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VASCULAR TRAUMA

 

 

Clinical Clearance of Cervical Spine Injury
Karim Brohi, trauma.org 7:4, April 2002

Cervical spine assessment

Spinal immobilisation is a priority in multiple trauma, spinal clearance is not.

The spine should be assessed and cleared when appropriate, given the injury characteristics and physiological state.

Imaging the spine does not take precedence over life-saving diagnostic and therapeutic procedures.

Initial Assessment of Spinal Trauma

Introduction
Spinal Stabilization
Clinical Clearance
Conscious Patients
Unconscious Patients
Thoracic & Lumbar Spine
Paediatric Spinal Injury

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.

Conscious, symptomatic patients

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

 

Conscious, symptomatic patients

trauma.org (7:4) April 2002