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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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(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? Review Topic

QID: 4500
FIGURES:
1

Soft cervical orthosis with early physical therapy

80%

(3560/4452)

2

Philadelphia collar with restricted motion

12%

(521/4452)

3

Halo immobilization

5%

(203/4452)

4

C2 pars screw osteosynthesis

1%

(62/4452)

5

C2 anterior screw osteosynthesis

1%

(64/4452)

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