspinous ligaments, facet capsulary ligaments, supraspinous ligaments, and intertransverse ligaments.
Figure 5: Illustration of the Ligamentous Structures from the Occiput Through the First Three Cervical Vertebrae
Reproduced from the 20th U.S. edition of Gray's Anatomy of the Human Body.
The spinal cord traverses through the spinal canal, which is located in the vertebral foramen of the cervical vertebrae. The spinal canal measures its widest in diameter at the level of C1-C3, ranging between 16 mm and 30 mm. It narrows to 14-23 mm at the level of C4-C7, with 40% of this diameter occupied by the spinal cord. When the neck is hyperextended, the spinal cord diameter is decreased by 2-3 mm, which may be important in the setting of such injuries.
The spinal column may be divided into two parallel elements: the anterior and posterior columns. The anterior column is comprised of the vertebral bodies and intervertebral discs. The posterior column consists of the spinal cord, spinal canal, and all structures posterior to the anterior column (pedicles, transverse processes, articulating facets, laminae, and spinous processes). The anterior and posterior longitudinal ligaments structurally support the anterior column, while the ligamentum flavum and the other network of ligaments support the posterior column.
Figure 6: Illustration of the Three-spinal Column of Denis
Reproduced with permission from Radiology Assistant http,://www.radiologyassistant.nl
Another system often used by many spine consultants is the three-spinal column theory of Denis, which helps predict stability associated with the different patterns of injury to the spine. (See Figure 6.) Mechanical stability is when vertebrae and associated structures maintain proper alignment and spacing during normal neck movements so that the spinal cord is protected from injury. In an unstable injury, movement of the neck can produce abnormal shifts between the vertebrae that produce distracting, twisting, tearing, or impingement upon the spinal cord. That said, even stable injuries can produce spinal cord damage if associated swelling, bleeding, or intravertebral disc protrusion press on the spinal cord. The three-column theory of Denis divides the spinal column into anterior, middle, and posterior columns. The anterior column consists of the anterior vertebral body, the anterior longitudinal ligament, and the anterior annulus fibrosis. The middle column consists of the posterior vertebral body, the posterior longitudinal ligament, and the posterior annulus. The posterior column consists of the posterior bony elements including the pedicles, the lamina, the facets, and the spinous processes, the ligaments including the ligamentum flavum, the interspinous, and supraspinous ligaments, and the facet joint capsule. When only one column is disrupted, the injury is considered mechanically stable. When two columns are disrupted, the injury is considered unstable. In general, this requires failure of the middle column with either the anterior or the posterior column.
Occipital Condyle Fractures
Occipital condyle fractures are rare fractures that may occur from a variety of mechanisms. The classification system most commonly used is the Anderson-Montesano system.12 The classification is based on fracture location, morphology, and presence of associated ligamentous instability. Type I is a comminuted fracture that occurs due to axial loading. The fracture is stable as long as the contralateral side is intact. Type II is a skull base fracture that propagates into one or both of the occipital condyles. These are generally stable fractures. Type III is an inferomedial avulsion fracture with medial displacement of the fracture fragment into the foramen magnum. These are considered unstable due to the disruption of the alar ligament.
Occipital condyle fractures may present with associated cranial nerve injuries. Freeman et al reported a case in which the hypoglossal nerve palsy developed six weeks after bilateral occipital condyle fractures.13 Injury to vertebral artery has been reported with associated Wallenberg syndrome.14
Treatment. For stable Anderson-Montesano type I and type II fractures, a soft collar or rigid cervico-thoracic brace worn for 6-12 weeks is sufficient. Halo vest immobilization or operative treatment is indicated for type III fractures, as they have the potential for instability. Unstable fractures are treated with occipitocervical fusion using rigid internal fixation.14
Atlas Fracture
Fractures of the first cervical vertebrae are also known as Jefferson fractures, so named for Sir Geoffrey Jefferson, who first described them in 1920 and characterized them as "burst fractures." Atlas fractures are a result of severe axial compression (for example, objects that fall directly on the top of the head or the top of the head striking a hard surface during diving into water). The compressive forces of the vertical load are transmitted through the occipital condyles onto the lateral masses of C1, forcing them outward and resulting in fractures of the anterior and posterior arches. They comprise 1-2% of all spinal fractures and 12-15% of cervical spine fractures.15-17
Since their original description, atlas fractures have been further classified as posterior arch, comminuted, anterior arch, transverse, lateral masses, and bursting (or Jefferson) fractures.15,16,18 The Jefferson fracture is classically described as a four-part burst fracture, which combines fractures of the anterior and posterior arches; however, there are variants, which include two- and three-part fractures. There are three general types of Jefferson fractures:
I: Bilateral single arch (anterior or posterior);
II: Concurrent anterior and posterior arch (classical 4 points);
III: Lateral mass fracture.
