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years, dens displacement >5 mm, and specific fracture patterns.

Type III: Surgical intervention is often reserved for cases of nonunion/malunion after trial of external immobilization.

CCS: Surgical decompression/fixation is indicated in setting of unstable injury, herniated disc, or when neurologic function deteriorates.

BCVI: Surgical and/or angiographic intervention may be required if there is evidence of pseudoaneurysm, total occlusion, or transection of the vessel.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Varies by injury; clinical judgment, imaging findings, concomitant injuries, and need for operative intervention

Advanced Trauma Life Support protocol with backboard and collar

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Follow patients with known injuries using serial imaging under the care of a specialist.

PATIENT EDUCATION

ThinkFirst Foundation: http://www.thinkfirst.org

PROGNOSIS

Presenting neurologic status is the most important factor in determining prognosis.

Fractures

–Hangman fracture: 93–100% fusion rate after 8 to 14 weeks external immobilization

–Odontoid fracture, fusion rate by type: type I, ~100% with external immobilization alone; type II, nonunion rates of up to 67% with halo immobilization alone, especially with dens displacement >6 mm or age >50

years; type III, 85% with external immobilization, 100% with surgical fixation

BCVI: Patients have fewer neurologic sequelae with early diagnosis and

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antithrombotic therapy.

CCS

–Spontaneous recovery of motor function in >50% over several weeks. Younger patients are more likely to regain function.

–Leg, bowel, and bladder functions return first, followed by upper extremities.

WAD: Prognostic factors for development of late whiplash syndrome (>6 months of symptoms affecting normal activity) include increased initial pain intensity, pain-related disability, and cold hyperalgesia.

COMPLICATIONS

Fractures: instability or malunion/nonunion necessitating second operation, reactions, and infection related to orthosis

BCVI: embolic ischemic events and pseudoaneurysm formation

REFERENCES

1.National Spinal Cord Injury Statistical Center. Spinal Cord Injury: Facts and Figures at a Glance. Birmingham, AL: National Spinal Cord Injury Statistical Center; 2016.

2.Walton DM, MacDermid JC, Giorgianni AA, et al. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(2):31–43.

3.Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510–2518.

4.Jull G, Kenardy J, Hendrikz J, et al. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain. 2013;154(9):1798–1806.

5.Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012;(1):CD001046.

6.Song KJ, Lee SK, Ko JH, et al. The clinical efficiency of short-term steroid treatment in multilevel anterior cervical arthrodesis. Spine J. 2014;14(12): 2954–2958.

ADDITIONALREADING

Franz RW, Willette PA, Wood MJ, et al. Asystematic review and metaanalysis of diagnostic screening criteria for blunt cerebrovascular injuries. J

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Am Coll Surg. 2012;214(3):313–327.

Puvanesarajah V, Qureshi R, Cancienne JM, et al. Traumatic sports-related cervical spine injuries. Clin Spine Surg. 2017;30(2):50–56.

Siasios I, Fountas K, Dimopoulos V, et al. The role of steroid administration in the management of dysphagia in anterior cervical procedures [published online ahead of print May 27, 2016]. Neurosurg Rev. doi:10.1007/s10143- 016-0741-8.

CODES

ICD10

S13.4XXASprain of ligaments of cervical spine, initial encounter

S13.101ADislocation of unspecified cervical vertebrae, init encntr S14.109AUnsp injury at unsp level of cervical spinal cord, init

CLINICALPEARLS

Follow NEXUS or Canadian Cervical Spine rules on every patient with potential neck injury to determine need for imaging.

Always perform imaging if clinical judgment suggests the need to do so.

Inquire about preexisting cervical spine conditions, especially in the elderly, as they may increase risk of injury or change radiographic interpretation.

Suspect SCI until cleared through exam and imaging.

Consider BCVI when neurologic deficits are inconsistent with level of known injury or in the setting of a significant mechanism of injury.

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CERVICALMALIGNANCY

Olga L. Nunez, MD Jean Khara G. Casillan, MD Stuti

Nagpal, MD, FAAFP

BASICS

DESCRIPTION

Invasive cancer of the uterine cervix

Most cervical cancers begin in the transformation zone. 60–75% of the cancers originate from squamous epithelium.

25–40% of the cancers are adenocarcinomas. These are more difficult to diagnose by cytology.

Commonly involves the vagina, parametria, and pelvic side walls

Invasion of bladder, rectum, and other pelvic structures can be seen in advanced stages.

EPIDEMIOLOGY

Incidence

Cervical cancer is the second most common malignancy in women worldwide and the most common gynecologic cancer.

The disease has a bimodal distribution, with the highest risk among women aged 40 to 59 years and >70 years.

In recent years, there has been an increase in incidence in women aged 30 to 35 years.

Prevalence

In 2017, the American Cancer Society (ACS) estimates 12,820 new cases of invasive cancer in the United States and 4,210 deaths.

The death rate has decreased by 50% in the last 40 years due to increased screening using Pap testing, which allows for early detection of atypical changes in the cells and/or invasive cancer in its most curable stage.

