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BACKGROUND AND PURPOSE: Multidetector CT is the workhorse for detecting blunt cervical spine injury. There is no standard of care for re-interpretation of radiology images for patients with blunt trauma transferred to a higher level of care. The clinical impact of discrepancies of cervical spine CT reads remains unclear. We evaluated the discordance between primary (from referring hospitals) and secondary radiology interpretations (from a receiving level I tertiary trauma center) of cervical spine CT scans in patients with blunt trauma and assessed the clinical implications of missed cervical spine fractures. MATERIALS AND METHODS: Medical records of patients with blunt trauma transferred to our institution between 2008 and 2015 were reviewed. Primary and secondary interpretations were compared and categorized as concordant and discordant. Two senior neuroradiologists adjudicated discordant reports. The benefit of re-interpretation was determined. For discordant cases, outcomes at discharge, injury severity pattern, treatment, and arrival in a cervical collar were assessed. RESULTS: Six hundred fifty patients were included; 608 (94%) presented with concordant reports: 401 (61.7%) with fractures and 207 (31.8%) with no fractures. There were 42 (6.5%) discordant reports; 18 (2.8%) were cervical spine injuries undetected on the primary interpretation. Following adjudication, the secondary interpretation improved the sensitivity (99.3% versus 95.7%) and specificity (99.1% versus 91.7%) in detecting cervical spine fractures compared with the primary interpretation alone (P

Paediatric neck injuries are a common presenting complaint to emergency departments (EDs). Medical imaging can assist diagnosis, however previous research suggests computed tomography (CT) scan results do not alter management in this patient group and therefore expose children to unnecessary radiation. Following an audit by the hospital Trauma Service that identified unnecessary cervical spine CTs in patients at Women's and Children's Hospital (WCH), Adelaide, the Clinical Procedure for imaging and clearance of the cervical spine in conscious patients was modified to include CT scan only at the request of the orthopaedic service. The aim of this study was to evaluate whether a change in hospital guideline resulted in a change in practice and radiation exposure.A retrospective review was performed for patients that presented to the WCH ED with a suspected cervical spine injury during two defined time periods pre- and post-guideline change. Mechanism of injury, imaging requested, radiation exposure and final diagnosis were compared.Three hundred seventy-nine patients were included, with 164 (43.3%) post-guideline changes. Radiograph use was similar between groups, 132/215 (61.4%) versus 101/164 (61.6%) (p = 0.97). CT scan use was lower post-guideline modification 19/215 (8.8%) versus 12/164 (7.3%), however was not statistically significant (p = 0.59), with an absolute reduction of 17%.Guideline modification at our hospital did not significantly reduce CT scan use or eliminate unnecessary CTs. Unnecessary CT scans followed lack of knowledge of and therefore compliance with guidelines. Individual hospitals should consider strategies to reduce unnecessary CTs, given the association with cancer risk in children.

Due to the inherent bony instability of the cervical spine, there is an over-reliance on ligamentous structures for stability, making this segment of the vertebral column most prone to traumatic injuries. The frequently occurring mechanisms of injury include axial compression, hyper-flexion, hyper-extension, and rotational type injuries. Good pre-hospital care and a thorough assessment in the emergency department of patients suspected to have a cervical spine injury (CSI) leads to improved clinical outcomes. The objective of the initial evaluation of a patient with a suspected CSI is to identify the presence of injuries through thorough clinical and radiologic assessments as missed injuries are potentially catastrophic. The treatment of cervical spine injuries can be conservative, pharmacological, or surgical, and aims to halt SCI progression, stabilize the spine, and to allow rehabilitation of the patient.

BackgroundA consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI.MethodsThe University of Iowa’s trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set.ResultsOverall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178–34.737); pConclusionMidline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.

Evidence supports the notion that craniofacial fractures are significant predictors of cervical spine injuries (CSIs), but some debate remains on the injury mechanism of co-existing CSIs in craniofacial fractures and the relationship between CSI and specific facial fractures. In this retrospective study, we aim to assess the incidence rates of specific facial fracture types as well as other important variables and their relationship with CSIs. The primary outcome variable, CSI, and several predictor variables, including facial fracture type, were evaluated with logistic regression analyses. Of 2919 patients, the total CSI incidence rate was 3.0%. Rates of CSI in patients with isolated mandibular fractures (OR 0.26 CI 0.10, 0.63; p = 0.006) were lower than those previously reported, whereas isolated nasal fractures were strongly associated with CSI (OR 2.67 CI 1.36, 5.22; p = 0.004). Patients with concomitant cranial injuries were twice as likely to have CSI (OR 2.00, CI 1.22, 3.27; p = 0.006). Even though there is a strong occurrence rate of CSIs in patients with cranial injuries, clinicians should be aware that patients presenting with isolated facial fractures are at significant risk for sustaining CSIs also. (C) 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

We present two cases of acute and delayed presentations of intraspinal pseudomeningoceles, which is a rare complication of spinal trauma or surgery. Our goal is to discuss the pathophysiology, clinical presentation, imaging findings, and treatment of this rare entity. This diagnosis should be considered in patients with unexplained neurologic symptoms in the setting of prior cervical spine injury or surgery.