In 1991, Levine and Edwards described five variants of C1 fractures (See Table 1.)19
Table 1: Five Variants of C1 Fractures Described by Levine and Edwards19
|
Classification |
Mechanism of Injury |
Stability |
|
I: Extra-articular fracture of transverse process |
Stable, may involve vertebral foramen/artery |
|
|
II: Isolated posterior arch fracture |
Hyperextension |
Stable |
|
III: Isolated anterior arch fracture |
Hyperextension |
Unstable if displaced |
|
IV: Comminuted lateral mass |
Lateral axial compression |
Unstable |
|
V: Burst fracture, 3 or more |
Axial compression |
Depends on displacement/integrity of transverse atlantal ligament |
When the C1 fracture is an isolated injury, neurologic deficits as a result of spinal cord injury are uncommon due to the width of the spinal canal at that cervical level. Jefferson fractures with intact transverse ligaments are stable, whereas those with greater than 6.9 mm displacement are unstable.14,16 Atlas fractures can occur in isolation or in combination with other cervical spine fractures.15,17
Anterior Arch Fractures
These fractures may be vertical or transverse. The proposed mechanism for the horizontal fracture is an avulsion of the anterior tubercle by the anterior longitudinal ligament or longus coli muscles.20,21 This fracture is stable. The plough fracture, another variant of the anterior arch fracture, occurs during hyperextension when the anterior arch is sheared off, causing forward propulsion of the dens.20 This is a rare, yet unstable fracture.
Posterior Arch Fracture
This fracture may be the product of hyperextension, pronounced flexion, or axial compression. It can occur when the head is hyperextended and the posterior neural arch of C1 is compressed between the occiput and the spinous process of C2. During axial compression, there is wedging of the posterior arch of the atlas between the joint masses of the occipital bone and the axis.
Figure 7: Open Mouth Odontoid View (OMO)
A normal OMO view showing the lateral masses of C1 aligning symmetrically over the body of C2.
Diagnosis. When using plain radiographs, it is essential to obtain open mouth, lateral, and flexion-extension views. On an open mouth radiograph, the C1 lateral masses should lie symmetrically over those of C2. (See Figure 7.) If they extend wider, a Jefferson-type fracture is present. The lateral view shows prevertebral soft tissue widening. Flexion-extension views are usually required to determine whether there is transverse ligament disruption. A CT scan with thin cuts is the optimal imaging modality, as it determines the extent of bony and ligamentous injury.
Figure 8: CT Scan of Jefferson Burst Fracture
Contributed by Basil Hubbi, MD, Department of Radiology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School.
Treatment. Stable atlas fractures are treated with cervical orthoses for 6-12 weeks. Unstable C1 or Jefferson fractures may initially be managed using a halo vest for 10-12 weeks. If alignment cannot be maintained, surgery may be warranted.14 Posterior atlantoaxial stabilization and fusion with transarticular screws is an effective treatment for residual C1-C2 instability following Jefferson or C1 burst fracture.13 Some authors have also recommended anterior osteosynthesis of C1 ring fractures.13,14
Axis Fractures
Odontoid Fractures. The most common fracture of C2, the odontoid (dens) fracture, occurs in about 15% of all cervical spine injuries.14,16 Odontoid fractures are also the most common cervical spine fractures in the elderly.9 The mechanism of injury is a combination of flexion, extension, and rotation, in addition to a shearing force. There is a bimodal age distribution of odontoid fractures associated with high- and low-energy mechanisms.14 In the younger population, the fractures are generally due to a high-energy mechanism such as a motor vehicle collision. In the elderly, the injury may occur from a fall from a standing position. Generally, the cases of odontoid fractures have no neurologic injury, yet there may be future occurrence due to atlantoaxial subluxation.
