Emergency Department Management of Neck Ligament Injury Without Fracture

Initial Assessment and Stabilization

The American College of Anaesthesia recommends immediate immobilization of the spine for any patient with suspected neck ligament injury to prevent neurological deterioration, even in the absence of fracture 1, 2
Apply appropriate cervical spine immobilization using a rigid neck brace for patients with suspected neck ligament injury to limit progression of neurological deficit 1, 2
Maintain systolic blood pressure >110 mmHg to reduce mortality in patients with suspected spinal cord injury 2
Classify patients based on clinical stability and presence of "hard signs" (requiring immediate surgical intervention) or "soft signs" (requiring further evaluation) 2

The American College of Radiology recommends CT cervical spine without IV contrast as the initial imaging for patients with suspected acute cervical spine trauma 3
For patients with suspected ligamentous injury without fracture on CT, MRI of the cervical spine without IV contrast is the appropriate next imaging modality 3, 2
CT angiography (CTA) should be performed if vascular injury is suspected, with 90-100% sensitivity and 98.6-100% specificity 2

Prolonged immobilization with rigid cervical collars carries significant risks, with most complications appearing and rapidly escalating after 48-72 hours of immobilization 4

If airway management is required, remove the anterior part of the cervical collar during intubation attempts to improve glottic visualization while minimizing cervical spine movement 5, 6
Consider manual in-line stabilization (MILS) during intubation, but have a low threshold for discontinuing if difficulties arise 5, 6
For intubation, use rapid sequence induction with direct laryngoscopy and a gum elastic bougie without Sellick maneuver 1, 2

For alert, reliable patients with no neurological deficits and normal CT imaging, the cervical collar can be removed after clinical examination confirms no midline tenderness 3
For obtunded patients with normal CT imaging, recent guidelines suggest that follow-up MRI may not be necessary in all cases 3
If there is concern for pure ligamentous injury, MRI is the most appropriate imaging modality 3, 2

Failing to maintain proper cervical spine immobilization during initial assessment 2
Relying solely on physical examination without appropriate imaging in stable patients 2