Burning Hands Syndrome is an unusual variant of central cord syndrome. There have been few published reports, and none in the emergency medicine literature. We present a case of Burning Hands Syndrome in which there were no computed tomography (CT) findings of cervical spine injury and only subtle magnetic resonance (MR) abnormalities. We discuss the importance of early diagnosis, as the optimal management of these patients ultimately depends upon prompt recognition of the underlying cervical trauma and a spinal cord at risk for further injury.

Author(s): Jabola, Raymond; Boswell, Benjamin; Lutz, Robert H.; Casey, Jack; Ceraulo, Anthony | Abstract: Introduction: Spinal cord injuries are a common reason for presentation to the emergency department (ED). Sports-related spinal injuries are one of the least common spinal injuries, falling behind vehicular accidents, acts of violence, and falls.Case Report: This case report describes a case of transient quadriplegia in a 17-year-old male who presented to the ED after a helmet-to-helmet collision while participating in football.Conclusion: Emergency physicians should be cognizant of potential spinal cord injury using clinical decision tools and radiologic imaging to properly disposition a patient presenting with cervical spine injury.

Psychosocial factors are known to affect recovery and return to work, but their relationship with the work status of patients with neck pain is not well-studied. The objectives of this study were (...

Background: The consequences of cervical spine injuries range from simple neck pain, to quadriplegia, or even death. MR imaging has become part of the diagnostic and prognostic tools for spinal cord injury. Aim: To prospectively evaluate cervical spine injuries by MR imaging and to find out association of MR imaging findings with degree of neurological deficit. Material and Methods: Descriptive longitudinal hospital based study was conducted on 30 patients with known or suspected cervical spine trauma who presented to the emergency department. Results: Mean age of the cases was about 42 years, with female to male ratio of 1:6.5. C6-C7 spinal level was most commonly involved. Proportions complete spinal cord injury (CSCI), incomplete spinal cord injury (ISCI) and neurologically normal (NN) were 23.33%, 60% and 16.67% respectively. Out of 12 MRI findings, cord haemorrhage, contusion, posterior element fracture, disc injury, prevertebral hematoma, subluxation and soft tissue injury was statistically associated with degree of neurological deficit. Cord contusion, cord haemorrhage and posterior element fracture were potential predictors of neurological status at admission. Cord contusion, cord haemorrhage and subluxation were potential predictors at 3 months. Conclusion: MRI proved a pivotal role in the diagnosis of SCIs, deciding prompt management and predicting neurological deficit and prognosis of neurological recovery. So, MRI is an excellent diagnostic modality for the evaluation of spinal trauma and predicting the degree of neurological deficit and recovery.

Cervical spine injury can be found in an estimated 5% of blunt trauma patients and poses some specific concerns for the otolaryngologist. Understanding the mechanisms and nature of injuries are essential to manage and minimize secondary spinal cord injury, particularly during intubation, or emergent or planned airway or other surgical procedures. Providers should be able to identify patients with potential cervical spine injury, be familiar with alternative methods of airway management and neck stabilization and have an understanding of basic management of cervical spine injury.

Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs).The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2.From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P0.001), Hispanic (17.5% vs 9.3%, P0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P0.001). Both groups had similar rates of complications and mortality (P0.05). The associated risk of a serious head (odds ratio = 3.17, P0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P0.05).Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.

Study design: Retrospective study.Purpose: to extract epidemiological data related to sub-axial cervical spine injury managed at our spine institute and evaluate outcome with rehabilitation protocol.Overview of literature: sub-axial cervical spine injuries are very serious injuries in all spinal injuries and usually associated with SCI or with neurological deficit and have highest morbidity and mortality in all type of spinal injuries.Method: Total of 142 patients study included who were admitted with sub-axial cervical (C3-C7) spine injury our spine institute western India from period of Feb 2018 to December 2019 and managed conservatively or operative manner and Rehabilitation protocol were given. Detailed information on epidemiological study was analyzed based on the medical records of patients and follow-up and final outcome evaluated.Results: most common age group was 30-50 yrs.48%, 94% male and 6% female with male to female ratio of 14:1. The commonest mode of trauma was fall from height 56% followed by 37% of RTA, 77% were laborers, average admission delay was 6.1 days, admission to surgery delay was 2.3 days, 53% had incomplete & 44% complete neurological deficit, 73% had involvement of bladder/ bowel, 74%were managed conservative while 26% operated, 6% had other associated injuries, 86% had received complete rehabilitation protocol, average hospital stay around 26 days, and significant improvement in ASIA score with rehabilitation protocol.Conclusion: This study evaluate epidemiological data and burden of sub-axial cervical spine injury in community, so improving awareness, infrastructure build up and early recognition and proper management and rehabilitation protocol have high chances of improvement with low mortality or morbidity.