In the United States, Hispanic women are at highest risk of developing cervical cancer followed by African Americans, Asians, and whites. American Indians and Alaskan natives have the lowest. This may be due to low screening rates.

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ETIOLOGYAND PATHOPHYSIOLOGY

Human papillomavirus (HPV) infection is the most important etiologic factor. Infection with serotypes 16 and 18 account for about 70% of cervical cancer.

Persistent HPV infection promotes coding errors in the cell cycle resulting in dysplastic changes to the endocervical cellular lining.

In addition HPV activates E6 and E7 oncogenic proteins, which inactivate p53 and Rb tumor suppressor genes. Tumor growth is via lymphatic and hematogenous spread (Halstedian growth).

Inheritance has not been established yet, except in very rare cases of PeutzJeghers syndrome.

RISK FACTORS

Persistent HPV infection is the number one risk factor for developing cervical cancer. HPV infection is very common: At least 3 out of 4 persons become infected during their lifetime.

Other risk factors include the following:

–Lack of regular Pap smears

–Early coitarche

–Multiple sexual partners

–Unprotected sex

–Ahistory of sexually transmitted diseases (STDs)

–Low socioeconomic status

–Obesity (increases the risk for adenocarcinoma type)

–High parity (>3 full term deliveries)

–Cigarette smoking (doubles the risk)

–Immunosuppression (HIV/AIDs, chemotherapy)

–Diethylstilbestrol (DES) exposure in utero

GENERALPREVENTION

Education on safe sex practices and smoking cessation

HPV vaccines: There are currently two effective vaccines in clinical use for the prevention of HPV infections.

The vaccines provide good protection against HPV types 16 and 18 and the cervical changes caused by them in young women with no previous HPV infection. The protective benefit from the vaccines appears to last for at least 6 years.

–Gardasil vaccine: 9-valent; FDA-approved in females and in males (for prevention of genital warts and anal cancer)

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–Cervarix vaccine: bivalent vaccine against oncogenic HPVstrains 16 and

18

–Recommended age of vaccination is 11 to 12 years (prior to coitarche), but

Gardasil is approved from 9 to 26 years and Cervarix from 10 to 25 years. Regular Pap smear (or likely high-risk HPV testing) is virtually the only way to identify premalignant lesions and possibly prevent progression to cancer.

Screening has the potential to prevent up to 80% of cervical cancer worldwide.

Although guideline changes are likely in 2018 to 2019, according to current guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP) screening should be performed as follows:

–Cytology alone every 3 years between 21 and 29 years (1)[A]

–Cytology plus HPV testing every 5 years after 30 years (1)[A]

The International Federation of Gynecology and Obstetrics (FIGO) recommends visual inspection with acetic acid (VIA) or Lugol iodine (VILI) as alternatives to Pap smears in resource-poor settings (2)[C].

Despite HPV vaccination, cervical cancer screening will remain the main preventive measure for both vaccinated and unvaccinated women.

COMMONLYASSOCIATED CONDITIONS

Condyloma acuminata

Preinvasive/invasive lesions of the vulva and vagina

DIAGNOSIS

HISTORY

Patient with HPV infection may be asymptomatic.

The most common symptom is postcoital vaginal bleeding.

Other symptoms include intermenstrual or postmenopausal bleeding and vaginal discharge.

Less common symptoms include low back pain with radiation down posterior leg, lower extremity edema, vesicovaginal and rectovaginal fistula, and urinary symptoms.

PHYSICALEXAM

Thorough pelvic exam is essential:

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–Many patients have a normal exam, especially with microinvasive disease.

–Lesions may be exophytic, endophytic, polypoid, papillary, ulcerative, or necrotic.

–May have watery, purulent, or bloody discharge

Bimanual and rectovaginal examination should be performed to evaluate uterine size, vaginal wall, rectovaginal septum, parametrial, uterosacral, and pelvic sidewall involvement.

Enlarged supraclavicular or inguinal lymphadenopathy, lower extremity edema, ascites, or decreased breath sounds with lung auscultation may indicate metastases or advanced stage disease.

DIFFERENTIALDIAGNOSIS

Marked cervicitis and erosion

Glandular hyperplasia

Sexually transmitted infection

Cervical condyloma, leiomyoma, or polyp

Metastasis from endometrial carcinoma or gestational trophoblastic neoplasia

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Biopsy of gross lesions and colposcopically directed biopsies are the definitive means of diagnosis.

CBC may show anemia.

Urinalysis may show hematuria.

In advanced disease, BUN, creatinine, and liver function tests (LFTs) may be helpful.

CT scan of the chest, abdomen, and pelvis and/or a positron emission tomography (PET) scan for metastatic workup

Apart from chest x-ray (CXR) and intravenous pyelogram (IVP), imaging does not alter tumor stage.

MRI may be helpful in evaluating parametrial involvement in patients who are surgical candidates or for radiation treatment planning.

