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

- MRI - dynamic fluoroscopy

-> until then, collar stays on

Jeremy Fernando (2011) 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)