Advances in perioperative care, surgical instrumentation, and understanding of the patho-physiology of trauma have engendered new treatment paradigms for these injuries within the last two decades. Evaluation of outcome of LATERAL MASS FIXATION in sub-axial cervical spine injury in terms of improvement of neurological deficit (ASIA Scale) in one, three, six and nine months follow up. Sub-axial cervical spine injury patients attending OPD, Emergency. Age group: between 15 to 75 years, both male and female. The study was a both retro and prospective, non randomized, uncontrolled, interventional study group. The study was performed over a cohort of adult patients. Our study attested to the safety and acceptability of lateral mass fixation as a established mean of posterior fixation with no failure rate after one year follow up and a lesser operative complication rate.

Objective. To study the etiological structure and antimicrobial resistance of hospital-acquired pneumonia pathogens in patients with complicated cervical spine injury. Materials and methods. A retrospective study included 418 bacterial isolates from sputum in 29 patients with hospital-acquired pneumonia who were treated in ICU during the period 2012–2013 and 2017–2018. Results. The most common pathogens from the lower respiratory tract, both in 2012–2013 and in 2017–2018 were Pseudomonas аeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae. The share of K. pneumoniae in 2017–2018 increased by 16.8 % (3.2 times more often), and the share of microorganisms of the Enterobacteriaceae — by 26.7 % (р

Background Clinically significant damage to the cervical spine in children is uncommon, but missing this can be life-changing for patients. The balance between rarity and severity leads to inconsistent scanning, with both resource and radiation implications. In 2014, the United Kingdom’s National Institute for Health and Care Excellence updated their computerised tomography neck imaging guidance in children. The aim of this study was to assess if the change in guidance had resulted in a change in diagnosis or imaging rates. Methods A retrospective review of the national Trauma Audit and Research Network’s data for computerised tomography spine imaging in children in 2012–2013 was compared to the same data sample collected in 2015–2016. Results The percentage of children presenting with neck trauma who were imaged reduced from 15.5 to 14.1% with an increase in confirmed cervical spine injury from 1.6 to 2.3% between the two time periods. The specificity of computerised tomography scanning increased from 10 to 16.4%. There was variation in scan rates, with major trauma centres scanning a greater percentage of children of all ages and with all injury scores, than trauma units. Discussion This study suggests national guidance can impact clinical care in a relatively short timeframe. Variation in how guidance is applied, with major trauma centres scanning proportionately more children with a lower yield, could be because scanning is more readily available, or because trauma protocols encourage more scans. Twenty per cent of injuries were not found on the initial computerised tomography, in keeping with previously reported data, because the injuries were ligamentous or cord contusion. This suggests a role for early magnetic resonance imaging in children with suspected spinal injury.

The choice of an implant for vertebra body defect replacement in corpectomy for traumatic lesions remains a point of discussion among spinal surgeons. Nanostructured carbon cages are promising for use in spinal surgery. The purpose of this study was to determine the rate and degree of cage subsidence in the patients with traumatic lesions of the cervical spine undergone a single-level anterior corpectomy in the subaxial part of the cervical spine with reconstruction using a carbon or titanium cage. Materials and Methods . A prospective study included 47 patients undergone a single-level corpectomy of the cervical spine due to traumatic injury. Two groups were formed by adaptive randomization: group I with the patients with carbon cages (n = 23), and group II with the patients with titanium cages (n = 24). The evaluation of cages subsidence and stability was carried by X-rays and CT before and after surgery. The quality of life before and after the surgery was evaluated using NDI and VAS questionnaires. Results . According to the questionnaires, the absolute majority of the patients in both groups showed a statistically significant improvement of quality of life in the postoperative period (p

Plain radiographs continue to play an important role in the assessment of the cervical spine, despite an ever-increasing uptake of cross sectional imaging. They are widely available and utilized in the setting of trauma to assess for cervical spine injury and stability as an integral part of the trauma series. Furthermore they can provide vital information such as dynamic stability in patients with underlying rheumatological conditions, most importantly rheumatoid arthritis. A systematic approach in analysing cervical spine radiographs can be used to glean important information regarding any underlying injury or instability, initiating further steps in the patient's management and crucially allowing the anaesthetist to take precautions in airway management. We outline some of the most important principles of reviewing such radiographs in the adult population in this article and also aim to outline some of the common pitfalls and limitations of assessing such studies in common practice. Finally we briefly review NICE guidelines on the imaging of cervical spine trauma.

Background:Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries.Methods:Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012–2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital’s data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P Results:Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01).Conclusion:Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

Traumatic atlanto-occipital dislocation (AOD) is a relatively uncommon traumatic cervical spine injury characterized by disruption and instability of the atlanto-occipital joint. At many centers, management of pediatric AOD includes occipitocervical arthrodesis, but whether external immobilization without surgery is a viable treatment option for some pediatric patients is unknown. To answer this question, we analyzed our outcomes of pediatric AOD at the Hospital for Sick Children. We performed a retrospective chart review of all children with clinical and radiographic evidence of traumatic AOD. A total of 10 patients met criteria for traumatic AOD: 8 were treated with external immobilization alone and 2 were treated with occipitocervical arthrodesis. Eight patients were treated exclusively with 3 months of halo immobilization. Two patients were treated with occipitocervical instrumentation and arthrodesis. No patient undergoing halo immobilization required subsequent operative fusion. Halo immobilization is a safe, viable, and definitive treatment option for the selected children with AOD.

