If cervical spinal cord injury (SCI) is suspected, hemodynamic stability is an initial priority [1]. An assessment of respiratory and cardiovascular functions should be done afterward. Firstly, a historical data about concomitant chronic pulmonary and circulatory diseases should be collected as they may interfere with vital laboratory data results [2].

Cervical segments of the spinal cord are responsible for delivering autonomic commands and regulation of cardiovascular and respiratory system, impairment in these systems should always be suspected. For pulmonary function assessment, it is important to consider the frequency of respiration, the involvement of abdominal and accessory respiratory muscles in breathing, the mobility of chest wall and possible injuries to it e.g. pneumothorax, hemothorax. In auscultation investigate lungs for abnormal sounds and impaired functioning. To measure blood oxygenation, perform ABG analysis and pulse oximetry [2].

When judging circulatory functions, the possibility of damage to the autonomic system should cause alertness for likely hemorrhagic or neurogenic shock. As nervous system conduit is impaired, the typical signs of shock e.g. vasoconstriction may be absent [2].

On examination of the neck, physicians should look for signs that could indicate an injury to the spinal cord, like hematomas, inflammation (redness, swelling), pain, tenderness and potential interruption of vertebral alignment. It is recognized, that clinical examination, although reliable, is prone to error and further radiologic investigations are essential [3] [4].

To determine the location of injured segments, a standardized evaluation method like International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is available. It is widely used and recognized [1], and provides information about motor, sensory and neurologic outcomes of the SCI [5]. Sensory characteristics are graded using pinching maneuver or abrasion on various dermatomes innervated by certain root nerves [1]. Motor functions are graded performing flexion, extension, as well as specific movements of muscle groups (myotomes) innervated by the certain nerves. Evaluation of type of SCI, whether it is complete or incomplete is also possible with ASIA Impairment Scale (AIS) [1].

Patients with cervical SCI can develop a constellation of syndromes associated with the injury, some of them are described here. Central cord syndrome is the most common and is combined with weakness in upper and lower limbs [5] [6]. Brown-Sequard syndrome is derived from a spinal cord lesion dividing it in half and is characterized as ipsilateral loss of sensation [6].

• High Fever

  Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. [ncbi.nlm.nih.gov]

• Muscle Spasticity

  Symptoms may include: Muscle weakness or paralysis in the trunk, arms or legs Loss of feeling in the trunk, arms, or legs Muscle spasticity Breathing problems Problems with heart rate and blood pressure Digestive problems Loss of bowel and bladder function [hopkinsmedicine.org]

  Some people with spinal cord injuries experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity). Fitness and wellness. [mayoclinic.org]

  Musculoskeletal management Patients with SCIs typically experience muscle spasticity as spinal shock recedes and reflexes return. Spasticity may take a flexor or extensor pattern or a combination. [americannursetoday.com]

  Motor function: A body function controlled by muscles. Spasticity: The permanent tightening of a joint into an abnormal position. Spinal cord: A long rope-like piece of nervous tissue that runs from the brain down the back. [encyclopedia.com]

• Hip Pain

  The clinical assessment suggested that her left-sided hip pain was attributable to severe right hip osteoarthritis. Her left hip pain resolved completely after she underwent a right total hip arthroplasty. [ncbi.nlm.nih.gov]

• Edema of the Upper Extremity

  There were no significant between-group differences for TPM of the fingers, edema and upper-extremity motor scores at 1 week, 1 month and 3 months after injury, although TPM of the fingers tended to be lower in the control group. [ncbi.nlm.nih.gov]

• Hysteria

  In some the neurologic problem was missed altogether; in others it was attributed to hysteria, intoxication, or to other neurologic or systemic diseases. [ncbi.nlm.nih.gov]

• Cervical Enlargement

  Impaired circulation in the artery of cervical enlargement is significant in extension of perifocal ischemia. [ncbi.nlm.nih.gov]

• Hyperreflexia

  While the cause of oculosympathetic spasm remains speculative, it may represent a localized form of autonomic hyperreflexia. [ncbi.nlm.nih.gov]

  Autonomic hyperreflexia The chronic phase in which spinal reflexes reappear is characterized by autonomic hyperreflexia in a high proportion of patients. [trauma.org]

  Sympathetic hyperreflexia can develop suddenly and without warning. [ceaccp.oxfordjournals.org]

  legal actions, workers' compensation) Babinski's sign and hyperreflexia are widely understood to be cardinal signs of the upper motor neuron syndrome that typically occurs in spinal cord compression. [aafp.org]

  absent bulbocavernosus reflex reflex characterized by anal sphincter contraction in response to squeezing the glans penis or tugging on an indwelling Foley catheter timing variable but usually resolves within 48 hours at its conclusion spasticity, hyperreflexia [orthobullets.com]

