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Spinal and spinal cord trauma and cervical spine clearance
In a trauma patient, restrict spinal movement, decide on cervical spine imaging by the NEXUS criteria or the Canadian rule, and distinguish neurogenic shock (hypotension with bradycardia) from spinal shock (temporary loss of reflexes) and from incomplete cord syndromes.
Why it matters in the exam
The common question is whether cervical spine imaging is needed. By NEXUS no imaging is needed when all five criteria are met: no midline tenderness, no neurological deficit, normal alertness, no intoxication and no distracting injury. The Canadian rule adds high-risk factors — age 65 or more, a dangerous mechanism or limb paraesthesia — and tests whether the patient can rotate the head 45 degrees to each side. The preferred imaging in an adult is CT.
Incomplete syndromes are also tested: the central cord syndrome in an older patient with cervical stenosis after hyperextension — arms weaker than legs; the anterior cord syndrome — loss of movement, pain and temperature with preserved position sense, and the worst prognosis; Brown-Séquard — same-side weakness and loss of position sense with contralateral loss of pain and temperature, and the best prognosis.
Neurogenic shock appears with injury above T6 and shows as hypotension, bradycardia and warm skin; it is a diagnosis of exclusion after bleeding has been sought. It is treated with fluids, vasopressors and atropine for bradycardia, and hypotension is avoided to preserve cord perfusion. High-dose steroids are not recommended. MRI suits a neurological deficit, suspected ligamentous injury and a patient who cannot be assessed. A seat-belt Chance fracture requires a search for abdominal injuries.
Key points
- NEXUS: five negative criteria — no imaging.
- Canadian rule: age 65 or more, dangerous mechanism or paraesthesia — image; rotation of 45 degrees to each side.
- CT in adults; MRI for a neurological deficit or suspected ligamentous injury.
- Neurogenic shock: hypotension, bradycardia, warm skin; exclude bleeding first.
- Central cord — arms; anterior cord — poor prognosis; Brown-Séquard — good prognosis.
Summary table
| Situation | Findings | Meaning | Action |
|---|---|---|---|
| NEXUS negative | No midline tenderness, no deficit, alert, not intoxicated, no distracting injury | Very low risk | No imaging needed |
| High risk by the Canadian rule | Age 65 or more, dangerous mechanism, paraesthesia | Cannot be cleared clinically | CT |
| Neurogenic shock | Hypotension, bradycardia, warm skin, injury above T6 | Loss of sympathetic tone | Fluids, vasopressors, atropine; exclude bleeding |
| Spinal shock | Temporary flaccid paralysis and areflexia | A transient phase | Reassess after reflexes return |
| Central cord syndrome | Arms weaker than legs, older patient, hyperextension | Central injury | MRI, usually conservative |
| Brown-Séquard | Same-side weakness, contralateral loss of pain and temperature | Hemisection, usually penetrating | Best prognosis |
A free exam question
מבין 4 המטופלים המתוארים להלן, אשר זקוקים להנשמה, במי ניתן לטפל על ידי SUCCINYLCHOLINE לצורך ביצוע RSI? (the question as examined, in Hebrew)
- א. בן 24, עם פגיעה רב מערכתית, לאחר מספר שעות בהן היה לכוד תחת הריסות בניין וחולץ
- ב. בן 65, מטופל המודיאליזה, אשר פספס את 2 מועדי הדיאליזה האחרונים שלו
- ג. בת 55, מרותקת לכסא גלגלים, 4 חודשים לאחר פגיעת עמוד שדרה צווארי
- ד. בת 70, עם חולשת צד שמאל ואפזיה מזה שבוע
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Sources
- Hoffman JR et al., NEXUS: Validity of a set of clinical criteria to rule out injury to the cervical spine (NEJM), 2000 — Results
- Stiell IG et al., The Canadian C-Spine Rule for radiography in alert and stable trauma patients (JAMA), 2001 — The rule
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Spine and spinal cord trauma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.