Capacity requests in the general hospital require the consultation-liaison (CL) psychiatrist to make assessments based on their evaluation of the patient’s ability to understand and make informed choices, as well as consideration of the clinical situation. When a patient does not have capacity to consent for surgery and the intervention is non-urgent, the ramifications of treating over objection must be considered carefully. We present a case of a patient with schizophrenia who refused a non-urgent surgical intervention to repair a cervical spine injury. We discuss important factors that impact medical decision-making in the general hospital. In this case, we give an example of how the interests of the surrogate medical decision maker and hospital may conflict with the patient’s authenticity and how this can complicate the capacity assessment, decision-making process, and hospital course. An ethics committee was utilized to discuss the risks and benefits of treating over objection and implications for the patient and care team.

Subaxial cervical spine injury especially in the elderly can be associated to severe complications and disability. Until today there is no consensus concerning the best operative treatment. A potential superiority of anterior or posterior fixation is the subject of controversial discussions.The aim of this study was to compare the outcome of anterior and posterior fixation after subaxial cervical spine trauma in the elderly focussing on the postoperative mortality.A retrospective cohort analysis was performed to analyse the data of 43 patients. Especially mortality data were collected.A total of 43 patients was identified. Anterior fixation was performed in 21 patients, posterior fixation was performed in 22 patients. There were no significant differences between these groups. Although statistical significance was not reached, a slightly higher mortality was found among patients undergoing anterior fixation (52,4 vs. 31,8%). Furthermore the male sex, a higher age, translation injuries, long duration of operation and hospitalisation as well as postoperative complications were slightly associated to a higher mortality.Subaxial cervical spine trauma is associated to a high mortality in the elderly. Although neither anterior nor posterior fixation could show a significant superiority, every surgical decision making should be performed individually for each patient balancing the advantages and disadvantages of each method.Subaxiale Halswirbelsäulenverletzungen können besonders beim alten Patienten schwerwiegende Folgen haben. Weiterhin besteht jedoch Uneinigkeit hinsichtlich des optimalen Operationsverfahrens. Eine potenzielle Überlegenheit von ventralen oder dorsalen Strategien wird kontrovers diskutiert.Ziel dieser Studie war die Analyse des Outcomes nach ventralen und dorsalen Operationsverfahren im Rahmen subaxialer Halswirbelsäulenverletzungen beim alten Menschen unter besonderer Betrachtung der postoperativen Mortalität.Im Zuge einer retrospektiven Kohortenanalyse wurden die Daten von 43 Patienten ausgewertet. Erfasst wurden neben einem ventralen oder dorsalen Operationsverfahren besonders Daten bez. des postoperativen Überlebens.Von den 43 Patienten wurden 21 ventral und 22 dorsal stabilisiert. Es zeigte sich kein statistisch signifikanter Unterschied im Vergleich der Operationsverfahren. Ein erhöhtes Versterben (52,4 vs. 31,8%) konnte jedoch in der Gruppe der ventral operierten Patienten festgemacht werden. Ebenfalls war das männliche Geschlecht, ein hohes Alter, Translationsverletzungen, lange Operations- und Hospitalisierungsdauern sowie postoperative Komplikationen mit einer höheren Mortalität verbunden.Subaxiale Halswirbelsäulenverletzungen sind beim alten Menschen mit einer hohen Mortalität assoziiert. Auch wenn bisher kein Operationsverfahren eine grundsätzliche Überlegenheit aufweisen konnte, sollte eine gezielte Therapieevaluation bei jedem Patienten individuell unter Abwägen der Vor- und Nachteile der entsprechenden Behandlungsmethoden durchgeführt werden.

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan–Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.

