The mechanism of injury can include flexion-extension, rotation, twisting, axial load, or compression forces. Flexion-extension injuries occur with MVAs and are very unstable. Axial loads result from a weight falling onto the head or from diving into shallow water, causing the body’s weight to be driven onto the head and neck.

The first consideration in diagnosis is the mechanism of injury. In the presence of a flexion-extension or axial-loading injury, there must be a suspicion of a C-spine injury. On physical examination, there may be tenderness over the soft tissues around the neck or over the spinous processes. Swelling or ecchymoses around the neck may be indicative of significant trauma. Head trauma, bruising, and lacerations may suggest force transferred to the neck. Loss of consciousness masks pain and neurologic deficits.

If any possibility of C-spine injury is present, C-spine radiographs should be taken immediately, including open-mouth odontoid view, anteroposterior (AP) and lateral views (showing all seven cervical vertebrae), and oblique views of the C-spine. If there is any question of C-spine subluxation, dislocation, or fracture, a computed tomography scan should be obtained. In obese or muscular patients, the lower cervical vertebra may not be visible on the standard lateral
radiograph. This visualization can be improved by taking a swimmer view or a shoulder pull-down view. The examiner stands at the foot of the bed and pulls down on both hands, preventing the shoulders from obscuring the spine.

The lateral view of the C-spine is the single most important view. The soft tissues should be examined, looking for displacement or widening of the soft tissue window anterior to the spine and behind the trachea. The alignment of the spinal column anterior and posterior to the vertebral body and spinous processes should be continuous. Any disruption may represent a fracture, subluxation, or dislocation. This view also shows fractures of the spinous processes. The open-mouth view allows for visualization of C-2 with the odontoid process and the alignment of the articulation of C-1 with C-2. Any obvious or questionable abnormality requires a computed tomography scan.

All patients with a C-spine injury should have a hard collar, and spine board imaging can be completed. Precautions include logrolling. Management begins with the ABCs of trauma. A complete neurologic examination must be performed, including extremity reflexes and a rectal examination.

Once a patient is stabilized and all C-spine radiographs have been obtained, it may be necessary to perform an MRI or flexion-extension radiographs to further diagnose the injury.

Spinous process fractures represent a low-energy injury diagnosed by posterior tenderness. These so-called clay shoveler’s fractures are seen on the lateral C-spine radiograph. These are avulsion fractures that result from a forceful flexion and extension. Historically, Georgia prisoners building roads injured their necks when the red clay would cling to the shovel, resulting in a sudden flexion-extension of the C-spine. These are stable injuries and are treated symptomatically with a soft collar and analgesics.

All other cervical injuries require consultation.

Any C-spine injury with loss of consciousness, neurologic impairment, or malalignment of the spinal column should be referred.