Updated: 1/6/2022

Cervical Spine Trauma Evaluation

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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 injury
        • 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
    • Utilizing updated clinical practice guidelines and Nexus critieria for pediatric C-spine clearance
      • less radiation expsosure with reduced CT scans for C-spine clearance
  • Radiographic Cervical Clearance
    • Methods 
      • radiographs
        • lateral
          • must include inferior endplate of C7
        • open-mouth odontoid
        • AP
      • CT scan
        • must include superior endplate of T1
  • 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
    • Mortality increased in geriatric patients

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(OBQ18.47) Which of the following has most effectively reduced radiation exposure in pediatric trauma patients?

QID: 212943

Increased use of fluoroscopy in injury evaluation

0%

(11/2257)

Implementing clinical practice guidelines resulting in less CT for cervical spine clearance

80%

(1806/2257)

Routine use of CT with low-dose radiation protocols

10%

(227/2257)

Avoiding radiographs to vital organ regions whenever possible

6%

(139/2257)

MRI for all patient cervical spine clearance

3%

(62/2257)

L 2 A

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(OBQ12.140) A 36-year-old female is involved in a motor vehicle accident in which she is rear-ended in slow moving traffic at less than 5MPH. She presents to the ER complaining of localized neck pain and stiffness. On physical exam she has paraspinal tenderness in the cervical region. She has limited motion in all planes secondary to pain. Her motor, sensory, and reflex exam are normal in her upper and lower extremities. Radiographs are obtained and shown in Figure A, B, C, and D. A photo of the damage on her car was brought to the ER by EMT and is shown in Figure D. Which of the following is most appropriate in the treatment of this patient's injury?

QID: 4500
FIGURES:

Soft cervical orthosis with early physical therapy

80%

(5457/6820)

Philadelphia collar with restricted motion

12%

(802/6820)

Halo immobilization

4%

(302/6820)

C2 pars screw osteosynthesis

2%

(113/6820)

C2 anterior screw osteosynthesis

1%

(85/6820)

L 2 C

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