Cervical Injury

Etiology

A common mechanism of injury is the sudden acceleration of the body in the forward direction; this motion forces the neck to hyperextend backward. Falls are more common in young children (eg, younger than 8) than in adults, and sports-related injuries are more common in adolescents than in adults.[5] 

The high-risk mechanisms for cervical spinal cord injury are as follows:

• Falls greater than 3 feet or higher than 5 stairs
• Diving involving an axial load to the head
• High-speed motor vehicle accident
• An accident involving a motorized all-terrain vehicle [6]

Pathophysiology

Cervical spine injuries can result from various mechanisms of blunt trauma, with motor vehicle accidents being the most common cause. The direction and magnitude of the force applied to the cervical spine often influence the specific type of injury sustained. Understanding these mechanisms is essential for accurate diagnosis and management.

Common mechanisms of cervical spine injury include:

• Flexion: Forward bending of the neck
• Extension: Backward bending of the neck
• Rotation: Twisting of the cervical spine
• Lateral bending: Side-to-side neck movement
• Distraction: Stretching forces applied along the spinal column
• Compression (axial loading): Vertical forces compressing the spine

High-energy or complex mechanism injuries, such as high-speed rollover motor vehicle collisions, often involve a combination of these forces. In such cases, the extent of injury may not be fully apparent during the initial assessment. Injuries that first appear incomplete can progress to complete lesions due to evolving pathophysiological changes, including free radical formation, vasogenic edema, and altered blood flow—all of which can lead to neurological deterioration.

History and Physical

History and Mechanism of Injury

Obtaining a thorough history is essential in suspected cervical spine trauma. High-energy mechanisms—such as motor vehicle collisions, falls, or direct blows—should immediately raise suspicion. Any patient presenting with axial neck pain, neurologic symptoms, or altered mental status after trauma should be considered at risk for cervical spine injury until proven otherwise. In unconscious or intoxicated individuals, a high index of suspicion is warranted, even in the absence of clear signs. When the mechanism is uncertain, clinicians should proceed as if a cervical spine injury is present.

Clinical Presentation

Patients with cervical spine injury may report midline neck pain or tenderness localized over the spinous processes. Other common complaints include decreased cervical range of motion, stiffness, torticollis, or localized crepitus. Neurologic involvement may present as numbness, paresthesias, or weakness in the extremities. These symptoms should prompt immediate further evaluation to determine the extent and location of potential spinal cord or nerve root involvement.

Physical Examination

Initial management should prioritize airway, breathing, and circulation. Once stabilized, a focused neurologic exam is essential. The physical exam should assess for midline tenderness, deformities, and range of motion if it is safe for the patient. A detailed neurologic evaluation helps to determine whether motor, sensory, or reflex abnormalities are present and to localize the level of injury.

Neurological Assessment

Signs of nerve root injury include focal muscle weakness, decreased or absent deep tendon reflexes, and sensory deficits corresponding to specific dermatomes. Loss of proprioception, vibration sense, or fine touch may indicate involvement of the posterior spinal tracts, while impaired pain and temperature sensation suggest involvement of the anterior cord.

Myotomes are groups of muscles innervated by the motor fibers of a single spinal nerve root. Each myotome corresponds to a specific level of the spinal cord, and testing these muscle groups helps clinicians assess the integrity of the nerve root at that level. 

Cervical spine myotomes include the following:

• C1–C2: Neck flexion
• C3: Lateral neck flexion
• C4: Shoulder shrug (trapezius)
• C5: Shoulder abduction (deltoid)
• C6: Elbow flexion and wrist extension
• C7: Elbow extension and wrist flexion
• C8: Finger flexion

Reflex testing enables clinicians to assess the function of specific nerve roots, as each deep tendon reflex is linked to a particular spinal nerve root. Abnormal reflex responses can help pinpoint the location of nerve or spinal cord damage.

Reflexes for the cervical spine include:

• C5: Biceps reflex
• C6: Brachioradialis reflex
• C7: Triceps reflex

Additional motor considerations:

• C3–C5: Motor control of the diaphragm through the phrenic nerve
  • Note: Injury at or above C3–C4 can compromise diaphragmatic function, potentially leading to respiratory distress or failure.
• C5–C8: Motor and reflex control of the upper extremities

Dermatomes are areas of skin mainly supplied by sensory nerve fibers from a single spinal nerve root. Testing the sensory function at a given level helps clinicians assess the integrity of that nerve root.