Figure 9: Anderson and D'Alonzo Classification of Odontoid Fractures
Reproduced with permission from Radiology Assistant http://www.radiologyassistant.nl
The Anderson and D'Alonzo classification is the most widely used system and is based on the anatomic location of the fracture. (See Figure 9.) There are three types of odontoid fractures:
Type 1 (rare): Oblique, avulsion fracture through the tips of the dens. This is considered a stable fracture, which represents an avulsion of the apical and/or alar ligaments.
Type 2 (most common): A fracture that extends through the base of the odontoid process. (See Figure 10.) This is considered an unstable fracture with a high complication rate of malunion and non-union.
Figure 10: Plain Radiograph of Type 2 Odontoid Fracture
Reproduced with permission from Adam Flanders, MD, Department of Radiology and Regional Spinal Cord Injury Center of the Delaware Valley, Thomas Jefferson University Hospital, Philadelphia, from the websitehttp://www.radiologyassistant.nl
Type 3: A fracture that extends into the body of the C2 vertebra. This is also considered an unstable fracture.
Treatment. Non-operative management can be appropriate for most odontoid fractures, using a soft collar, rigid cervical orthosis, or halo vest.13 Type 1 stable injuries are treated with collar immobilization for 6-8 weeks. There is a lot of controversy surrounding the management of type 2 fractures. When managed non-surgically, there is a very high non-union rate due to the lack of blood supply. It is believed that the type 2 fractures should be managed initially with a halo vest for 12-14 weeks. However, in the elderly population, the halo vest has been associated with an increased risk of complications and mortality.9 Surgical options include osteosynthesis with an anterior odontoid screw, posterior C1-2 fusion, and anterior C1-2 fusion. Management of type 2 fractures is also dependent upon the age of the patient. In younger patients, these fractures can be managed with odontoid screw osteosynthesis or posterior C1-C2 fusion.14 In the elderly population, they are generally managed with posterior C1-C2 fusion with internal fixation. The posterior fusion has a high rate of success; however, this does limit the extent of cervical rotation. Type 3 stable fractures are generally managed with a halo vest; however, the unstable type 3 fractures are managed surgically by a posterior C1-2 fusion.
Hangman's Fractures (Traumatic Spondylolisthesis)
The hangman's fracture describes bilateral fractures of the pedicles of the second cervical vertebra due to extreme hyperextension as a result of abrupt deceleration. (See Figure 11.) Although this injury was originally described in hanging victims, the most common cause is motor vehicle accidents. The mechanism of injury with the "judicial hangings" was distraction and extension, whereas the more common "hangman's fracture"/traumatic spondylolisthesis is a combination of hyperextension, compression, and rebound flexion. The hangman's fracture is considered unstable; however, neurologic deficits are uncommon due to the fact that the spinal canal is at its largest diameter at this level and the fractures of the pedicles allow decompression of the spinal canal.
Figure 11: Hangman's Fracture
Reproduced with permission from Adam Flanders, MD, Department of Radiology and Regional Spinal Cord Injury Center of the Delaware Valley, Thomas Jefferson University Hospital, Philadelphia, from the website http://www.radiologyassistant.nl
A modification of Effendi's original classification by Levine and Edwards is based on the displacement and stability.
Type 1: An isolated hairline fracture with less than 3 mm of anterior body displacement, less than 15-degree angle at fracture site, and normal C2-C3 disc space. This is caused by hyperextension in conjunction with axial loading and is commonly associated with C1 posterior arch fractures, C1 lateral mass fractures, and odontoid fractures. This is considered a stable fracture.
