Dear panel of trauma goo-roo's,

how do y'all clear your intubated, versed and morphine dripped, norcuron gomers c-spines when they been radiographically cleared, but not clinically cleared. keep in mind these patients are being resuscitated with massive amounts of fluid. do u removed the c-collars with both ct of the c-1 thru c-7 and plain xrays (negative) or do u keep the collar on thru the dough boy metamorphism.

we've been keeping the collars on until the pt is able to follow commands and thus able to respond appropriately to the clinical questions. i believe cook county hospital in chicago keeps the c-collar on until cleared clinically. we're just curious to see what's going on in other trauma centers.

I work at il masonic med center in chicago. level one trauma.

please let me know your protocol.

We currently do not routinely perform flex/ext views in comatose patients who have no abnormality on conventional 3 views =/- CT. We are revisting the literature in light of the spinal clearance algorythym published at www.trauma.org as well as protocols at many other centers that do require routine flex/ext views or c-collar until awake. Prolonged maintenance in a c collar has it's own potential hazards including difficult airway management and pressure sores. If anyone is aware of a paper clearly examining risk/benefit expense ratios of routine flex/ext views in comatose patients, could they please forward the reference.

J.Kortbeek - Calgary

How big a problem are pressure sores caused by c-collars? It's not really something I've experianced, but seems perfectly logical that a problem could arise.

Louise (med.stud.)

Some of these pressure sores become big, gaping, nasty wounds that are difficult to treat given their location. There are rigid collars that are designed for prolonged use (Miami collar, etc). They have gel padding in appropriate areas. They are more expensive but certainly worth it for patients who need a rigid collar for a lengthy time. However, I'd be willing to bet that you can have problems even with these collars in some patients.

Jean Proehl
Emergency Clinical Nurse Specialist
Dartmouth-Hitchcock Medical Center

They certainly can arise. You also have to remember to give regular pressure care to the orthopod who's been sitting in front of the x-ray viewer for hours trying to decide what to do about the neck.

It's nice to see a student in the group. Don't be put off by the bickering. People always say things in e-mails they wouldn't dare say face to face. I mean Chris Taylor for instance. I bet he's really quite a nice bloke....:)

Even one pressure sore may be too many if it is in your patient. I can recall working with a case in which the pressure sore (due to the collar) was directly over the operative site and delayed surgical stabilization of the spine. Collars intended for temporary use tend to be left on longer than anticipated and unfortunately, produce complications.

Judy Halpern, RN, MS

I recently had to accompany a patient through a radiology department for a series of C-spine X-rays. He had fallen down stairs after an alcohol binge, kept having fits, and had been put in a hard collar for a possible C-spine fracture.

I was given strict instructions by the A&E nurse on how to ensure manual in-line stabilisation and ‘not to move his neck as the consequences would be my responsibility’.

So I was absolutely petrified when the radiographer wanted to take the collar off, straighten his neck (as it was slightly off centre) and get me out of the way! I caused a bit of a scene by asking if I could check with his doctor first, and everyone was held up while someone found the casualty officer (as I wouldn’t let go of the patient’s neck!).

The collar was taken off, the neck moved back to the centre and the patient co-operated with the X-rays. He was found not to have a C-spine fracture.

I’m still a little confused as to what you can and cannot do in these situations. It seems bizarre to have to move the C-spine in order to get it into the position in which it can be radiologically cleared!

OK, I'll bite, how come no tongs or halo type traction in these folks? My understanding was that if cervical immobilization had to be on for more that a couple of days in an ambulatory patient, then a Halo set with shoulder braces was the way to go- like wise, cranial tongs for the bed bound types- both have the advantages of providing skeletal traction (which would decrease the amount of soft tissue pressure areas) along with doing a better job of immobilizing the affected joints than even the gel padded Philedelphia collars.

I think there are probably more students lurking than you realize.

HD (pre-med student)

the problem is in the patient who is unable to tell you if they can move their neck or have pain in their neck. the patient that is medically sedated and paralyed, how do u cleard their necks? do u leave the c-collar on until u give them a chemical holiday even though neck films and ct of cervical vertebra r cleared?

I've just been reading the suggested protocol on the trauma.org page. Do people REALLY use flexion/extension views?

We are trying to get together a formal policy for our dept., and while I go along with the ideas that a cooperative, non-drunk, non-drugged fully conscious patient with no neck pain and a normal clinical exam. probably does not need radiology of any kind, shouldn't there be a place in there somewhere for mechanism of injury, even if they appear completely symptomless? Rugby players especially round our way are renowned for their complete inability to feel pain, and their remarkable ability to hold their C1s on their C2s with no visible means of support.

Flexio/exstension views do not have a place in the initial "pack" of x-rays. First of all, if the patient has neck pain, his muscle contraction will prevent movement of the spine to a degree that it will be a non conclusive investigation. If no neck pain it will not add any info.

I have however had a few patients with cervical spine injury that have come the hospital a week or so after trauma because of continous pain. These patients had in two cases densfractures that needed treatment. I also belive that neckpain could be masked by other injuries with moore intense pain. I still take a lateral, AP and oblique views at least before "clearing" the spine.

Teddy Fagerstrom, MD
Dep of orthopedics and spine center
Linkoping Sweden

Using thin cuts with our spiral CT scanner we pick up a larger number of occult

c-spine injuries in patients whose x-rays are non-diagnostic. Although this has greatly reduced the number of flexion/ext view x-rays, we still pick up a few patients a year with ligamentous injury found only on flex/ext who had normal initial x-rays and persistant c/o pain which prompted the further study. Also notable is that we have a number of c-spine injuries each year easily notable on on initial surveillance 3 view x-rays in which the patient is completely asymptomatic.