Мета: провести первинну оцінку прогностичних можливостей трактографії у пацієнтів з ускладненою хребетно-спинномозковою травмою шийного відділу хребта на субаксіальному рівні.Матеріали і методи. Клінічну групу утворили 5 пацієнтів, які перебували на стаціонарному лікуванні у відділенні патології спинного мозку та хребта Інституту нейрохірургії ім. акад. А.П. Ромоданова НАМН України в період з квітня до липня 2019 р. із травматичним ушкодженням шийного відділу хребта та спинного мозку тяжкого ступеня. В післяопераційний період на 5-ту–7-му добу пацієнтам проведено магнітно-резонансну томографію в режимах Т1W, Т2W, FLAIR, STIR, T2W FFE, CSF flow і дифузійно-тензорного зображення. Оцінювали динаміку регресу неврологічних порушень за International Standards for Neurological Classification of Spinal Cord Injury. Ступінь травматичного стенозу хребтового каналу визначали за допомогою спіральної комп’ютерної томографії до і після хірургічної корекції. З огляду на малу клінічну групу статистичну обробку отриманих цифрових показників не проводили. Основним завданням було виявлення загальних закономірностей для визначення напрямів подальших деталізованих досліджень.Результати. Набряк спинного мозку на рівні ушкодження, що відповідало ступеню неврологічних розладів, спостерігали в усіх пацієнтів. Наявність геморагічного компонента виявлено у 3 пацієнтів (по 1 випадку посттравматичного стенозу хребтового каналу >50 %, Objective: the primary assessment of the prognostic features of tractography in patients with severe subaxial cervical spine and spinal cord injury.Materials and methods. The clinical group consisted of 5 patients admitted to the Department of Spine Surgery of Romodanov Neurosurgery Institute during the period from April to July 2019 with severe traumatic injury of the cervical spine and spinal cord. MRI was performed in the following modes: T1W, T2W, FLAIR, STIR, T2W FFE, CSF flow and DTI in 5–7 days after surgery. The dynamics of neurological disorders regression were evaluated according to the International Standards for Neurological Classification of Spinal Cord Injury. The level of spinal canal traumatic stenosis was determined by SCT both before and after surgical correction. Due to the small clinical group, statistical processing of the obtained digital indicators was not performed. The main task was to identify general patterns in order to determine the direction of further detailed studies.Results. Spinal cord edema at the damage level was observed in 100 % of patients that corresponded to the level of neurological disorders. The presence of hemorrhagic component was detected in 3 patients, while post-traumatic spinal stenosis was: more than 50 % — in one patient, up to 50 % — one patient and less than 25 % — one patient. Spinal cord parenchyma edema was accompanied by varying degrees of compression of the cerebrospinal spaces, from subtotal to total, with the presence or absence of a hemorrhagic component that did not impact the intensity of cerebrospinal fluid flow disorders. Evaluation of DTI results showed a moderate inverse relationship between FA and MD indicators. Two patients presented with a regression of neurological disorders. Restoration of sensory-motor functions did not correlate with the degree of compression of the spinal canal or the nature of changes in the parenchyma of the spinal cord, but was noted in patients with maximum FA values and low MD.Conclusions. Tractography is an informative predictor of the regression of neurological disorders in patients with severe spine and spinal cord injury. Further studies are needed to identify the optimal timing of its implementation and to establish diagnostically significant values of anisotropic diffusion indices., Цель: провести первичную оценку прогностических возможностей трактографии у пациентов с осложненной позвоночно-спинномозговой травмой шейного отдела позвоночника на субаксиальном уровне.Материалы и методы. Клиническую группу образовали 5 пациентов, находившихся на стационарном лечении в отделении патологии спинного мозга и позвоночника Института нейрохирургии им. акад. А.П. Ромоданова в период с апреля по июль 2019 г. с травматическим повреждением шейного отдела позвоночника и спинного мозга тяжелой степени. В послеоперационный период на 5–7-е сутки пациентам проведена магнитно-резонансная томография в режимах Т1W, Т2W, FLAIR, STIR, T2W FFE, CSF flow и диффузионно-тензорного изображения. Оценивали динамику регресса неврологических нарушений по International Standards for Neurological Classification of Spinal Cord Injury. Степень травматического стеноза позвоночного канала определяли с помощью спиральной компьютерной томографии до и после хирургической коррекции. Учитывая малую клиническую группу, статистическую обработку полученных цифровых показателей не проводили. Основной задачей было выявление общих закономерностей для определения направлений дальнейших детальных исследований.Результаты. Отек спинного мозга на уровне повреждения, что соответствовало степени неврологических расстройств, наблюдали у всех пациентов. Наличие геморрагического компонента выявлено у 3 пациентов (по 1 случаю посттравматического стеноза позвоночного канала >50 %

Background: There is uncertainty about the optimal guidelines for screening clinically important cervical spine injuries following blunt trauma. The Canadian C Spine rule (CCR) and the National Emergency X Radiography Utilization system (NEXUS) are two widely accepted guidelines to help emergency physicians and trauma surgeons in case of cervical blunt trauma. Methods: We conducted a prospective analytical study between June 2019 to July 2020 at Mahatma Gandhi Mission’s Hospital (MGM), Navi Mumbai comparing the diagnostic accuracy of CCR and NEXUS as applied to alert patients with trauma who were in stable condition.Result: Among the 400 trauma patients randomly selected for the study 280(70%) patients were male and 120(30%) were female. According to the NEXUS guidelines, 202(50.5%) patients and according to the CCR guidelines 210(52.5%) patients required radiography, however as per the results obtained from the cervical spine imaging only 20 (5%) patients had cervical spine injury. Both the NEXUS and CCR guidelines had similar true positive and false negative rates of 5% and 0.5% respectively. Both tests had sensitivity of about 91% and specificity 56.54% and 45.54% respectively.Conclusion: Based on studies with modest methodologic quality and only one direct comparison indicated that both CCR and NEXUS carry the same sensitivity for evaluating which patients need to undergo cervical spine imaging. Further the NEXUS guidelines have the same effectiveness as CCR for determining which patients must be subjected to cervical spine imaging.