Follow-Up Tests & Special Considerations

Prompt multidisciplinary plan of care

Exam under anesthesia may help in determining clinical stage and disease extent and determine if patient is a surgical candidate.

Endocervical curettage and cervical conization as indicated to determine depth

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of invasion and presence of lymphovascular involvement

Cystoscopy to evaluate bladder invasion

Proctoscopy for invasion into rectum

Test Interpretation

Majority of cases are invasive squamous cell types usually arising from the ectocervix.

Adenocarcinomas of cervical cancer arising from endocervical mucusproducing glandular cells. Often, a “bulky,” “barrel-shaped” cervix is present on exam.

Other cell types that may be present include rare mixed cell types, neuroendocrine tumors, sarcomas, lymphomas, and melanomas.

TREATMENT

GENERALMEASURES

Improve nutritional state, correct anemia (Hb <12 g/dL), and treat any vaginal and/or pelvic infections.

MEDICATION

Chemoradiation with cisplatin-containing regimen has superior survival over pelvic and extended-field radiation alone.

Neoadjuvant chemotherapy may improve survival for early and locally advanced tumors, but more data are needed (3)[A].

Adjuvant chemotherapy after chemoradiation may improve progression-free survival in patients who receive primary chemoradiation for stages IIB to IVA tumors. The OUTBACK trial will further investigate these findings (http://www.clinicaltrials.gov).

The addition of the antiangiogenesis drug bevacizumab to standard combination chemotherapy (cisplatin/topotecan or cisplatin/paclitaxel) for recurrent, persistent, or metastatic disease has been shown to improve overall survival (4)[A].

ISSUES FOR REFERRAL

Multidisciplinary management of patients as needed and in a timely fashion

ADDITIONALTHERAPIES

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Chemoradiation (without surgery) is the first-line therapy for tumors stage IIB and higher (gross lesions with obvious parametrial involvement) and for most bulky stage IB2 tumors.

Combination of external beam pelvic radiation and brachytherapy is usually employed.

If para-aortic lymph node metastases are suspected, extended-field radiation or lymph node dissection prior to radiation therapy may be performed.

SURGERY/OTHER PROCEDURES

Surgical management is an option for patients with early-stage tumors. Robotic surgery is one option for surgical management of cervical cancer. It has several advantages over abdominal surgery with decreased estimated blood loss, postoperative hospital stay, and complications.

Removal of precursor lesions (cervical intraepithelial neoplasia [CIN]) by loop electrosurgical excision procedure (LEEP), cold knife conization, laser ablation, or cryotherapy

Stage IA1 (lesions with <3-mm invasion from basement membrane) without lymphovascular space invasion: option of conization or simple extrafascial hysterectomy

Stage IA2 (lesions with >3-mm but <5-mm invasion from basement membrane): option of radical hysterectomy with lymph node dissection or radiation, depending on clinical setting

Stages IA2 to IB1: Fertility-sparing radical trachelectomy may be considered in selected patients.

Stages IB1 to IIA(gross lesions without obvious parametrial involvement): option of radical hysterectomy with lymph node sampling or primary chemoradiation with brachytherapy and teletherapy, depending on clinical setting

Stage IVA(lesions limited to central metastasis to the bladder and/or rectum): Primary pelvic exenteration may be feasible.

Stage IVB disease is treated with goal of palliation. Early referral to palliative care should be made.

Pregnancy Considerations

Management is guided by consideration of stage of lesion, gestational age, and maternal assessment of risks and benefits from treatment.

Abnormal cytology is best followed up by colposcopy with directed biopsies. In pregnant women diagnosed with cervical cancer before 16 weeks of gestation, treatment should be started immediately.

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In pregnant women with early states (IA1, IA2, IB) diagnosed after 16 weeks of gestation, treatment may be delayed to allow for fetal maturity.

In pregnant women with advance disease 1B2 diagnosed after 16 weeks, treatment may be based on gestational age at the time of diagnosis. Microinvasive carcinoma: conization or trachelectomy. If depth of invasion ≤3 mm, follow-up at the 6-week postpartum visit.

Invasive carcinoma requires definitive therapy, with timing determined by maternal preference, stage of disease, and gestational age at the time of diagnosis.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Signs of active bleeding

Urinary symptoms

Dehydration

Complications from surgery, chemotherapy, or radiation

Active vaginal bleeding can be controlled with timely vaginal packing and radiation therapy.

Recognition of ureteral blockage, hydronephrosis, urosepsis, and timely intervention

Discharge criteria based on multidisciplinary assessment

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

With completion of definitive therapy and based on individual risk factors, patients are evaluated with physical/pelvic examinations:

–Every 3 to 6 months for 2 years

–Every 6 to 12 months until the 5th year

–Yearly thereafter

Pap smears may be performed yearly but have a low sensitivity for detecting recurrence.

CT and PET scan are useful in locating metastases when recurrence is suspected.

Signs of recurrence include vaginal bleeding, unexplained weight loss, leg

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