Attention to C-Spine in Craniofacial Trauma-An Update-Juniper publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY
Abstract
The evolution of research and techniques in
management of a trauma patient has reduced the mortality rate
significantly in the golden hour. Severe maxillofacial and neck trauma
exposes patients to life threatening complications such as airway
compromise and hemorrhagic shock. These conditions require rapid actions
(diagnosis and management) and a strong interplay between first level
health care providers, surgeons and anesthesiologists. The cases with
pan facial trauma need at most scrutiny due to proximity to cranial and
cervical structures. In this article an insight into the C-spine
injuries in a pan facial trauma patient has been discussed.
Keywords: C-spine injury; Craniofacial traumaIntroduction
Maxillofacial injuries are frequent cause of
presentations in an emergency department. Varying from simple, common
nasal fractures to gross combination of the face, management of such
injuries can be extremely challenging. Injuries of this highly vascular
zone are complicated by the presence of upper airway and proximity with
the cranial and cervical structures that may be concomitantly involved.
The usual techniques of airway breathing and circulation (ABC)
management are often modified or supplemented with other methods in case
of maxillofacial injuries [1]. Polytrauma patient admitted to hospital
may have injury to cervical spine which is not immediately obvious.
Because patient is neurological normal, with no neck pain or patient is
having distracting pain or patient is unconscious. In case where there
is no clear indication of cervical spine injury, however, patients still
needs to be evaluated for cervical spine injuries because an unstable
cervical spine injury could to delayed & result in neurological
deterioration. Cervical spine injuries have been reported to occur in up
to 3% of patients with major trauma and up to 10% of patients with
serious head injury [2].
Neck Anatomy
It is useful to divide the anatomical structures of
the neck into five major functional groups, to facilitate and ensure a
comprehensive assessment and surgical approach:
- Airway - pharynx, larynx, trachea, lung.
- Major blood vessels-carotid artery, innominate artery, aortic arch, jugular vein, subclavian vein.
- Gastrointestinal tract-pharynx, esophagus.
- Nerves - spinal cord, brachial plexus, cranial nerves, peripheral nerves.
- Bones-mandibular angles, styloid processes, cervical spine.
The platysma defines the border between the
superficial and the deep structures of the neck. If a wound does not
penetrate deep to the platysma, it is not classified as a significant
penetrating neck wound. As transverse cervical veins running superficial
to the platysma may bleed profusely when severed, they are easily
controlled by direct pressure, and can be managed by a simple ligature.
The sternocleidomastoid muscle divides the neck into the posterior
triangle which contains the spine and muscles, and the anterior triangle
which contains the vasculature, nerves, airway, esophagus and salivary
glands [3].
When evaluating penetrating neck injuries, the neck
is divided into three anatomic zones for purposes of initial assessment
and management planning:
- Zone I: Extends between the clavicle/suprasternal notch and the cricoid cartilage (including the thoracic inlet).Surgical access to this zone may require thoracotomy or sternotomy. Major arteries and veins, trachea and nerves, esophagus, lower thyroid and parathyroid glands and thymus are in this zone.
- Zone II: Lies between horizontal lines drawn at the level of the cricoid cartilage and the angle of the mandible. It contains the internal and external carotid arteries, jugular veins, pharynx, larynx, esophagus, recurrent laryngeal nerves, spinal cord, trachea, upper thyroid and parathyroid glands.
- Zone III: Extends between the angle of the mandible and base of skull. It contains the extracranial carotid and vertebral arteries, jugular veins, cranial nerves IX–XII and sympathetic nerve trunk [4].
Cervical Spine and Maxillofacial Trauma
In a complex maxillofacial trauma scenario, cervical spine
fracture should always be considered unless proven otherwise.
Because of the proximity of cervical spine any force of such
magnitude that causes facial fractures can potentially traumatize
the c-spine and its ligamentous attachments [5].
Clinical awareness about the status of cervical spine is
achieved using the most commonly used three evidence-based
decision protocols, Nexus criteria [6], Canadian spine rule [7],
Harbor view criteria [8]. In patients who are awake, clearance
protocol can be effectively implemented by a detailed clinical
examination; however, in an unconscious patient, it is not
possible. The clearance of such patients hinges on clinical
examination, risk, and radiographic examination such as
noncontract computerized tomography, static flexon extension
radiography, magnetic resonance imaging, and dynamic
fluoroscopy [1,9].
Anderson et al. [10] reviewed cervical spine clearance in blunt
trauma patients and classified patients based on their symptoms
and ability to provide a reliable evaluation. Patients are acutely
categorized into one of four groups
a) Asymptomatic: There are two main protocols for
cervical clearance in the asymptomatic patient that have been
and continue to be widely utilized:
i. National Emergency X-Radiography Utilization Study
(NEXUS) Low-Risk Criteria (NLC) [6] and
ii. Canadian Cervical-Spine Rule (CCR) [7,11].
b) Temporarily non-assessable: Temporarily non
assessable patients have a transient inability to provide a
reliable examination. These patients are expected to resume
their baseline cognitive function and be evaluable within
24-48 hours. Harris et al. [11] reported on this group of
patients and found that most common factors in the category
of temporarily non assessable are drug/alcohol intoxication,
concussion, or pain from distracting injuries. Once the patient
has regained adequate cognitive function and is deemed clinically asymptomatic after a comprehensive examination,
he or she can be treated as such and cleared clinically without
imaging. If a patient is presumed to regain his or her normal
baseline cognitive function within the 24-48 hours time but
cervical clearance becomes more urgent, such as when surgical
intervention is required for other injuries, the individual can
be evaluated as an obtunded patient with advanced imaging.