Dermatomes for the cervical spine include:

• C2: Posterior head and upper neck (occipital region)
• C3: Lateral neck, lower jaw area, and posterior head
• C4: Shoulder area, particularly the upper trapezius region
• C5: Lateral upper arm (deltoid area)
• C6: Lateral forearm, thumb, and index finger ("6-shooter" pattern)
• C7: Middle finger and central part of the posterior forearm
• C8: Ring and little fingers, medial forearm
• T1: Medial upper arm near the elbow

Spinal Column Stability and Injury Classification

Both anterior and posterior structural columns support the cervical spine. The anterior column includes the vertebral bodies and intervertebral discs, while the posterior column comprises the facet joints, laminae, and spinous processes. If both columns are compromised, the injury is considered unstable, significantly increasing the risk of spinal cord damage.

Vital Signs and Mental Status

Vital signs can also offer clues to cervical spinal cord involvement. Injuries above the level of C5 may impair respiratory drive, leading to hypoventilation or apnea. Disruption of sympathetic nervous system outflow, which originates in the thoracolumbar spinal cord, may cause hypotension due to unopposed parasympathetic tone. Altered mental status in a trauma patient may reflect decreased cerebral perfusion or concomitant traumatic brain injury.

Additional Neurologic and Reflex Findings

The presence of a positive Babinski sign, priapism, or loss of the bulbocavernosus reflex may indicate spinal cord involvement. The absence of the bulbocavernosus reflex is particularly concerning in cases of acute spinal cord injury, as it often indicates a complete lesion. Similarly, significant weakness or flaccid paralysis accompanied by sensory loss and absent reflexes should prompt urgent imaging and intervention.

Spinal Cord Injury Syndromes

Several distinct spinal cord injury patterns are recognized:

• Anterior cord syndrome is typically caused by a flexion injury and results in motor paralysis and loss of pain and temperature sensation below the level of injury, with preservation of vibration and position sense.
• Central cord syndrome typically results from a hyperextension injury and is characterized by greater motor weakness in the upper extremities compared to the lower extremities; this is the most common incomplete spinal cord injury.
• Posterior cord syndrome, although rare, results in loss of proprioception and vibratory sense while preserving motor function and pain/temperature sensation.
• Brown-Séquard syndrome results from a hemisection of the spinal cord and presents with ipsilateral loss of motor function and proprioception, along with contralateral loss of pain and temperature sensation.

Evaluation

The clinical evaluation begins with stabilizing the cervical spine and applying the American College of Surgeons Advanced Trauma Life Support algorithm. The primary goal is to identify patients with potentially life-threatening conditions and cervical spine injuries. The initial survey should assess the patient's airway, breathing, and circulation, followed by a comprehensive head-to-toe examination to identify any associated major injuries that may contribute to the cervical spine injury. Examine for midline neck tenderness, torticollis, and neurologic deficits while maintaining inline neck stabilization.

The initial diagnostic evaluation of a patient who is stable with a suspected cervical injury includes radiographs of the cervical spine, which should include anteroposterior, lateral, oblique, and odontoid views. An adequate lateral radiograph must include all 7 cervical vertebrae and the C7 to T1 disc space.[7][8][9] This may require the addition of a "swimmer's" view to visualize the lower levels.

The National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian Cervical Spine Rule are useful in guiding imaging practice; however, they have limited utility in young children.[10][11][12][13] The purpose of these decisions directing rules is to identify individuals with a low risk of cervical spine trauma who can safely forgo the need for an imaging evaluation.[14] The NEXUS Low-risk Criteria and the Canadian C-Spine Rule are guidelines for determining whether cervical spine radiographs are indicated.

According to the NEXUS Low-Risk criteria, imaging is indicated if the patient exhibits any of the following:

• Midline spine tenderness 
• Focal neurologic deficit
• Altered level of consciousness
• Intoxication
• Distracting injury

Radiographs may not be necessary if all the following criteria are met:

• Absence of posterior midline cervical tenderness
• A normal level of alertness
• No evidence of intoxication
• No abnormal neurologic findings
• No painful, distracting injuries

The cervical spine radiographs include a 3-view series, which is good for screening patients with normal mental status and no focal neurologic findings. The lateral view, the most important single view, identifies up to 80% of injuries.[15] The anteroposterior view provides an overall assessment of spine alignment, evaluates the alignment of the spinous processes, assesses the lateral masses, and examines for subtle signs of fracture or subluxation. The open-mouth view assesses the dens and the alignment of the lateral masses of C1 and C2.