Type 2: Anterior displacement or angulation of the C2 vertebral body with C2-C3 disc disruption. The injury pattern involves hyperextension with concomitant axial loading, followed by flexion with axial compression. Associated injuries involve compression fracture of C3. This is an unstable fracture.
Type 2a: No anterior displacement but significant angulation at the fracture site, with disruption of C2-C3 disc space. This is caused by flexion with concomitant distraction. This is also an unstable fracture.
Type 3: Type 2 fracture with associated C2-C3 articular facet dislocation. There is severe angulation and anterior displacement. The mechanism of injury is flexion with axial compression. This is an unstable fracture with associated high morbidity and mortality.12,22
Figure 12: Illustration of an Extension Teardrop Fracture
Reproduced with permission from Radiology Assistant http://www.radiologyassistant.nl
Management. Type 1 fractures are generally managed with a cervical collar or cervical orthosis with a high success rate. Type 2 fractures are generally treated with traction followed by halo vest immobilization for 12-16 weeks. If desired results are not achieved, open reduction and anterior cervical plating can be performed. Type 2a fractures should never be reduced via traction, as this will escalate the injury. Type 2a fractures can be managed non-operatively or operatively. Once closed reduction via compression and extension is obtained fluoroscopically, it is followed by halo immobilization. Surgical treatment involves C2 transpedicular screws and anterior cervical plating. Type 3 fractures are irreducible and treated surgically with open reduction and internal fixation, which should occur within a timely manner.14
Figure 13: Extension Teardrop Fracture of C2
(a) Plain film (AP and lateral views), (b) CT scan and (c) MRI.
Reproduced with permission from Adam Flanders, MD, Department of Radiology and Regional Spinal Cord Injury Center of the Delaware Valley, Thomas Jefferson University Hospital, Philadelphia, from the website http://www.radiologyassistant.nl
Extension Teardrop Fractures
The teardrop fracture is a triangular-shaped avulsion fracture of the anterior longitudinal ligament off the anteroinferior endplate of the vertebral body. This type of fracture generally occurs from hyperextension of the head and upper cervical spine caused by a direct blow to the forehead or mandible. (See Figures 12 and 13.) It is a common fracture among elderly patients with osteoporosis/osteopenia, occurring most commonly at C2. There is minimal to no prevertebral soft-tissue swelling radiographically and no associated neurologic injuries.23,24 This injury is important to identify because while it tends to be stable in flexion, it is unstable in extension. When this injury occurs at the lower cervical spine levels (C5-C7), there may be buckling of the ligamentum flavum into the spinal cord, causing central cord syndrome.25 The recommended treatment is cervical collar immobilization for comfort and activity restriction for 2-3 weeks.
Atlantoaxial Instability
This ligamentous injury involves at minimum the C1-C2 facet capsules and the transverse ligament with or without alar ligament disruption. The most common form entails anterior subluxation secondary to rupture of the transverse ligament. Most, if not all, are unstable. The classification is based on the direction and consideration of the osseous and ligamentous structures injured.14
Anterior
1. Transverse ligament rupture
2. Odontoid fracture
3. Associated occipitocervical instability (alar ligament rupture)
4. Unstable Jefferson fracture
Posterior
1. Odontoid fracture
2. Posterior dislocation
Lateral
1. Fracture lateral mass C-1
2. Fracture lateral mass C-2
3. Unilateral alar ligament rupture
Rotary
1. Facet subluxation
2. Transverse ligament rupture (3-5 mm displacement)
3. Transverse and alar ligament rupture (> 5 mm displacement)
Vertical
1. Alar ligament and tectorial membrane rupture.
There are also three patterns of atlantoaxial instability: flexion-extension, distraction, and rotation.