Since 2013, neurosurgeons have been guided by the RUANS recommendation protocol for surgical management of patients with acute cervical spine fractures in Russia. However, there are no studies devoted to interobserver agreement between specialists with different experience.To evaluate the role of the RUANS recommendation protocol for decision-making in patients with acute traumatic cervical spine injuries.Twenty-one neurosurgeons from 5 hospitals estimated data of 64 patients with cervical spine fractures. The study implied choosing an option for patient treatment (conservative therapy; anterior, posterior and circular fusion surgery). Two evaluations of CT and MR scans with an interval of 1.5 months were conducted. In the main group (9/21), neurosurgeons strictly followed the RUANS recommendation protocol during re-evaluation. In the control group (12/21), neurosurgeons analysed data considering their own knowledge and experience. Interobserver agreement was evaluated using a Fleiss' or Cohen's Kappa (K).Among the junior neurosurgeons (up to 5 years of experience), change in consent level during re-evaluation was greater in the main group (∆The RUANS recommendation protocol can significantly improve interobserver agreement between specialists with various levels of experience regarding management of acute cervical spine injury.С 2013 г. в России при выборе тактики лечения пострадавших с острыми переломами шейного отдела позвоночника нейрохирург может руководствоваться соответствующим рекомендательным протоколом. Исследований, посвященных уровню согласованности решений, принимаемых на основе рекомендательного протокола специалистами с разным уровнем опыта, нет.Оценить влияние рекомендательного протокола лечения острой осложненной и неосложненной травмы позвоночника у взрослых, предложенного Общероссийской общественной организацией «Ассоциация нейрохирургов России» (Рекомендательный протокол АНР), на уровень согласия специалистов разной квалификации при принятии решения о тактике лечения пострадавших с острой травмой шейного отдела позвоночника.Клинические и радиологические данные 64 пациентов с переломами шейного отдела позвоночника оценены 21 нейрохирургом из 5 стационаров. Следовало выбрать оптимальный вариант лечения (консервативная терапия, передний, задний и циркулярный спондилодез). Все участники оценивали данные 2 раза с интервалом в 1,5 мес. Первую оценку все участники проводили на основании личного опыта. При повторной оценке нейрохирурги основной группы (9 человек) строго следовали Рекомендательному протоколу АНР, участники контрольной группы (12), как и прежде, основывались на собственных знаниях и опыте. Уровень согласия наблюдателей в зависимости от числа участников оценивали при помощи каппы (К) Флейса или Коэна.У хирургов основной группы с опытом работы до 5 лет изменение уровня согласия при повторной оценке было большим (∆Применение рекомендательного протокола лечения острой осложненной и неосложненной травмы позвоночника у взрослых, предложенного Общероссийской общественной организацией «Ассоциация нейрохирургов России», позволяет существенно повысить уровень согласия специалистов разной квалификации при принятии решения о тактике лечения пострадавших с острой травмой шейного отдела позвоночника.

Background CT is considered the best method for vertebral fracture detection clinically, but its efficacy in laboratory studies is unknown. Therefore, our objective was to determine the sensitivity, precision, and specificity of high-resolution CT imaging compared to detailed anatomic dissection in an axial compression and lateral bending cervical spine biomechanical injury model. Methods 35 three-vertebra human cadaver cervical spine specimens were impacted in dynamic axial compression (0.5 m/s) at one of three lateral eccentricities (low 5% of the spine transverse diameter, middle 50%, high 150%) and two end conditions (19 constrained lateral translation and 16 unconstrained). All specimens were imaged using high resolution CT imaging (246 μm). Two clinicians (spine surgeon and neuroradiologist) diagnosed the vertebral fractures based on 34 discrete anatomical structures using both the CT images and anatomical dissection. Findings The sensitivity of CT was highest for fractures of the facet joint (59%) and vertebral endplate (57%), and was lowest for pedicle (13%) and lateral mass fractures (23%). The precision of CT was highest for spinous process fractures (83%) and lowest for pedicle (21%), uncinate process and lateral mass (both 23%) fractures. The specificity of CT exceeded 90% for all fractures. The Kappa value between the two reviewers was 0.52, indicating moderate agreement. Interpretation In this in vitro cervical spine injury model, high resolution CT scanning missed many fractures, notably those of the lateral mass and pedicle. This finding is potentially important clinically, as the integrity of these structures is important to clinical stability and surgical fixation planning.

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients.Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p

In 2015, new practice recommendations to remove equipment prior to transport when cervical spine injury is suspected were released. The purpose of this study was to determine current emergency management practices and perceptions of the new practice recommendation. We received completed mixed-method surveys from 143 athletic trainers practicing in the Mid-Atlantic region (response rate = 10.11%). The majority of respondents stated that the number of personnel required, along with the training and time to practice equipment removal, were barriers to implementation. Requiring assistance from emergency medical services (EMS) was common, but many failed to practice with local EMS. Emergency management procedures should be appropriate given the resources (personnel and training) available. Collaboration between athletic trainers and EMS is needed.