PECARN prediction rule

A clinical prediction rule was developed and validated to inform an algorithm guiding radiographic screening for cervical spine injury in children presenting to the emergency department.[16] Due to the higher radiation exposure, computed tomography scans should only be performed in high-risk individuals, such as those with altered mental status. If plain radiographs are normal and the patient has no neurological deficits, flexion and extension x-rays may be performed. Obtain a computed tomography scan when:

• Cervical spine radiographs are inadequate
• Concerning findings are present on plain radiographs
• Fracture or bone displacement is observed on plain radiographs
• A high-risk mechanism of injury has occurred

Magnetic resonance imaging

Consider magnetic resonance imaging (MRI) if neurologic signs or symptoms are present and plain radiographs or computed tomography scans are normal. MRI can also be used to evaluate the extent of nerve root compression. MRI is superior to computed tomography for visualizing soft tissues and identifying intervertebral disk herniation, ligamentous injuries, spinal cord edema, hemorrhage, compression, and transection.[17] 

Cervical Injury Classification

The classification of cervical spine injuries is based on the location of the injury. Injuries from the occiput to C2 can be classified as occipital-cervical spine injuries. C3 through C7 injuries are classified as sub-axial cervical spine injuries. Wedge fractures are a result of flexion of the cervical spine. Burst fractures occur when the spine is subjected to vertical compression. Laminar fractures can be vertical or horizontal and are usually associated with another type of fracture. Atlanto-occipital dislocation is a type of extension injury involving the C1 and C2 vertebrae. Atlantoaxial dislocation is a flexion-rotation injury involving C1 and C2. Jefferson fractures are unstable C1 fractures that result from compression.

Jefferson fracture (C1)

A Jefferson fracture is a C1 burst fracture of the atlas caused by severe axial compression. This fracture occurs when the force is transmitted through the occipital condyles to the superior articular surfaces of the lateral masses of C1. Diving is a common mechanism for axial loading that can lead to this type of fracture. The fracture pattern correlates with the position of the head during traumatic impact.

The impact force drives the lateral masses outward, disrupting the transverse ligament and resulting in fractures of the anterior and posterior arches of the atlas. A lateral radiograph may show a widening of the predental space between the anterior arch of C1 and the odontoid process or dens. The open-mouth odontoid view may show displacement of the lateral masses of C1 relative to C2. If the sum of the offset distances from the right and left sides exceeds 7 mm, a fracture should be suspected.

Hangman fracture (C2 Fracture)

A hangman fracture involves a bilateral fracture through the pedicles or pars interarticularis of the C2 vertebra and typically results from extreme hyperextension of the cervical spine, often due to sudden deceleration. During this mechanism, the skull, atlas (C1), and axis (C2) move as a single unit. Hangman fractures are commonly caused by diving accidents and high-impact motor vehicle collisions, particularly those involving head-on impact. Although the fracture is considered unstable due to its location, spinal cord injury is typically minimal or absent because the spinal canal is widest at the C2 level, providing a relative degree of protection. Hangman fracture classification is based on the amount of displacement of the fracture. 

• Type I: Vertical fractures with less than 3 mm of displacement and no angulation
• Type II: More than 3 mm of displacement with angulation
• Type III: Vertical fractures with significant displacement and a high risk of neurological deficit

Odontoid fracture

Although the mechanisms of odontoid fractures are complex and often unclear, flexion, extension, and rotation may contribute to their occurrence. Odontoid fractures are classified into 3 types:

• Type I: The fracture of the odontoid process, which usually appears as an avulsion of the distal tip or the apex of the dens above the transverse ligaments. This fracture is usually stable and is not associated with spinal cord injury. However, it may occur in association with atlanto-occipital dislocation, which is a severe injury and must be excluded before conservative treatment is initiated.
• Type II: The fracture at the base of the odontoid process, where it attaches to the body of C2. This fracture is a more common fracture than a type I fracture and is unstable with a high mortality rate. The limited blood supply to the dens often results in a nonunion of the fracture.
• Type III: The fracture extends into the body of C2. This injury is considered an unstable injury because it allows the atlas and occiput to move as a unit.

Treatment / Management

Cervical Spine Management in Trauma

Initial management of cervical spine injuries should begin with resuscitation, according to the American College of Surgeons’ Advanced Trauma Life Support algorithm. In cases of blunt trauma, immediate cervical spine immobilization is critical. This is typically achieved by placing the patient in a rigid cervical collar and minimizing neck movement to prevent further injury.[18][19] The patient should be positioned on a rigid backboard with the head and body stabilized using blocks and straps to ensure stability. However, prolonged use of the backboard should be avoided and should be discontinued as soon as it is clinically appropriate to minimize complications associated with extended immobilization. Analgesia should be administered early to ensure adequate pain control, but care must be taken to avoid medications that may alter the patient's level of consciousness.(A1)