Diagnosis. Plain radiograph findings may include atlanto-dens interval greater than 3 mm, a change in the spinolaminar line between C1 and C2 and C3, widening between C1-C2 lamina, and a change in the parallel contours between the dens and anterior arch. A CT scan with reconstructions best confirms the diagnosis. MRI delineates transverse ligament disruption or avulsion, occult bony injury, and hemorrhage.14,16
Management. Initial treatment is placement in traction with light amounts of weights. Anterior, lateral, and rotatory subluxation with transverse ligament injury is treated by C1-C2 fusion using internal fixation. Vertical instability is treated by occipitocervical fusion. Type 1 rotary instabilities are usually stable, requiring closed reduction and cranial traction, followed by cervical collar immobilization for 4-6 weeks. Type 2 and 3 are unstable, and posterior C1-C2 fusion with internal fixation is recommended.14
Burst Fracture
A burst fracture is an injury in which the vertebral body is compressed by a downward axial force onto the spine with forces strong enough to crush the vertebrae and cause compression in all directions. (See Figure 14.) The fracture includes disruption through the body and the posterior element. If fracture fragments are retropulsed posteriorly, there may be injury to the spinal cord resulting in partial or full neurologic damage, including paralysis. The burst fracture is categorized by the severity of the deformity, the severity of spinal canal compromise, the degree of loss of vertebral body height, and the degree of neurologic deficit.26 Patients may experience a moderate amount of pain with burst fractures. The more complicated the fracture, the more severe the pain. Pain is generally at the level of the fracture, but can also present as "pins and needles" in the nerve distribution secondary to the direct spinal cord injury. Burst fractures result in a permanent decrease in the anterior height of the vertebrae, with varying degrees of kyphosis and possible changes in neurological signal intensity with possible deterioration over time. Over a lifetime, patients may experience ancillary pain and discomfort in the spine and limbs, with increasing neurological dysfunction.
Figure 14: Burst Fracture
(a) Plain film demonstrating a burst fracture of the fifth cervical vertebra. (b) Magnified lateral view of this injury. (c) Sagittal view of this injury on CT scan. Reproduced with permission from Hughey, MEd., "Operational Medicine, Health Care in Military Settings," NAVMEDPUB 5139. Bureau of Medicine and Surgery, Department of the Navy, Washington, D.C., 2001
Treatment. Non-surgical management is possible when the burst fracture patient is intact neurologically. Most patients will have total contact orthosis after wearing external immobilization for 4-6 months.27 Surgical management is required when the burst fracture is unstable involving spinal cord injury. Immediate neurosurgical decompression and stabilization along with hospitalization are required due to the involvement of the spinal cord.
Compression Fractures
Compression fractures are the result of axial and flexion forces. This injury has the characteristics of the burst fracture, but it only involves loss of the vertebral body height anteriorly. The posterior wall of the vertebrae remains intact, causing downward rotation of the upper vertebrae about the two facet joints. The injury is commonly seen in the cervical spine area C4-C5 or C5-C6. Compression fractures are normally stable and rarely involve spinal cord injury, but it is important to distinguish the unstable fracture. The fracture is considered unstable when the amount of anterior compression is greater than 50% of the vertebrae height without posterior wall compression; ligamentous injury is also involved.28
Diagnosis. Radiographic imaging distinguishes between burst and compression fractures. A CT scan has the advantage of visualization of the spinal canal and degree of neural compromise, and it delineates element involvement. The disadvantage of CT scan is its inability to detect subtle horizontally oriented fractures of the vertebral bodies; thus, fractures may be missed. Reformatting the CT scan images in the frontal and sagittal planes is helpful if there is a high clinical suspicion for this injury.29
Management. Non-surgical management remains the standard of care for stable fractures after orthopedic or neurosurgery spine consult. Short-term bed rest is advocated until pain is improved, with early ambulation in a hyperextended cast or brace. Surgical management is the treatment for any unstable compression fracture for stabilization and arthrodesis.30 Complications may include failure of the bones to fuse after surgery, and spinal cord or nerve root compression. The patient may also develop kyphoplastic deformity known as "humpback."30
References
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I see many patients brought by EMS from motor vehicle collisions and ground level falls. The majority arrive with a rigid cervical collar placed by the EMTs or paramedics because of neck pain or a concern about possible cervical spine injury based on the mechanism of injury. If the patient did not have initial pain, most will have developed pain by the time of arrival because of their placement in a rigid cervical collar and on a hard backboard.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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