Cervical Spine Clearance in the Trauma Patient: - Wheeless' Textbook of Orthopaedics

- Discussion:
   - truama workup:
    - radiology of the cervical spine
            - flourscopy of C-spine:
            - MRI of the spine :
            - CT in cervical frx
            - pediatric C-spine:
            - SCIWORA syndrome
    - distribution of injuries in c-spine trauma:
- MVA: 1st > 5th > 6th > 7th cervical vertebrae;
- fall: 5th > 6th > 7th
            - ref: Risk factors predicting mortality after blunt traumatic cervical fracture.
    - portable lateral xray:
             - even in emergencies (eg. knee dislocation w/ vascular comprimise), a lateral xray (or swimmer's view) from occiput down to T1 is manditory;
          - while some unstable cervical spine injuries can be surgically managed on a delayed basis (if cord compression is not present) other injuries such
             as a bilateral facet dislocation usually need to be managed acutely (and this is why a good cross table lateral view is required in ER);
            - references:
- Limitations of cervical radiography in the evaluation of acute cervical trauma.
- Reliability of indications for cervical spine films in trauma patients.
    - concomitant spine fractures:
         - always consider the need for thoracic and lumbar films in patients involved in MVA or in fall from a height;
         - it is a mistake,however, to routinely order a full set of cervical, thoracic, and lumbar radiographs in the ER (inorder to "clear the spine");
                  for trauma patients with limb threatening injuries;
- always ask yourself, how will this change my management strategy?
- for instance, if a Jefferson frx were diagnosed from an odontoid view, it would not change the fact that a patient
w/ a limb threatening injury would still require GEA and management in the OR;
         - references:
           - Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures.

- cervical spine clearance in the alert patient:
- cervical spine clearance is easy and routine in alert patients;
- if radiographs of the C-spine from the skull to T1 are negative and the patient has moderate to severe cervical spine tenderness,
then the collar is left in place until voluntary flexion and extension radiographs or MRI is taken;

    - cervical spine clearance in the comatose patient:
- mechanism for clearing the cervical spine in patients with altered mental status remains controversial;
- recommendations have ranged from removal of the cervical collar after 24 hours in patients with
normal radiographs, to indefinite immobilization in a cervical collar, CT scan evaluation and more recently
cervical flexion-extension examinations using dynamic fluoroscopy;
- flouroscopy for clearance of the cervcial spine:
                    - CT scan:
- allows simultaneous assessment of the head and cervical spine in patients with altered mental status;
- in the report by CA. Barba, MD et al, authors assessed a C spine clearance protocol for blunt trauma patients using helical CT scan of C-spine;
- 324 patients were admitted to the trauma center after blunt trauma during the first 6 months of protocol implementation;
- lateral plain radiographs alone failed to detect 46% (n = 6) of all injuries.
- selective use of helical CT scanning with plain radiography increased accuracy w/ which C spine injury was detected from 54% to 100%;
- they recommend use of helical CT scan of entire C-spine as diagnostic procedure for those blunt trauma patients undergoing CT scanning of the head;
- references:
- A New Cervical Spine Clearance Protocol Using CT. CA. Barba. J. of Trauma 2001;51:652-657
- Value of cervical CT scanning in identifying C. spine injury in unevaluable blunt trauma patient w/ multiple injuries: J Trauma. 2000; 48: 988-989.
- Helical CT Alone Compared with Plain Radiographs with Adjunct CT to Evaluate the C. Spine After High-Energy Trauma.
- C spine injury: accuracy of helical CT used as a screening technique. Hanson JA Emerg Radiol. 2000; 7: 31-35.
- Cervical dynamic screening in spinal clearance: now redundant.
                                  - Major trauma & cervical clearance radiation doses & cancer induction.

Is the cervical spine clear? Undetected cervical fractures diagnosed only at autopsy. Sweeney JF Ann Emerg Med. 1992; 21: 1288-1290.

Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation. Ajini AE Anaesth Intensive Care. 1998; 26: 487-491.

Radiographic evaluation of cervical spine injuries. CR Clark et al. Spine Vol 13. 1988. p 742-747.

Fracture and dislocation of cervical spine - Analysis of 300 patients and review of the litterature. HH Bohlman. JBJS. Vol 61-A. p 1119. Dec 1979.

Prospective Evaluation of a Critical Care Pathway for Clearance of the Cervical Spine Using the Bolster and Active Range-of-Motion Flexion/Extension Techniques.