Cervical Spine Clearance and Clinical Evaluation

In alert and cooperative individuals with trauma who lack midline cervical tenderness, neurological deficits, or distracting injuries, clinical clearance of the cervical spine has become the standard of care.[20][21] In such cases, and regardless of the mechanism of injury, radiographic imaging is generally not required. However, a careful and thorough clinical examination remains essential before clearing the cervical spine.[22] During airway management, particularly intubation, the cervical spine must be manipulated with extreme caution to avoid exacerbating any existing injuries.[23] The ideal intubation position is known as the "sniffing position," which involves extending the atlanto-occipital and atlantoaxial joints and flexing the lower cervical spine.(A1)

Definitive Management Based on Injury Severity

Subsequent management of cervical spine injuries depends on the nature and severity of the injury. Minor, stable fractures without neurological deficits may be treated conservatively with pain management, external immobilization using a cervical collar or halo vest, and scheduled follow-up. In contrast, unstable injuries or those associated with neurological compromise often require surgical intervention. Surgical strategies may include decompression of the spinal cord and stabilization using internal fixation.

Fusion of the cervical vertebrae, with or without metal hardware (eg, plates and screws), may be indicated based on the injury pattern. Subaxial fractures are commonly managed with anterior, posterior, or combined fixation approaches. When decompression of the neural elements is required due to spinal cord or nerve root compression, procedures such as laminectomy, laminoplasty, foraminotomy, or discectomy may be employed. The overarching goals of surgical management are to relieve pressure on the spinal cord and ensure long-term mechanical stability of the cervical spine.[24][25](B2)

Differential Diagnosis

 Differential diagnosis for cervical injury includes:

• Acute torticollis is characterized by the contraction of neck muscles that results in lateral neck flexion and rotation. Trauma may be a contributing factor, but a cause for torticollis is often not identified.
• Cauda equina syndrome results from central disc herniation that compresses the cauda equina and presents with back pain and bilateral leg pain. Bladder and bowel difficulty, such as incontinence and frequency, saddle anesthesia, decreased perianal sensation, impotence, diminished rectal tone, and motor deficit, can be present.
• Cervical strain commonly results from hyperextension of the cervical spine, often due to rear-end motor vehicle collisions. This acceleration-deceleration mechanism affects the paracervical musculature. In some cases, intervertebral disc herniation may occur, potentially irritating the cervical sympathetic chain and resulting in Horner syndrome (ptosis, miosis, and anhidrosis).
• Hanging injuries are a subset of strangulation injuries with compression to structures of the airway, blood vessels, and nerves of the neck. Both local injury and systemic consequences of anoxia and brainstem compression, such as arrhythmia, respiratory compromise, and cardiac arrest, can result. 

Prognosis

Cervical spine and spinal cord injuries often carry a poor prognosis, frequently resulting in severe and lasting consequences such as permanent disability or death.[26][27] Neurological injury occurs in up to one-third of pediatric patients with cervical trauma, underscoring the importance of early recognition and intervention.[5] Mortality is closely related to the level of the injury. High cervical spine injuries—particularly those involving C1 to C4—are associated with significantly greater mortality rates compared to lower cervical injuries due to their proximity to the respiratory centers and critical neurovascular structures.

Neurological recovery, when it occurs, tends to follow a predictable pattern. Functional improvement typically begins in the lower extremities, followed by the return of bladder control. Recovery of upper limb function comes later, with hand and finger dexterity being the slowest to improve, if it returns at all.[28] Missed cervical spine injuries remain a concern in trauma care. Study results estimate that between 4% and 8% of cervical spine injuries are initially undiagnosed, which may contribute to delayed treatment and worsened outcomes.[29]

Complications

Injuries to the cervical spine represent a significant source of long-term disability and can result in catastrophic neurological and functional impairment. The consequences are often profound, affecting multiple organ systems and dramatically altering quality of life. These include, but are not limited to:

• Quadriplegia (tetraplegia): Damage to the cervical spinal cord may lead to complete or partial paralysis of all 4 limbs. Individuals with high cervical injuries often lose voluntary motor function and sensation below the level of injury, resulting in permanent dependence on others for all activities of daily living, including mobility, feeding, bathing, and dressing.
• Respiratory compromise: Injury at or above the level of C5 may impair diaphragmatic function due to involvement of the phrenic nerve (C3–C5), necessitating long-term mechanical ventilation or tracheostomy care. Even injuries below this level can weaken accessory respiratory muscles, increasing susceptibility to infections, hypoventilation, and respiratory failure.
• Bowel and bladder dysfunction: Cervical spinal cord injury disrupts autonomic regulation of bladder and bowel control, leading to urinary retention, incontinence, and constipation. Patients may require intermittent catheterization, bowel regimens, or surgical diversion procedures to manage these functions.

These impairments not only impose a high burden on the patient but also place significant emotional, physical, and financial strain on caregivers and healthcare systems. Early identification, stabilization, and comprehensive rehabilitation are critical to minimizing morbidity and optimizing long-term outcomes.