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Updated: Jan 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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