Head and neck injuries are common and can be associated with cervical vessel injury. In some cases, the cor­rect diagnosis of artery dissection can be a real challenge given the nonspecific signs. We present the case of a spinal cord-injured patient with neurological sequelae and delayed posterior circu­la­tion stroke caused by bilateral vertebral artery dissection. The signs of cerebellar and occipital lobe ischemia were masked by manifestations of spinal cord injury. The patient was unconscious and in a serious condition, but, despite no proper stroke treatment, only residual dysarthria and upper limb ataxia were seen after reha­bilitation. Any clinical suspicion based on the combination of head or neck trauma with atypical or evolving neuro­logical symptoms should be verified for the possibility of a vertebral artery dissection.

Objective The AOSpine Subaxial Cervical Spine Injury Classification System was introduced to improve communication, clinical management, and research. Here, the system was studied in relation to injury severity along with admission and long term neurologic follow-up. Methods A retrospective study was performed in subaxial cervical spine injury patients. Morphology was classified using the AOSpine Subaxial Cervical Spine Injury Classification System. Six major morphology subtypes were selected for analysis. The American Spinal Injury Association (ASIA) motor and Abbreviated Injury Severity (AIS) scores were recorded at admission and at follow-up >6 months. Admission intramedullary lesion length (IMLL) on MRI was recorded. Results In all, 82 patients met criteria for analysis. The mean follow-up time was 11 months (range, 6–33 months). The were 36 patients with morphology subtypes A0, 4 with A1/A2, 9 with A3/A4, 8 with B2, 11 with B3, and 14 with C. The A1/2 subtype had the least severe injuries on admission. The C and A3/A4 subtypes had the most severe injuries. The subtype C had the lowest ASIA Motor Score (AMS) and second highest percentage of complete injuries. A3/A4 patients had the highest percentage of complete injuries on admission. At follow-up, A3/A4 patients had the lowest AMS, and 33% of patients continued to have complete injuries. C subtype injuries all converted to AIS incomplete injuries on follow-up (P = 0.04). IMLL was found to be significantly different compared across multiple morphologic subtypes. Surgical management for each morphology subtype was reported. Conclusion The AOSpine Subaxial Cervical Spine Injury Classification System successfully associated injury morphology with IMLL along with admission and long-term neurologic function and recovery.

Bicycle mishap, a common and ordinary event occurring in children, can have devastating consequences associated with cervical spine injury. Furthermore, either diagnosis or surgical management of cervical spine injury in children is a challenging issue. This research report a challenging case of an anterior cervical corpectomy and fusion with plating in a 7-year-old boy due to cervical spine instability with spinal cord compression after a bicycle mishap. After 20 months of the primary surgery, the titanium-based cervical plate was removed by a second surgery to allow the growth of the cervical spine.

The study objective is to review the Russian and foreign studies and to identify an optimal classification system for lower cervical spine injuries. Materials and methods. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We conducted a search for articles published in English (PubMed database) and Russian (eLIBRARY.ru). The inclusion criteria were as follows: available full text, patient age ≥18 years, and information on one of the validation phases for classifications according to L. Audige et al. Results. A total of 30 articles were eligible. Of them, 3 studies were published in Russian (by one group of authors); however, they didn’t contain required statistical parameters and had duplicated data; therefore, they were excluded from the analysis. Out of 27 articles published in English, 8 articles met all the criteria and were included into the systematic review. The AOSpine and Subaxial Injury Classification Systems demonstrated the highest reliability and reproducibility of the results. The Allen–Fergusson classification has lower intraobserver and interobserver agreement coefficients, but it can give a clearer visual representation of injuries. We also assessed J. Harris classification system. The reliability of the scale developed by С. Argenson et al. was not evaluated. The analyzed publications contained no data for full evaluation of the Cervical Spine Injury Severity Score. Our analysis clearly demonstrated the need for a more thorough evaluation of all available scales and classifications. This study should be multicenter and involve experts with different levels of experience (from residents to experienced spinal surgeons). Moreover, it should analyze not only the reproducibility of individual classifications, but also the aspects of learning and the relationship between individual scales and systems. The main study limitations included insufficient number of publications, small sample sizes, heterogeneity of groups, and differences in the experience of experts. Conclusion. The AOSpine and Subaxial Injury Classification Systems are the most reliable classification systems. However, the data available in literature is not sufficient for a full comparison of all existing scales and systems. Further multicenter studies on the reliability of classifications are needed to select an optimal one.

There is mounting experimental evidence that therapeutic hypothermia (TH) mitigates secondary mechanisms of spinal cord injury (SCI). There is a potential synergistic neuroprotective effect for SCI...

