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Introduction
  • All trauma patients have a cervical spine injury until proven otherwise
  • Cervical spine clearance defined as confirming the absence of cervical spine injury
    • important to clear cervical spine and remove collar in an efficient manner
      • delayed clearance associated with increased complication rate
    • cervical clearance can be performed with
      • physical exam
      • radiographically
  • Missed cervical spine injuries
    • may lead to permanent disability
    • careful clinical and radiographic evaluation is paramount
      • high rate of missed cervical spine injuries due to
        • inadequate imaging of affected level
        • loss of consciousness
        • multisystem trauma
    • cervical spine injury necessitates careful examination of entire spine
      • noncontiguous spinal column injuries reported in 10-15% of patients
History
  • Details of accident
    • energy of accident
      • higher level of concern when there is a history of high energy trauma as indicated by
        • MVA at > 35 MPH
        • fall from > 10 feet
        • closed head injuries
        • neurologic deficits referable to cervical spine
        • pelvis and extremity fractures
    • mechanism of accident
      • e.g., elderly person falls and hits forehead (hyperextension injury)
      • e.g., patient rear-ended at high speed (hyperextension injury)
    • condition of patient at scene of accident
      • general condition
      • degree of consciousness
      • presence or absence of neurologic deficits
  • Identify associated conditions and comorbidities
    • ankylosing spondylitis (AS) 
    • diffuse idiopathic skeletal hyperostosis (DISH)
    • previous cervical spine fusion (congenital or acquired)
    • connective tissue disorders leading to ligamentous laxity
Physical Exam
  • Useful for detecting major injuries
  • Primary survey
    • airway
    • breathing
    • circulation
    • visual and manual inspection of entire spine should be performed
      • manual inline traction should be applied whenever cervical immobilization is removed for securing airway
      • seat belt sign (abdominal ecchymosis) should raise suspicion for flexion distraction injuries of thoracolumbar spine
  • Secondary survey
    • cervical spine exam
      • remove immobilization collar
      • examine face and scalp for evidence of direct trauma
      • inspect for angular or rotational deformities in the holding position of the patient's head
        • rotational deformity may indicate a unilateral facet dislocation
      • palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
        • absence of posterior midline tenderness in the awake, alert patient predicts low probability of significant cervical injury7,
      • log roll patient to inspect and palpate entire spinal axis
      • perform careful neurologic exam
Clinical Cervical Clearance
  • Removal of cervical collar WITHOUT radiographic studies allowed if
    • patient is awake, alert, and not intoxicated AND
    • has no neck pain, tenderness, or neurologic deficits AND
    • has no distracting injuries
Radiographic Cervical Clearance
  • Indications for obtaining radiographic clearance
    • intoxicated patients OR
    • patients with altered mental status OR
    • neck pain or tenderness present OR
    • distracting injury present
  • Mandatory radiographic clearance with either
    • cervical spine radiographic series
      • must include top of T1 vertebra 
      • includes
        • AP
        • lateral
        • open-mouth odontoid view
      • inadequate radiographs are the most common reason for missed injury to the cervical spine
      • assess alignment by looking at the four parallel lines on the lateral radiograph
      • look for subtle abnormalities such as
        • soft-tissue swelling
        • hypolordosis
        • disk-space narrowing or widening
        • widening of the interspinous distances
    • CT to bottom of first thoracic vertebra 
      • replacing conventional radiographs as initial imaging in most trauma centers
      • pros
        • more sensitive in detecting injury than plain radiographs
        • some studies show faster to obtain than plain radiographs
      • cons
        • increased radiation exposure
  • Supplementary radiographic studies include
    • flexion-extension radiographs
      • pros
        • effective at ruling-out instability
      • cons
        • can only be performed in awake and alert patient
    • MRI
      • pros
        • highly sensitive for detection of soft tissue injuries
          • disc herniations
          • posterior ligament injuries
          • spinal cord changes
      • cons
        • high rate of false positives
        • only effective if done within 48 hours of injury
        • can be difficult to obtain in obtunded or intoxicated patients
    • MR and CT angiography
      • pros
        • effective for evaluating vertebral artery 
Treatment
  • Nonoperative
    • cervical collar
      • indications
        • initiated at scene of injury until directed examination performed
    • early active range of motion
      • indications
        • "whiplash-like" symptoms and
        • cleared from a serious cervical injury by exam or imaging 
Complications
  • Delayed clearance associated with increased complication rate including
    • increased risk of aspiration
    • inhibition of respiratory function
    • decubitus ulcers in occipital and submandibular areas
    • possible increase in intracranial pressure
 

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