a pain in the neck

Monday, August 8, 2011

It takes less than a half second for a fastball to get from the pitcher to the batter. AS the ball heads to the plate, the pitcher needs to recover his balance and protect himself from the potential ball that is hit right back at him. Juan Nicasio, Colorado Rockies pitcher couldn’t get his hands up fast enough and was hit on the side of the head with the batted ball. Though the mechanism of his injury was witnessed, the extent of the damaged couldn’t be immediately recognized; not just a head injury but a neck fracture as well.

How could getting hit on the side of the head break a neck? Even watching slow motion repays, it’s hard to appreciate that as Mr. Nicasio fell to the ground, the crown of his head hit first, crunching his neck into the ground. Fortunately, the trainers and paramedics were well versed in and practiced Advanced Trauma Life Support protocols: anybody who has evidence of trauma above the collarbones, may have an associated neck injury. For that reason, it took time to immobilize Mr. Nicasio and it’s why it take so long to take football players off the field for fear of missing a neck injury.

The mantra of keeping patients immobilized until their neck is cleared is medical speak for presuming the worst until proving the worst isn’t there. This is especially true in trauma, where the initial assessment of the patient bears the caveat that caution be taken to protect the neck. If the patient isn’t breathing, the patient may need to be intubated but always maintaining cervical spine control. It is disaster, not to mention bad form, to save a patient’s life while at the same time rendering him quadriplegic.

The spinal cord starts at the base of the skull and runs within the bony protection of the spinal canal that is made up of 7 cervical (neck), 12 thoracic (chest) and 5 lumbar (low back) vertebrae. Ligaments run up and down the spine giving support as do surrounding muscles.
By diving into the ground, Mr. Nicasio sustained a Jefferson burst fracture of C1, the first cervical vertebra. This is an axial loading injury, meaning that the weight of the body compresses down on the head and because of the way the neck is built, crunches C1 between the skull and C2. It is often seen when a victim dives into a shallow pool, river or lake or when a weight falls directly on their head, imagine a car rollover when the roof collapses. The good news is that the burst opens lots of room where the spinal cord is located. The bad news is that the fracture can be unstable and the bony fragments can move and kink or otherwise damaged the spinal cord causing it to stop working.

If a neck injury is suspected, the patient is placed in a hard cervical collar or neck brace and it is left in place until the care providers are comfortable that no injury exists. The decision can be made clinically: there is no pain or tenderness, there is a normal neurologic exam AND the patient is fully awake, not intoxicated AND there is no other painful injury that could distract the patient from complaining of neck pain. X-rays may be needed but are sometimes it’s hard to see all the cervical vertebrae. CT may be more appropriate and if a head CT is needed, the Ct of the C spine is often done instead of plain films. Even if the studies are normal, the collar may be left in place until the patient is fully awake and coherent and has had other injuries identified.

Since medicine and trauma are never easy, it’s also possible to have SCIWORA, spinal cord injury without radiographic abnormality. This can be due to a ligament injury, a disc prolapse, or damage because of underlying arthritis that has narrowed the spinal canal (Spondylosis).

The good news for Mr. Nicasio is that everybody did their job, he was immobilized, the injury was found, surgery was performed to stabilize the fracture and allow it to heal and he should be good to go in a few weeks. The first lesson to be learned is that good samaritans and bystanders willing to help should handle injury victims with care. The first lesson of medicine is “do no harm”. The second lesson is that taking a first aid course should be the first lesson for everyone.

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