## INTRODUCTION

The prompt diagnosis of a cervical spine (C-spine) injury is imperative to provide early treatment and prevent secondary spinal cord injury. Since 2010, motor vehicle collisions (MVCs) account for the majority of spinal cord injuries (38%), followed by falls (30.5%), acts of violence (i.e., gunshot wounds, 13.5%), and sporting injuries (9%).1 Cervical spine injuries are found in 2% to 4% of blunt trauma patients that undergo imaging.2,3 The cervical spine is the most common location in the spine to be injured, accounting for upward of 50% to 60% of spinal injuries.1,4 Unfortunately, a delay in diagnosis occurs in one-quarter of cases. Spinal cord injuries lead to significant reductions in life expectancy as well as high individual lifetime costs for care, ranging from $2.1 to$4.7 million based on age at the time of injury.1

The upper cervical spine, consisting of the occiput, C1 (atlas), and C2 (axis), is unique from the remainder of the cervical spine. It is designed to allow for rotation of the head. The C1 vertebra is a ring structure that articulates with the occiput. The C2 vertebra is composed of a body with a bony projection (dens) that goes through the anterior portion of the ring of C1. The dens is stabilized by both the transverse and the alar ligaments (Fig. 9–1). The transverse ligament is located along the posterior surface of the dens, attaching on either side of C1. Injury to this ligament may be catastrophic to the patient in the form of atlantoaxial instability and a high cervical cord lesion.

###### Figure 9-1.

The transverse and alar ligaments and their importance in stabilizing the C1 and C2 vertebrae.

The lower cervical spine can be divided into two columns, where disruption of an entire column is required to alter stability. The anterior column consists of the anterior and posterior longitudinal ligaments and the vertebral body. The posterior column comprises the pedicle, lamina, articular facet joints, and ligamentum flavum.

### Spinal Immobilization

Immobilization of the cervical spine has been a long-standing practice after traumatic events in the prehospital setting on the premise that it will prevent further neurologic deterioration. Patients are typically placed in a rigid collar and transported to the emergency department (ED) for evaluation. Evidence demonstrates risks associated with routine immobilization, including skin ischemia; pressure sores; and increased respiratory effort, pain, intracranial pressure, and aspiration risk.5–7 Cervical immobilization also increases extraction time and compromises the ability to maintain a safe airway.7 No studies have confirmed the benefits of spinal immobilization, or demonstrated improved patient outcomes or prevention of neurologic deterioration.8,9 Thus, clearance of the cervical spine and removal of the cervical collar in a timely manner in patients that do not require immobilization is paramount.

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