The most common guideline for this patient population is to
have them undergo a multi-detector CT scan and/or maintain
their cervical collar [11].
c) Symptomatic: Symptomatic patients are those with
neck pain, tenderness, or neurologic symptoms. This
subgroup requires spinal imaging. The various imaging
options include static and dynamic plain radiographs, CT, and
MRI. Each of these various imaging methodologies has specific
advantages and disadvantages, not only regarding sensitivity
and specificity but also in terms of timing and cost. Plain
radiography is one of the earliest imaging modalities and is
currently readily available, fast, and low cost in comparison
to other types of studies. In patients with suspected spine
trauma, plain radiographic evaluation has been shown to
have a wide range of reported sensitivity for cervical spine
injuries ranging from 31.6 to 52% depending on the study
[11,12].
d) Obtunded: Cervical spine clearance in the obtunded
patient is the most controversial aspect and focuses mainly on
whether an MRI is necessary in addition to a negative MDCT.
Though an exceedingly rare incident, isolated neurologic
injury does occur and can lead to significant morbidity. The
percentage of acute trauma patients who are obtunded at the
time of evaluation ranges from about 20 to 30% [3,11,13].
Diagnostic Imaging
Plain radiography
The lateral view is 83% sensitive and 97% specific for
detecting cervical spine fracture. Adding an open mouth view and
AP view increases sensitivity to nearly 100%. The open mouth
view is essential for excluding C1 arch or C2 odontoid process
fractures. The AP view assesses alignment of uncovertebral
joints and spinous processes. Oblique views can be used to
assess facet joints, pedicles, and lateral mass, especially at the
cervicothoracic junction. If the cervico-thoracic junction cannot
be visualized on the lateral view, obtain a swimmer’s lateral view
or a CT scan.
Obtain a CT scan if the patient has normal x-rays but
persistent cervical tenderness and pain. Flexion extension views
are not useful in the acute setting. Pain and discomfort preclude
adequate motion to assess for ligamentous injuries. Only perform
a flexion-extension view on an alert patient under supervision.
Flexion with an occult ligamentous injury may precipitate
neurologic injury [2,14,15].
CT scan
A CT scan is useful for determining the presence and extent
of osseous injury. In fact, it is superior to MRI in this situation.
In blunt trauma patients, CT scan detects 99.3% of cervical spine
fractures. Injuries in the transverse plane may be missed on axial
cuts, i.e., odontoid fractures. It is essential to obtain coronal and
sagittal reconstructions [2,16].
MRI
MRI is indicated for evaluating neurologic deficits and
ligamentous injuries.MRI is superior to CT for demonstrating
spinal cord pathology, intervertebral disc herniation, and
ligamentous disruption. MRI has limited usefulness as the
primary means for initial cervical clearance. The highly sensitive
images of MRI show muscular and soft tissue images that do not
necessarily correlate with clinical instability. MRI is not necessary
if the initial screening CT is negative and the patient does not
demonstrate neurologic abnormalities. CT has evolved to be first
line modality in obtunded patient in a trauma setting. If the CT
is negative, Anderson supports discontinuing the cervical collar.
MRI may find abnormalities even if the CT is negative; however,
these abnormalities are not likely to be clinically significant. The
American College of Radiology advocates both CT and MRI for
clearance of the obtunded patient [2,17,18] (Figure 1).
Conclusion
There is a continuing debate about the credibility of these
clinical protocols in C-spine without the aid of radiographic
assessment. In a neurologically unstable patient, the cervical spine
must be immobilized irrespective of the injury. The universally
accepted method of C-spine management includes hard collars,
block and straps, and manual axial inline stabilization. These
management methods are rather emotional and lack adequate
scientific basis, especially in conscious patients. However, the
generally accepted fact is that the application of collar protects
and stabilizes the cervical spine temporarily until definitive
management is done. The cervical collar should be applied by
an experienced person or a person trained to do that. It should
be snugly fitted to aid immobilization and while applying care
should be taken not to compress the neck. Improper applications
of collars are implicated in airway obstruction and perhaps
rise in intracranial pressure by affecting the venous return
from the brain. This complicates head injury and increases the
cerebrospinal fluid leakage form skull base fractures and creates
problems during operative repair of maxillofacial injuries. The
gravity of all maxillofacial injuries lies in the fact that they pose
an immediate threat to life because of its proximity to both
the airway and brain. All the same, each case is unique; thus,
the management is exacting even for the most experienced of
professionals. In any given scenario, no treatment approach can be sure and flawless. The need of the hour is a multipronged
approach requiring a partnership between several departments.
While new technology and material developments [19] have
helped ease the situation, it is the timely intervention, she
er skill,
and presence of mind of emergency personnel, and surgeons
that counts.
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