eMedicine Specialties > Sports Medicine > Spine
Cervical Spine Acute Bony Injuries: Treatment & Medication
Updated: May 27, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Treat the site of injury with spinal precautions, and address the ABCs. Immobilize the athlete's neck in neutral position with a cervical collar, towel rolls, or whatever is available. Immobilize the spinal column on a backboard, with the head secured such that the entire column is in neutral position and can be moved en bloc. Transport the athlete to a facility with the ability to stabilize the athlete and to radiographically evaluate the neck.4,9,12
If a fracture is detected, immediately consult a spinal orthopedic surgeon or neurosurgeon. The consultant should make the recommendations regarding the further stabilization of the fracture if needed. This may include Gardner-Wells tongs, surgical intervention, halo immobilization, a cervical collar, or no intervention. The consultant should be a part of all further decisions regarding rehabilitation, return to play, and long-term prognosis.
The patient should rest and remain immobilized, as directed by the consultant. Some patients with very stable fractures may be able to enter an early strengthening and exercise program.12,29
Related Medscape topics:
Specialty Site Neurology & Neurosurgery
Specialty Site Orthopaedics
Occupational Therapy
Early occupational therapy may help increase function in those with neurologic deficits.
Medical Issues/Complications
- The cervical spine must always be considered injured until proven otherwise by history and physical or radiologic evaluation.
- Establishing the ABCs and searching for other injuries are priorities.
- Early consultation of a spinal expert is mandatory for patients with fractures.
Surgical Intervention
Surgery may very well be necessary, especially in cases of unstable fractures. The consulting surgeon determines whether surgical intervention is necessary.
Consultations
Consult an orthopedic surgeon or neurosurgeon. Other consultants may be contacted, as determined by the patient's injuries. Early psychologic counseling may also be warranted because these injuries may be devastating to the athlete.
Related Medscape topic:
Resource Center Depression
Other Treatment
- Do not remove helmets and shoulder pads on the field if the athlete has a potential unstable cervical injury or if the patient is unconscious. Remove the face guard with a screwdriver or cutters. Athletes with respiratory compromise should be intubated with the helmet on.2,30
- Transport the athlete with helmet and pads in place. The chinstrap should remain attached if possible. No cervical collar should be placed, but the athlete and helmet should be secured to a backboard.
- Unless the patient can be clinically cleared, obtain plain radiographs while the protective gear is in place. If the radiographs are inadequate, consider CT scanning with the helmet and pads in place. Caution: The helmet and shoulder pads should be removed by individuals who are trained and qualified in their removal.31
Recovery Phase
Rehabilitation Program
Physical Therapy
Treatment is determined by the patient's injuries. An exercise and strengthening program may be initiated, as well as a maintenance program for uninvolved areas. At this time, all involved physicians should discuss the type of sports and activities that the athlete will be able to participate in. If a change in sports or activity is needed, plans to encourage the athlete should begin.
Related Medscape topic:
Resource Center Exercise and Sports Medicine
Occupational Therapy
Occupational therapy is initiated as determined by the injury and neurologic involvement.
Medical Issues/Complications
- Monitor the athlete for signs of depression.
- If the athlete is immobilized, monitor for problems such as skin breakdown or deep venous thrombosis (DVT).
Related eMedicine topics:
Deep Venous Thrombosis and Thrombophlebitis
Pulmonary Embolism
Surgical Intervention
The consulting surgeon addresses any potential surgical intervention issues (eg, delayed surgical repair, revisions).
Maintenance Phase
Rehabilitation Program
Physical Therapy
Treatment is determined by the patient's injuries. Continue exercise and strengthening program, as well as the maintenance program for uninvolved areas. Continue to evaluate the type of sports and level of activity that the athlete will be able to participate in. If a change in sports or activity is needed, plans to encourage the athlete should begin.
Occupational Therapy
Occupational therapy is initiated as determined by the patient's injury and neurologic involvement.
Medical Issues/Complications
- Monitor the athlete for signs of depression.
- If the athlete is immobilized, monitor for potential problems such as skin breakdown or DVT.
Surgical Intervention
The consulting surgeon addresses any potential surgical intervention issues (eg, delayed surgical repair, revisions).
Medication
As with all fractures, pain management should be a primary concern. Often acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) is prescribed for the acute pain of a fracture. However, additional pain relief may be indicated if the patient does not have relief with acetaminophen or NSAIDs alone. In this case, an opiate may be required, particularly for breakthrough pain. Adjustment of pain medications may be necessary, especially in the acute phase.
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained injuries.
Acetaminophen (Tylenol, Feverall, Tempera, Aspirin Free Anacin, Tylenol-3)
Indicated for mild to moderate pain. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses that exceed the recommended maximum dose.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-600 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR, Tylox, Roxiprin)
Indicated for moderate to severe pain.
Adult
5-30 mg PO q4h prn
Pediatric
0.05-0.15 mg/kg/dose; not to exceed 5 mg/dose of q4-6h PO prn
Phenothiazines may decrease the analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of the total daily dose of acetaminophen the patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity; high association of abuse and addiction with OxyContin
Hydrocodone and acetaminophen (Vicodin, Margesic, Lortab, Norcet, Lorcet-HD)
Indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg/dose hydrocodone bitartrate or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high-altitude cerebral edema (HACE); elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Codeine
Indicated for moderate to severe pain. Binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering perception and response to pain.
Adult
10-20 mg/dose PO q4-6h prn for cough; not to exceed 120 mg/d
Pediatric
<2 years: Not established
2-6 years: Not to exceed 30 mg/d
6-12 years: Not to exceed 60 mg/d
Toxicity increases with concurrent administration of tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Documented hypersensitivity; HACE diagnosis; elevated ICP
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use to treat cough in patients diagnosed with HACE only if absolutely necessary; may depress hypoxic ventilatory rate and respiratory drive during sleep
Corticosteroids
Corticosteroid agents have anti-inflammatory properties that may be protective in acute spinal cord injuries with neurologic deficits.
Methylprednisolone (Solu-Medrol, Depo-Medrol)
Decrease inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Indicated for known or suspected spinal cord injury. To be administered within 8 h of injury.
Adult
30 mg/kg IV as a bolus; followed by continuous IV drip 5.4 mg/kg q1h for 1 d
Pediatric
Administer as in adults
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase the levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease the levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when they are taking medication concurrently with diuretics.
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use.
More on Cervical Spine Acute Bony Injuries |
| Overview: Cervical Spine Acute Bony Injuries |
| Differential Diagnoses & Workup: Cervical Spine Acute Bony Injuries |
 Treatment & Medication: Cervical Spine Acute Bony Injuries |
| Follow-up: Cervical Spine Acute Bony Injuries |
| Multimedia: Cervical Spine Acute Bony Injuries |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
cervical spine fracture, C-spine trauma / injury, spinal injury, spinal trauma, neck fracture, neck injury
