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 x-ray:
            - in high energy trauma (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;
         - reference:
           - 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;
            - an alert, asymptomatic patient without a distracting injury or neurologic deficit who is able to complete a functional range-of-motion examination
                     may safely be cleared from cervical spine immobilization without radiographic evaluation
            - 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;
            - references:
                    - Clearance of the asymptomatic cervical spine: a meta-analysis.
                    - Canadian cervical spine rule compared with computed tomography: a prospective analysis
                    - Erect Radiographs to Assess Clinical Instability in Patients with Blunt Cervical Spine Trauma
                    - Prospective Evaluation of a Critical Care Pathway for Clearance of Cervical Spine Using the Bolster and Active Range-Of-Motion Flexion/Extension Techniques.

- 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 Barba CA, 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 computed tomography.
                                  - Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.
                                  - Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical 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.
                                  - Cervical spine clearance in obtunded blunt trauma patients: a prospective study.
                                  - Safe cervical spine clearance in adult obtunded blunt trauma patients on basis of a normal multidetector CT scan-A meta-analysis and cohort study.
                                  - The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography.