Is it safe to clear C-spine injury nonradiographically ?

Jack.

Yes it is! read our article in J Trauma 1996;40:383-389

DD

You asked if it was safe to clear C-spine basically without an x-ray. Depends I think on the situation and location - If you are in a city, and the x-ray is available within 30 or so minutes, sure is simple to wrap the pt up and not take a chance - legally....

Now in a wilderness aspect, yes, I think you can clear the c-spine depending on the circumstances of how the pt was injured and if it would help in the overall situation (delayed transport - hours into days before getting to a hospital); rough terrain prevents the easy removal of the patient (cave) - but the patient is first - don't clear the c-spine just to make ur job in getting them to the hospital easier.

WEMSI (the Wilderness EMS Institute) has some information on clearing the c-spine in the field. Their web is: www.wemsi.on.ca/

It is not safe to clear a C-spine INJURY non-radiographically.:)

However, there are times you can clear the C-spine (that is not injured) by clinical exam in an awake alert (non-multiple trauma) patient without a "distracting" injury. I suppose different hospitals have different protocols based on the literature.

My practice is to get c-spine x-rays in (awake) patients with a "significant" mechanism of injury, neck pain or tenderness, who have sustained a more than mild head injury, any neurologic deficit, or who are not developmentally able to cooperate for an exam (an infant or young child). Obviously all less than alert trauma patients get C-spine series.

Terry Adirim

With all due respect Dr. Palmer, to imply that nonradiologic clearance of c-spine is malpractice is absurd! Just because a patient arrives with a c-collar on doesn't mean films must be taken. Clinical judgement will allow the vast majority of patients to be cleared. I follow these guidelines.

1. No significant mechanism
2. No altered mental status or intoxication
3. No complaint of neck pain or neurologic symptoms
4. No distracting injury which could mask neck pain

If these conditions are met the collar is opened and the neck palpated. No pain?.. the patient is asked to move through range of motion. No complaint?...No Xrays.

Keith Wesley, MD
Director, EMS Education & Trauma Care
Sacred Heart Hospital
Eau Claire, WI

You asked: can you clear a C-Spine non-radiographically...... There was a paper at last year's AAST meeting by Drs Zabel, Tinkoff, Wittenborn, Ballard and Fulda from the Medical Center of Delaware in Wilmington that tried to address your question. They assessed the value of the lateral C-spine in alert, high risk blunt trauma patients. They concluded, after 353 patients, that physical examination alone more accurate and had a lower predictive probability rate than the lateral C-spine.......

Thus, Jack, you can... in this narrow group of patients.... but most of the auto accident victims I deal with are usually drunk or otherwise altered.... Our approach is to do 3-5 views of the neck, and clear it only if the physical exam is completely clear.. and this is usually the next day.

Peter Meade, MD
King/Drew Medical Center
Los Angeles

while I agree with Terry- the cavat here is "no distracting injury"- had a 4 wheeler wreck several years ago- 45 yo wf with dislocated Right shoulder, no other injuries found even on close inspection, no pain to palpation, no significant bruising noted- reduced the shoulder, and lo and behold, the neck starts hurting in the C6 region- radiographically found a small chip fracture of the lateral process on the right....most embarassing, as I had to fess up to the chief of the ED about it....

Charles S. Krin, DO FAAFP
Member, PGBFH

From: Merlin Curry
Date: 02.06.97 04:32 GMT

Just to clarify the point that it is possible to clear the spine without xray I'll let you know that I did it this very day, and do it fairly regularly, as do all prehospital care providers. Whenever you come on a wreck and don't immediately spine everybody involved you (as a prehospital care provider) have, whether you know it or not, gone through the 4 point check list previously mentioned. Of course the mechanism is minor and the patients are all ambulatory so it's easy to let them go. It's when the mechanism is greater and the patient has spine being held when you arrive that this skill becomes challenging.

Today we had a police officer involved in a serious MVA. The occupant of the other car was a trauma system entry, the cop was on the ground being protected and told not to move. After a quick secondary, and very consciously moving through a similar checklist I deferred the need to take spinal precautions. These guidelines, coupled with a strong intuition are very accurate in the hands of skilled practiontioners.

Merlin

I have had a very low volume trauma experience (residency 1977-1982 at U KS Kansas City and rural private practice) so definitely have only anecdotal experience to share.

2 of my most memorable C-spine injuries were
1. Patient with minor injuries, awake alert, no real complaints (minimal if any neck pain) I was an intern and ordered a C-spine films and got called by the Radiologist to come immediately to X-ray since he had an unstable C-spine fracture (at this time physicians were not allowed in the KU X-ray dept, in fact, Paul O'Boynick, MD, Neurosurgery was arrested by our campus cops when he refused as a senior resident to leave a patient with a C-spine fracture unattended in X-ray---needless to say Paul eventually got his way, but it was highly unusual to be asked to come to X-ray to help with a patient

2. Last year lady in her 70's in van-car accident, got out of van, got lawn chair out of back of van and was found by paramedics sitting in lawnchair in front lawn of house that she had crashed near.

She had an unstable C-2 fracture plus flail chest.

Now, obviously, this lady was going to get C-spine X-rays because of major other injuries.

Both patients survived neurologically intact.

Gail Waldby, MD
Huron Clinic SD

"Distracting" injuries (distracting to the patient)in the awake, alert, non-intoxicated patient do not preclude clinically clearing the C-spine. I think that these injuries are actually "distracting" to only the physician. Disciplined review of systems and physical exam will keep the physician out of trouble. Check out the LAC-USC study I believe has already been referenced. Hopefully, one day we can stop wasting so much time and resources on this one anatomic area.

RGMarvin
UT Houston