Management of old people with neck trauma.

Injury to the cervical cord is common but may be overlooked The first important requirement in managing any patient with an injury to the cervical spine is to make the diagnosis: failure to do this in a patient with traumatic spinal instability may lead to increased neurological deficit. In one large series of such injuries the diagnosis was missed in the accident and emergency department in one third of cases.' Just under two thirds ofcervical spine injuries occur in the second, third, and fourth decades of life, and most are in men hurt in road traffic accidents, falls, or sporting accidents. When they occur at the top end of the age range the injuries have special features. In the elderly any cervical degenerative disease may cause anatomical, if not clinical, compromise of the cervical cord, making it more susceptible to damage caused by excessive movement. An injury to the cervical spine may lead to complete or incomplete lesions of the anterior cord or hemicord or damage to the central cord. We should distinguish those older patients who have survived for several decades after a spinal injury from those patients in whom the injury occurs after the age of 55 or 60 years (F W Meinke, paper to the International Medical Society of Paraplegia 28th annual scientific meeting, Rome, 1989). Injury to the cervical spine may be obvious when there is a history of a fall while horse riding or diving into the shallow end of a swimming pool. In other circumstances it may be less clear that the cervical spine is damaged, but suspicions should be aroused, for instance, if after a traffic accident there are injuries to the head and face together with those to the trunk or arm. Clearly the part in the middle-the cervical spine-may also be damaged in such cases. Injury to the cervical spine produces a tense, painful neck that may be locally tender. A good quality lateral x ray film of all seven cervical vertebrae is mandatory for such patients. From this an experienced radiologist will be able to see, or at least strongly suspect, most cervical spine injuries. Once the diagnosis has been made the patient is immobilised and more elaborate investigation such as dynamic x ray views of the cervical spine, computed tomography combined with myelography, or magnetic resonance imaging carried out. After reduction and realignment the spine is stabilised either internally …