A Medicolegal Perspective on Cervical Spine Injuries

The cervical spine comprises the bones that make up the neck. Injuries to this area can be caused by road traffic accidents, falls, workplace- or sports-related accidents and physical assaults. Cervical spine injury (CSI), which can consist of fractures, spinal cord injury or a combination of both, is seen most frequently in young men, but there is a second peak of incidence in the elderly population. CSI is relatively rare, being found in only 5–10% of trauma patients. However, this part of the spine is the area most likely to be damaged and accounts for up to 50% of all spinal injuries. Furthermore, the consequences of a missed cervical spine injury can be devastating, so prompt diagnosis is vital.  

CSI commonly presents with symptoms such as neck pain, torticollis, altered mental state, sensory and motor loss, and respiratory arrest. Imaging can aid diagnosis, and one or more of several techniques may be used. Plain radiography is usually used in children, as it is readily available, portable and the patient receives a relatively low radiation dose. Plain radiographs are generally adequate for screening alert patients who do not appear to have neurological abnormalities. Computed tomography (CT) is the best modality for detecting bony CSI and is better than radiography for detecting fractures. It delivers a much higher radiation dose and although recommendations are that it should not be carried out routinely in the neck area, it remains the gold standard investigative method in cases of major trauma. CT angiography can also be used as an initial screening tool to rule out significant arterial damage, the symptoms of which may not otherwise become apparent for up to 72 hours after injury.  

Magnetic resonance imaging (MRI) does not use radiation. Another advantage is that it is better than both radiography and CT at detecting soft-tissue abnormalities and is particularly useful at detecting cases of spinal cord injury without radiographic abnormalities. In this condition, microscopic haemorrhages affect the spinal cord in the absence of other major abnormalities. Although these lesions may only be identifiable by advanced imaging techniques, they can still be lethal, so diagnosis is vital. MRI is also useful for monitoring the progress of treatment. The disadvantages of MRI include high cost, length of screening time and limited availability.  

A major issue with both radiography and CT is that patients are exposed to radiation, which can increase the lifetime risk of developing cancer, particularly of the thyroid. There is also an associated financial cost. It is therefore important to identify when imaging is really necessary, while minimising the risk of missing an injury. In order to identify patients who require imaging, numerous tools have been developed. These seek to divide the patient population into those at low or high risk of CSI; further evaluation by imaging is only required for the high-risk group, which includes patients with neurological symptoms, those who are intubated or have a low Glasgow Coma Scale score. Patients with obvious bony injury, or high suspicion of injury despite normal radiographs, may also require further imaging. In elderly patients, age-related degeneration of the spine means that low-energy trauma can result in severe lesions, so a lower threshold for requesting imaging should be used for this patient group. While low-risk patients only require clinical follow-up, it is vital that any immobilising precautions, such as a neck brace, are maintained until a CSI can be definitively ruled out.  

Once a CSI has been diagnosed, treatment options include external fixation of the cervical spine with a rigid or soft collar, brace, or halo frame. Alternatively, internal surgical fixation can be used. The method chosen will be dictated by the type and location of the injury, which will also influence outcome and prognosis. The cervical spine is a complex structure, the components of which have different susceptibility to trauma and capacity to heal. Therefore, the outcome will depend on the degree of neurological injury, the type and severity of any bone fractures, the amount of dislocation and the stability of all the structures involved in the injury. It is also influenced by post-injury physiotherapy, which is crucial in getting the joints moving and muscles activated, so that the strength of the injured area can be gradually built up.  

While the pattern of CSI in older children and teenagers is similar to that seen in adults, children aged less than 8 years generally display different types of injury. This is due to the unique anatomical features, including a relatively large head, immature neck musculature, laxity of the ligaments and horizontal articulation of the facet joints, found in this age group. Compared to the preponderance of sub-axial injuries seen in older patients, younger children are more likely to experience injury at the cranio-cervical junction and upper cervical spine.  

This is important, because the outcome and risk of adverse sequelae is directly influenced by the location of the injury. Injuries higher up in the cervical spine are associated with higher levels of both mortality and morbidity than those lower down. Patients who damage the top two vertebrae are nearly five times more likely to die than those who sustain injuries in the C3 to C7 region. Life-changing neurological damage is also common, affecting up to 60% of patients. CSI also has a significant effect on life expectancy, which is reduced by 6–45 years, depending on the nature of the injury. Many patients go on to develop one of two types of progressive spinal deformity: paralytic scoliosis or cervical kyphosis secondary to laminectomy. In addition, there are psychological and societal costs.  

Further reading: 

Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NW, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev. 2017 Dec 7;12(12):CD011686.  

Zanza C, Tornatore G, Naturale C, Longhitano Y, Saviano A, Piccioni A, Maiese A, Ferrara M, Volonnino G, Bertozzi G, Grassi R, Donati F, Karaboue MAA. Cervical spine injury: clinical and medico-legal overview. Radiol Med. 2023 Jan;128(1):103-112.