What is Geriatric Cervical Spine Injury?
Based on the National Hospital Ambulatory Medical Care Survey, every year, for every 100 people over the age of 65, there are 12 visits to the emergency department related to injury. Elderly patients make up a quarter of all trauma admissions across the country. Neck (or cervical spine) injuries are relatively frequent among this group of people. Sadly, these injuries often come with severe health problems and a high risk of death.
The number of elderly patients experiencing trauma has been increasing, and this trend is expected to continue in the coming years. Doctors and healthcare workers are warned to stay alert and investigate thoroughly to rule out any neck injuries, even if the cause of the injury seems minor, such as falls from standing height. Older adults who come into the emergency department because of trauma often have other health issues that can confuse the issue. These can include dementia, hearing and vision problems, and difficulty cooperating with a physical examination given the urgency of the situation.
What Causes Geriatric Cervical Spine Injury?
Most neck injuries in elderly people happen because of falls, which are responsible for more than 60% of these injuries. However, they can also occur due to other types of trauma, like car accidents or violent attacks. Additionally, injuries from forced over-bending or over-stretching can also cause this type of damage.
Elderly individuals have a higher risk of getting hurt from low-impact injuries. This is due, in part, to conditions like osteoporosis or osteopenia, which make their bones weaker. Additionally, as people age, their spinal columns lose some of their natural ability to protect the body due to decreased mobility and wear and tear changes. This all contributes to a higher risk of spinal injury for the elderly.
Risk Factors and Frequency for Geriatric Cervical Spine Injury
Every year, one third of older adults have at least one fall, and 12% visit the emergency department for injuries. This is a big issue, especially given that people over 65 years old are the fastest growing age group.
While there’s not a lot of known data on neck fractures as a result of trauma among adults in general, what we do know is that these injuries tend to happen in two distinct age groups. The first group is between ages 15 to 54, and the second group is between ages 65 to 80. In people over 65, the occurrence of these fractures is between 2.6% and 4.7%. Most of these injuries result from low energy or ground level falls.
- Every year, a third of elderly people fall at least once.
- 12% of elderly people go to the emergency department for injuries each year.
- Neck fractures due to trauma often happen in two age groups: 15 to 54 and 65 to 80.
- In people over 65, neck fractures occur in 2.6% to 4.7% of the population.
- Most of these neck fractures happen because of falls from standing height or lower.
Signs and Symptoms of Geriatric Cervical Spine Injury
Elderly patients with injuries to the neck or cervical spine often have a history of accidents or trauma. However, sometimes these injuries could result from minor incidents that the patient didn’t think were important enough to mention. For example, forcefully pulling on the hand when there’s already a spinal tumor present could cause an injury. Also, keep in mind that cognitive decline is common in older individuals, whether they live at home or in care facilities. This could limit their ability to provide a complete history of what happened, meaning potential trauma may go undetected. Therefore, it’s crucial to get information from witnesses or caregivers if possible.
Another thing to remember is that there might be an underlying medical reason behind the trauma incident. Elderly patients might get involved in car accidents or experience falls due to heart arrhythmia, stroke, dissection, infection, seizures, metabolic disturbances, hemorrhage, or multiple medications usage. Therefore, patients could be dealing with both a medical condition and a traumatic injury, which both need careful examination and evaluation.
Lastly, a thorough physical assessment should be performed, starting with the basics like airway, breathing, and circulation (The ABCs), followed by a complete neurological exam. It should also include fully opening their clothing and positioning the patient to check for any other signs of injuries or infections. Each joint should be moved through its full range of motion to make sure no injuries are overlooked.
Testing for Geriatric Cervical Spine Injury
A CT scan is the best quick and efficient test available to doctors to check for injuries to the neck bones in an emergency setting. This method is particularly used for elderly patients. Using regular X-rays can be challenging in older people due to changes in their bones, such as thinning (osteopenia) and arthritis (osteoarthritis). Moreover, regular X-rays cannot clearly show the uppermost section of the neck bones, which are the regions most prone to injury in the elderly. Consequently, when doctors need to do an imaging test on an older patient, they usually go for a CT scan.
However, CT scans can be expensive and also expose patients to a low dose of radiation. Given that damage to the neck is less common and considering the costs and radiation, specific guidelines, validated through research, are followed to determine which patients need advanced imaging such as a CT scan. Two common guidelines used are the Canadian C-Spine Rule and the NEXUS rule. However, these guidelines often require imaging for any patient over 65 years of age and they require the patient to be fully conscious, which doesn’t help in reducing imaging procedures in older patients.
The NEXUS rule (which considers if there is no specific nerve damage, no effects of drunkenness or drugs, no tenderness along the middle of the neck, and no other injuries that cause the patient pain in a fully alert person) has been confirmed to work well for older patients when it comes to identifying significant injuries. However, some data conflict, and many doctors hesitate to use this guideline in elderly patients. The NEXUS rule is also challenging to apply consistently since “normal alertness” and “absence of other injuries” can be interpreted differently by different doctors. On the other hand, another study on older patients, which replaced “normal alertness” with “typical mental status” and “absence of other injures” with “signs of head or neck injuries”, found that the NEXUS rule was entirely accurate in identifying neck injuries. Yet, the occurrence of these injuries in this study was low.
Despite these complications, there is strong evidence supporting the use of these guidelines to avoid unnecessary imaging in older patients. However, because older patients have a twice as high risk of neck injuries compared to younger patients, doctors tend to opt for imaging tests more readily in this population.
Elderly patients who have a neck fracture also have a high chance of having fractures in other parts of their backbones. Therefore, finding a fracture in the neck bones of such patients should lead to further imaging tests for the entire backbone.
Treatment Options for Geriatric Cervical Spine Injury
Treating neck (cervical spine) injuries in older adults can be a complex process with several different strategies. These can include wearing a sturdy neck collar without adjusting the spine, wearing a special halo cast that adjusts the spine, or undergoing surgery. When researchers looked at these different strategies, they didn’t see any significant differences in terms of patients’ health outcomes, death rates, complications, or in the success of the spine to heal properly, which was often problematic.
As these patients usually have additional injuries, it’s best to have a team of various healthcare professionals managing their care. This could include trauma surgeons, orthopedic specialists, physical therapists, and general physicians.
What else can Geriatric Cervical Spine Injury be?
When dealing with certain health issues, doctors may investigate the following potential causes or related conditions:
- Acute torticollis (sudden “twisted neck”)
- Cauda equina and conus medullaris syndrome (problems with the bundle of nerve roots at the lower end of the spinal cord)
- Cervical strain (a strain of the neck)
- Hanging injuries and strangulation
- Neck trauma
- Septic shock (a life-threatening condition triggered by infection)
- Spinal cord infections
- Spinal cord injuries
- Spinal cord tumors
- Thoracic outlet syndrome imaging (a group of disorders that occur when blood vessels or nerves in the lower neck are compressed)
- Vertebral artery dissection (a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain)
