Emergency Medicine

NECK INJURIES

228 Surgical Emergencies

(v) MRI is more sensitive than CT and plain X-ray for identifying

soft-tissue damage such as ligamentous injuries, disc herniation

or a haemorrhage causing compression of the spinal cord or

cervical nerve roots

(a) it is rarely available in the acute situation, but may be

arranged subsequently.

MANAGEMENT

1 Always apply a semi-rigid collar, minimize head movements in any suspected

neck injury, and use laterally placed sandbags taped to the forehead to

prevent head rotation.

2 Arrange urgent airway control with orotracheal intubation for the un-

conscious patient or for respiratory distress.

(i) Only an airway-skilled doctor should perform this, usually by a

rapid sequence induction (RSI) intubation technique (see p. 467)

with in-line manual immobilization to protect the neck from any

movement.

3 Restore the circulatory volume if the patient is hypotensive.

(i) First look for sources of blood loss before diagnosing neurogenic

shock.

(ii) Neurogenic shock causes hypotension in a patient with a cervical

cord injury due to loss of sympathetic tone with vasodilation and

bradycardia.

(iii) Place a urinary catheter to monitor urinary output.

4 Severe ligamentous damage with cervical spine instability may occur, with

an apparent ly norma l X-ray.

(i) This is more likely in children, in whom up to 50% of serious

spinal injuries have normal X-rays (SCIWORA – spinal cord

injury without radiological abnormality).

(ii) Neck hyperextension may cause predominant weakness of the

arms in elderly patients with cervical spondylosis, without any

associated fracture or dislocation, known as the central cord

syndrome.

(iii) Arrange an MRI in these circumstances.

5 Refer all suspected cervical spine injuries to the orthopaedic or surgical team

and begin pressure-area nursing.

6 The value of high-dose methylprednisolone to improve neurological

outcome in patients with complete or incomplete spinal cord damage

remains unconvincing and controversial, and has been abandoned in many

centres.

(i) Start treatment within 8 h of injury, guided by the advice of the

regional spinal injuries unit.