Background Retropharyngeal hematoma following cervical spine trauma may lead to life-threatening upper airway obstruction and difficult airway management. This retrospective study was performed to investigate whether the extension of retropharyngeal space (RPS) was associated with difficult intubation by direct laryngoscopy in traumatic cervical spine injury. Patients and methods Sixty-two patients who had undergone direct endotracheal intubation under general anesthesia for cervical spine surgery were retrospectively identified. Laryngoscopic grade by Cormack-Lehane (C-L) classification was collected; grade 1 or 2 was categorized as easy laryngoscopy, whereas grade 3 or 4 was categorized as difficult laryngoscopy. In these patients, RPS thickness and the proportions of RPS to the vertebral bodies were measured at the 2nd, 5th and 7th cervical spine levels using magnetic resonance imaging (MRI) of the cervical spine. Measures of RPS were compared between easy and difficult laryngoscopy. Relationships between measures of RPS and difficult laryngoscopy were analyzed with logistic regression analysis. Results RPS thickness at C2 was significantly greater in difficult laryngoscopy (median 14.29 mm, IQR: 9.75-18.04) than easy laryngoscopy (median 5.10, IQR: 4.33-5.94, p

This article provides a detailed illustrated description of currently available classification and scoring systems for lower cervical spine injuries (including Allen–Fergusson, J. Harris et al., C. Argenson et al., and AOSpine classifications, Subaxial Injury Classification System and Cervical Spine Injury Severity Score). The present review primarily aims to discuss the advantages and disadvantages of each classification system.

Application of AOSpine subaxial cervical spine injury classification system to explore the optimal surgical decompression timing for different types of traumatic cervical spinal cord injury (CSCI). A single-center prospective cohort study was conducted that included patients with traumatic CSCIs (C3–C7) between February 2015 and October 2016. After enrollment, patients underwent either early (

Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.

Critically evaluate the current evidence in evaluation of the cervical spine following trauma. Little has changed in the evaluation of the cervical spine following penetrating trauma. Significant advances have been made in the evaluation following blunt trauma. Recent research has focused on evaluating the accuracy of recent generation-computed tomographic (CT) scanners in excluding (or identifying) significant cervical spine injury. Secondly, recent literature has evaluated the utility of magnetic resonance imaging (MRI) in the evaluation of the cervical spine injury following blunt trauma. Current evidence supports (1) in an adult patient if a high-quality CT scan, interpreted by a trained neuro-radiologist, does not demonstrate any abnormal findings, significant cervical spine injury can be excluded and the collar safely removed; (2) MRI adds little to the evaluation if the CT scan is negative; and (3) MRI scan is helpful if a CT is equivocal or to plan therapy when the CT demonstrates injury.

Up to 4% of adults with blunt trauma suffer cervical spine injury. Clinicians who evaluate trauma patients can use validated clinical decision tools to assess whether patients are at risk for these injuries. Beyond these tools, imaging (most often CT) remains the mainstay of evaluation. Further challenges exist when patients have persistent pain or cannot be evaluated clinically. This article reviews the evidence available to assist clinicians in evaluating adults for significant cervical spine injury after blunt trauma.

Background: Surgical management of lower cervical spine injury is a very important issue among these patients. Objective: The purpose of the present study was todetermine the early neurological outcome of delayed anterior decompression and stabilization of lower cervical spine injury. Methodology: This cross sectional study was carried out in the Department of Neurosurgery at Dhaka Medical College and Hospital, Dhaka, Bangladesh within the period of January 2010 to July 2011 for a period of one year and 6 months. Neurological outcome following anterior decompression and stabilization of lower cervical spine injury was observe. Patients presented with lower cervical spine injury were included in this prospective study. Quantification of neurologic deficit in lower cervical spine injury patients were carried out by following The American Spinal Injury Association (ASIA) impairment scale. Early neurological outcome was also assessed after operation by using ASIA impairment scale in the follow up period at one, three and six months interval. Result: A total of 31 patients were included in this study. Based on the ASIA impairment scale, preoperatively, 6.4 5% of the injuries were grade A, 16.13 % of the injuries were Grade B, 16.13% of the injuries were Grade C and 35.48 % of the injuries were Grade D. early post-operative complications include dysphagia in 3 5.48% cases, donor site infection in 9.67% cases, CSF leak in 3.22%; catheter related urinary tract infection 9.67% and bed sore occurred in 6.45% cases. Conclusion: In conclusion significant neurological recovery can be expected following delayed anterior decompression and stabilization of lower cervical spine in lower cervical spine injury patient. Journal of National Institute of Neurosciences Bangladesh, 2018;4(2): 82-86

The unique anatomy and flexibility of the cervical spine predispose it to a risk of injury. Trauma to the cervical spine encompasses a wide range of injuries from minor muscular strains to life-threatening fracture-dislocations associated with spinal cord lesions. Initial assessment and management should follow the Advanced Trauma Life Support (ATLS) protocols with adequate protection of the cervical spine through triple immobilisation to prevent any unnecessary movement, which can make the patient susceptible to further neurological injuries. Although the presence of cervical spine injury is very often overt, reliance on clinical examination alone is sometimes not sufficient and potentially requires further imaging. Clinical decision rules such as the Canadian C-Spine Rule are frequently used to risk-stratify patients needing radiography. The level of cervical spine instability and knowledge of their unique classification systems is of paramount importance and assists in the decision-making process to guide definitive management. In this review, we also propose an algorithm to aid the initial management of a patient with suspected cervical spine injury in the emergency department.

Study Design: Cross-sectional survey. Objectives: Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture. Methods: A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures. Results: There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%. Conclusions: Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.

Purpose: The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series. Methods: Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure. Results: There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman’s and Spurling’s sign, independently, were significantly associated with a positive neck extension exam (p