<p>Cervical Spine Assessment</p><p>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</p><p>- 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)</p><p>- removal of hard collar desirable for a number of reasons: </p><p>(1) increased ICP (2) more difficult CVL insertion (3) increased VTE (4) increased VAP & pressure sores (5) increased staffing requirements</p><p>CLINICAL</p><p>Pre-requisites</p><p>- GCS 15 - no intoxification - no distracting injuries</p><p>Normal examination</p><p>- no midline tenderness - FROM - no referable neurological deficit</p><p>RADIOLOGICAL</p><p>Conservative view requires: </p><p>- c-spine xrays + CT + an awake patient who can be examined based on ATLS guidelines</p><p>OR</p><p>- MRI - dynamic fluoroscopy</p><p>-> until then, collar stays on</p><p>Jeremy Fernando (2011) Liberal view requires:</p><p>- lateral c-spine cleared -> take off collar</p><p>REALITY</p><p>- 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)</p><p>MY APPROACH</p><p>(1) Full spinal immobilization care until cleared</p><p>(2) Detailed history + examination</p><p>-> mechanism of injury -> speed -> other injuries</p><p>(3) CT c-spine (high resolution, 1mm slices with sagittal reconstructions)</p><p>(4) Formal radiologist + Orthopaedic/Neurosurgical expert opinion</p><p>(5) Any doubt:</p><p>-> High risk injury or neurological deficit -> MRI -> CT abnormal -> MRI -> Normal -> clear cervical spine</p><p>Jeremy Fernando (2011)</p>