• Spastic Paralysis

  Muscle relaxants: If spastic paralysis develops, muscle relaxants, such as baclofen or tizanidine, may be used. [merckmanuals.com]

• Lethargy

  Uncontrolled hyponatremia may lead to lethargy, seizures, coma, cardiac arrhythmia and death. Therefore, the complication of hyponatremia should be paid attention after cervical spinal cord injury. [ncbi.nlm.nih.gov]

• Encephalopathy

  The initial diagnosis of hypoxic ischaemic encephalopathy delayed recognition of an upper cervical spinal and cord injury, which was subsequently confirmed by magnetic resonance imaging. [ncbi.nlm.nih.gov]

• Apraxia

  The oral phase was observed with respect to apraxia. After initiation of the swallowing reflex, the presence of predeglutitive aspiration, retentions, penetration or aspiration of yoghurt was noticed. [nature.com]

Spinal cord injury can be primary (from trauma) as well as secondary (from consequent edematous or hemorrhagic compression), for that reason radiographic imaging and magnetic resonance imaging (MRI) are necessary. Diagnostics are necessary for distinguishing the location of the lesion, its size, and signs of compression for further treatment.

• Plain radiography has almost been dismissed from favorable technique list for its low sensitivity, and more sophisticated radiologic examinations, preferably, MRI are recommended [7]. If physicians choose an X-ray, anterospinal, lateral and odontoid views should be performed [8].
• Computed tomography (CT) is usually the first test to be executed when on suspicion of SCI, particularly if patient is lethargic, unconscious, has neurological disturbances, pain, and sensitivity in the cervical area [3]. CT detects most lesions of bone tissue but does not detect those of ligaments and spinal cord [8]. CT scans are more convenient than plain radiography and can demonstrate sites of the injury that are obscure to X-ray. Images of occiput to T1 segment should be obtained in coronal and sagittal planes [8].
• Magnetic resonance imaging is the most accurate and reliable test that is usually carried out after pathology in CT cervical scan is confirmed [9]. In MRI a radiologist usually looks for signs and level of compression in the spinal cord that could be due to hemorrhages and perifocal edemas. Parameters of the spinal cord lesions, surrounding soft tissue injuries, and herniations in disks are also established if present [10].

• Hyponatremia

  Uncontrolled hyponatremia may lead to lethargy, seizures, coma, cardiac arrhythmia and death. Therefore, the complication of hyponatremia should be paid attention after cervical spinal cord injury. [ncbi.nlm.nih.gov]

1. Van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and Prognosis of Traumatic Spinal Cord Injury. Global Spine J. 2011;1(1):1-8.
2. Wuermser LA, Ho CH, Chiodo AE, Priebe MM, Kirshblum SC, Scelza WM. Spinal cord injury medicine. 2. Acute care management of traumatic and nontraumatic injury. Arch Phys Med Rehabil. 2007 Mar. 88(3 Suppl 1):S55-61.
3. Como JJ, Diaz JJ, Dunham CM, et al. Practice Management Guidelines for Identification of Cervical Spine Injuries Following Trauma: Update From the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma. September 2009; 67(3):651-659.
4. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma. N Engl J Med 2000; 343:94-99.6. Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. Central cord syndrome. J Am Acad Orthop Surg. 2009 Dec;17(12):756-65.
5. Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for neurological classification of spinal cord injury (Revised 2011). J Spinal Cord Med. 2011 Nov; 34(6): 535–546.
6. Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. Central cord syndrome. J Am Acad Orthop Surg. 2009 Dec;17(12):756-65.
7. Van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and Prognosis of Traumatic Spinal Cord Injury. Global Spine J. 2011;1(1):1-8.
8. Como JJ, Thompson MA, Anderson JS, et al. Is Magnetic Resonance Imaging Essential in Clearing the Cervical Spine in Obtunded Patients With Blunt Trauma? J Trauma: September 2007; 63(3):544-549.
9. Mathen RBS, Inaba K, Munera F, et al. Prospective Evaluation of Multislice Computed Tomography Versus Plain Radiographic Cervical Spine Clearance in Trauma Patients. J Trauma.June 2007; 62 (6): 1427-1431
10. Miyanji F, Furlan JC, Aarabi B, et al. Acute Cervical Traumatic Spinal Cord Injury: MR Imaging Findings Correlated with Neurologic Outcome—Prospective Study with 100 Consecutive Patients. Radiology. June 2007; 243(3).