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Clinical clearance of Cervical Spine
Injury
Numerous large prospective studies have described the
large cost and low yield of the indiscriminate use of
cervical spine radiology in trauma patients. Although
there are case reports of bony or ligamentous injuries
in asymptomatic patients, no asymptomatic patient in
the literature has had an unstable cervical spine fracture
or suffered neurological deterioration due to the injury.
There is no conclusive evidence in the literature that
supports clinical clearance of the spine in the prehospital
environment. There is enough variation between prehospital
and in-hospital assessments to recommend that prehospital
removal of spinal immobilisation be avoided. Mechanism
of injury alone does not determine the need for radiological
investigation.
The cervical spine may be cleared clinically if the
following preconditions are met:
- Fully alert and orientated
- No head injury
- No drugs or alcohol
- No neck pain
- No abnormal neurology
- No significant other 'distracting' injury (another
injury which may 'distract' the patient from complaining
about a possible spinal injury).
Provided these preconditions are met, the neck may
then be examined. If there is no bruising or deformity,
no tenderness and a pain free range of active
movements, the cervical spine can be cleared. Radiographic
studies of the cervical spine are not indicated.
References
Prehospital
Domeier RM; Evans RW; Swor RA et al. The
reliability of prehospital clinical evaluation for potential
spinal injury is not affected by the mechanism of injury.
Prehosp Emerg Care 3:4, 332-7, 1999
Meldon SW, Brant TA, Cydulka RK et al. Out-of-hospital
cervical spine clearance: agreement between emergency
medical technicians and emergency physicians.
J Trauma 45:1058-61, 1998
In-hospital
Bachulis BL, Long WB, Hynes GD, et al: Clinical
indications for cervical spine radiographs in the traumatized
patient. Am J Surg 153:473-8, 1987
Cadoux CG, White JD, Hedberg MC: High-yield roentgenographic
criteria for cervical spine injuries. Ann Emerg
Med 16:738-42, 1987
Gonzalez RP, Fried PO, Bukhalo M et al: Role of
clinical examination in screening for blunt cervical
injury. J Am Coll Surg 189:152-8, 1999
Hoffman JR, Mower WR, Wolfson AB, Todd KH, et al. Validity
of a set of clinical criteria to rule out injury to
the cervical spine in patients with blunt trauma. National
Emergency X-Radiography Utilization Study Group
N Engl J Med 343(2): 94-99, 2000
Kreipke DL, Gillespie KR, McCarthy MC, et al: Reliability
of indications for cervical spine films in trauma patients.
J Trauma 29:1438-9, 1989
Mahadevan S; Mower WR; Hoffman JR; Peeples N; Goldberg
W; Sonner R Interrater reliability of cervical spine
injury criteria in patients with blunt trauma. Ann
Emerg Med, 31:97-201, 1998
McNamara RM, O'Brien MC, Davidheiser S: Post-traumatic
neck pain: A prospective and follow-up study. Ann
Emerg Med 17:906-11, 1988
McNamara RM, Heine E, Esposito B: Cervical spine
injury and radiography in alert, high-risk patients.
J Emerg Med 8:177-82, 1990
Mirvis SE, Diaconis JN, Chirico PA, et al: Protocol-driven
radiologic evaluation of suspected cervical spine injury:
Efficacy study. Radiology 170:831-4, 1989
Ringenberg BJ, Fisher AK, Urdaneta LF, et al: Rational
ordering of cervical spine radiographs following trauma.
Ann Emerg Med 17:792-6, 1988
Roberge RJ, Wears RC: Evaluation of neck discomfort,
neck tenderness, and neurologic deficits as indicators
for radiography in blunt trauma victims. J Emerg
Med 10:539-44, 1992
Roberge RJ, Wears RC, Kelly M, et al: Selective
application of cervical spine radiography in alert victims
of blunt trauma: A prospective study. J Trauma 28:784-8,
1988
Ross SE, O'Malley KF, Delong WG, et al: Clinical
predictors of unstable cervical spinal injury in multiply
injured patients. Injury 23:317-9, 1992
Roth BJ, Martin RR, Foley K, et al: Roentgenographic
evaluation of the cervical spine. A selective approach.
Arch Surg 129:643-5, 1994
Saddison D, Vanek VW, Racanelli JL: Clinical indications
for cervical spine radiographs in alert trauma patients.
Am Surg 57:366-9, 1991
Velmahos GC, Theodorou D, Tatevossian R et al. Radiographic
cervical spine evaluation in the alert asymptomatic
blunt trauma victim: much ado about nothing. J Trauma
40:768-74, 1996
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