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 Indications for obtaining radiographic clearance intoxicated patients OR patients with altered mental status OR Cervical Conditions neck pain or tenderness present OR distracting injury present 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