Cervical Spine Acute Bony Injuries in Sports Medicine Workup

  • Author: George L Hertner, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Sep 23, 2011
 

Laboratory Studies

Laboratory studies are not typically useful in the diagnosis of cervical spine injuries.

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Imaging Studies

Plain radiography

Obtain plain radiographs when cervical injury is suspected. Two large studies looked at when radiographs should be obtained. The criteria for radiography differ, and some controversy remains regarding which system is better.[17, 18, 19] Keep in mind as well that these studies were not focused on athletes or athletic mechanisms of injury. Use of these guidelines should be taken with precaution in athletes.

According to the National Emergency X-Radiography Utilization Study (NEXUS) study criteria, the patient must exhibit the following criteria in order for the mechanism and dynamics of injury to be considered low risk, and, if any of the below criteria are present, radiographs should be obtained[20] :

  • No posterior midline cervical spine tenderness
  • No evidence of intoxication
  • Normal level of alertness
  • No focal neurologic deficit
  • No painful distracting injuries

The Canadian C-Spine Rule (CCR) uses more criteria to determine who should undergo radiographs[18, 21, 22] :

  • Primary criteria – First, take the following into consideration: (1) patient age older than 65 years, (2) mechanism of injury considered dangerous, and (3) numbness or tingling present in the extremities.
    • A dangerous mechanism of injury would be, for example, a fall from an elevation of 3 feet or higher, a bicycle collision, an axial load to the head (eg, resulting from a dive into an empty swimming pool), or a motor vehicle collision involving high speed, rollover, or ejection.
    • If any of these high-risk factors is present, then the patient is at risk for having a cervical spine injury and neck radiography should be performed.
  • Additional criteria: If the patient does not meet any of the above criteria, then the question becomes whether the patient is voluntarily able to actively rotate the neck 45° in each direction.
  • NOTE: Before any neck rotation test is performed, at least one of the following low-risk factors must be present: (1) simple rear-end motor vehicle collision, (2) patient ambulatory at any time since injury, (3) delayed onset of neck pain, (4) patient in sitting position in emergency department, or (5) absence of midline cervical spine tenderness. If none of these criteria is met, radiography should be preformed.
  • Finally, if the athlete is unable to voluntarily rotate to 45° in each direction, radiography should be preformed.

The standard radiographs obtained in a cervical spine series vary slightly by facility. Usefulness of some views in routine radiographic screening has been debated. A large patient study indicated that standard 3-view imaging is reliable for screening trauma patients.[23]

The 3-view series includes cross-table lateral, anteroposterior, and open-mouth odontoid views. Additional radiographic views include oblique views, odontoid tip shots, swimmer's view, and flexion/extension views.[24, 25, 26]

Computed tomography (CT) scanning

Perform CT scanning after plain radiography to further evaluate abnormalities.[27] CT scanning is also useful in the evaluation of areas that are difficult to evaluate or see in plain radiographs, such as the lower cervical spine in very large individuals secondary to body habitus.

CT scanning provides much greater visualization of fractures and the capability to form 3-dimensional (3-D) reconstructions of the vertebrae, which may be helpful preoperatively. CT imaging is preferable in the obtunded patient and may facilitate the evaluation of the unstable spine in these patients.[28]

CT scanning is becoming more commonly used in unconscious patients and for those with abnormal plain radiographs. In some institutions, this imaging modality has replaced plain radiographs in many situations. There is a greater exposure to radiation with this modality and this should be considered as well.

Magnetic resonance imaging (MRI)

  • MRI serves best in evaluating the soft structures of the spinal column.
  • MRI is helpful in the evaluation of ligamentous injuries and neural tissue.
  • MRI is helpful in the evaluation of spinal stenosis.
  • MRI assessments after spinal cord injury correlate with patient neurologic status and are predictive of outcome at long-term follow-up.[29]

Bone scanning

Bone scanning may be of assistance in the evaluation of stress fractures, infections, and tumors.

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Contributor Information and Disclosures
Author

George L Hertner, MD  Medical Director, Department of Emergency Medicine, Memorial Hospital North of Colorado Springs

George L Hertner, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Colorado Medical Society, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nathaniel Johnson Stewart Jr, MD, FACEP  Director for Education and Professional Services, Department of Emergency Medicine, Palmetto Health Richland Hospital

Nathaniel Johnson Stewart Jr, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Janos P Ertl, MD  Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Henry T Goitz, MD  Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author coauthor Mark Leski, MD, to the development and writing of this article.

References

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Anteroposterior view of atlantooccipital dislocation.
Odontoid view of a Jefferson fracture.
Lateral view of a C2 fracture dislocation.
Odontoid type 2 fracture.
Lateral view of type 3 odontoid fracture.
Computed tomography scans of odontoid type 3 fracture.
Lateral view of a C3 spinous fracture.
Lateral view of hangman's fracture.
C3 flexion fracture.
C4 burst fracture.
Clay shoveler's fracture.
Unilateral locked facets on C5 and C6.
Bilateral facet fracture/dislocation at C6/C7.
Child with C6 flexion wedge fracture.
C7 lamina fracture.
 
 
 
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