Assessment of Cervical Spine
Cervical Spine Assessment
15/12/10
C. G. T. Morris and E. McCoy (2004) ‘Clearing the cervical spine in unconscious polytrauma
victims, balancing risks and effective screening’ Review Article, Anaesthesia, 59, pages 464–482
SP Notes
- controversial issue
- 5-10% of severe TBI have an associated unstable cervical fracture
- can be cleared clinically and/or radiologically
- in the patient with TBI clinical clearance is not an option
- until cleared patients must be immobilized (hard collar, in-line stabilisation, log rolling)
- removal of hard collar desirable for a number of reasons:
(1) increased ICP
(2) more difficult CVL insertion
(3) increased VTE
(4) increased VAP & pressure sores
(5) increased staffing requirements
CLINICAL
Pre-requisites
- GCS 15
- no intoxification
- no distracting injuries
Normal examination
- no midline tenderness
- FROM
- no referable neurological deficit
RADIOLOGICAL
Conservative view requires:
- c-spine xrays + CT + an awake patient who can be examined based on ATLS guidelines
OR
- MRI
- dynamic fluoroscopy
-> until then, collar stays on
Liberal view requires:
- lateral c-spine cleared -> take off collar
REALITY
- lateral c-spine only misses 15% of injuries
- lateral c-spine, AP and PEG misses 10% of injuries (25-50% of studies being inadequate)
- lateral c-spine, AP, PEG, swimmers (oblique views) still misses 10% and may displace injuries!
- 3 view xrays + CT (high resolution, 1.5-2mm slices with sagittal reconstructions) misses <1% on injuries
- CT alone (misses ligamentous injury without bone fracture, risk 1/1000)
MY APPROACH
(1) Full spinal immobilization care until cleared
(2) Detailed history + examination
- mechanism of injury
- speed
- other injuries
(3) CT c-spine (high resolution, 1mm slices with sagittal reconstructions)
(4) Formal radiologist + Orthopaedic/Neurosurgical expert opinion
(5) Any doubt:
-> High risk injury or neurological deficit -> MRI
-> CT abnormal -> MRI
-> Normal -> clear cervical spine
Jeremy Fernando (2011)