C1 (Atlas) Fractures Guidelines

Updated: Apr 07, 2022
  • Author: J Allan Goodrich, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
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Guidelines

ACS Trauma Quality Programs Guidelines on Spine Injury

In March 2022, the American College of Surgeons (ACS) published best practices guidelines on spine injury [19] ; these guidelines were also reviewed and recommended by the American College of Rehabilitation Medicine (ACRM).

Recommended initial measures included the following:

  • Spinal motion restriction (SMR) can be achieved with a backboard, scoop stretcher, vacuum splint, ambulance cot, or other similar devices. When indicated, it should be applied to the entire spine.
  • The cervical collar can be discontinued without additional radiographic imaging in an awake, asymptomatic adult trauma patient with (1) a normal neurologic exam, (2) no high-risk injury mechanism, (3) free range of cervical motion, and (4) no neck tenderness. Collar removal is recommended for an adult blunt trauma patient with no neurologic symptoms and a negative helical cervical computed tomography (CT) scan. A negative helical cervical CT scan suffices for collar removal in an adult blunt trauma patient who is obtunded or unevaluable.
  • Plain radiographs of the cervical and thoracolumbar spine are not recommended in the initial screening of spinal trauma; noncontrast multidetector CT (MDCT) is the initial imaging modality of choice. Magnetic resonance imaging (MRI) is the only modality for evaluating the internal structure of the spinal cord.

Recommendations for injury management included the following:

  • Occipital condyle fractures without neural compression or craniocervical misalignment can be managed with a rigid or semirigid cervical orthosis. Treatment of cervical fractures is individualized according to fracture type and patient factors (eg, age). Stable thoracolumbar fractures without neurologic deficits can be treated with adequate pain control and early ambulation without a brace.
  • The vast majority of penetrating spinal cord injuries (SCIs) result in complete (American Spinal Injury Association [ASIA] A) injuries. Few gunshot SCIs require surgical stabilization. Steroids are not recommended.

Recommendations for care of patients with SCIs included the following:

  • Hypotension must be avoided. The use of mean arterial pressure (MAP) goals of 85-90 mm Hg for 7 days must be weighed against data limitations and associated risks. An agent with both alpha- and beta-adrenergic activity is recommended.
  • The use of methylprednisolone within 8 hours following SCI cannot be definitively recommended. No other potential therapeutic agents have demonstrated efficacy.
  • Chemoprophylaxis for venous thromboembolism (VTE) should be initiated as early as medically possible (typically ≤72 hr), with duration determined on an individualized basis. Surveillance duplex ultrasonography (US) is not recommended in asymptomatic patients but may be considered in high-risk patients who cannot have chemoprophylaxis during the acute period.
  • Treatment of persistent bradycardia or intermittent severe bradycardia may include a beta2-adrenergic agonist, chronotropic agents, or phosphodiesterase inhibitors.
  • Early tracheostomy is recommended to aid in mechanical ventilation in high SCI. Stimulation of the diaphragm should be considered. Open or percutaneous tracheostomy can be performed early after anterior cervical spinal stabilization without increasing the risk of infection or other wound complications.
  • Pain management is a priority in acute SCI and should be delivered via a multimodal approach.
  • Symptoms associated with SCI, such as acute autonomic dysreflexia, spasticity, and skin breakdown, should be adequately addressed.
  • A bowel management program should be initiated for all acute SCI patients. Bladder management should be individualized.
  • Physical and occupational therapy should be initiated within 1 week after injury for acute SCI patients who are determined to be medically ready.