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C-spine clearance

Karim Brohi trauma-list@trauma.org
Fri, 25 Apr 2003 17:45:43 +0100


We changed our protocol on 1st February 2002 to use whole-cspine CT in
unconscious patients to clear the cervical spine and then remove spinal
precautions.  We're submitting a year's worth of unconscious, intubated
patients (236) to the J Trauma this month.

No one wants to miss an injury.  However the incidence of unstable,
ligamentous or disc injury without CT evidence is very low.  Our previous
protocol included MRI but proved to expensive - in terms of intensivist time
away from the unit and MRI time - and as such patients still were not being
cleared until day 4,5,6,7...  Our Trauma Committee concluded that the
detrimental effects on the majority of patients of prolonged spinal
immobilisation outweighed the potential possibility of missing an
undisplaced, unstable ligamentous injury.

Individual institutions must decide what level of risk they are prepared to
accept, and at what cost, given that no test is ever 100%.


PS.  If one were to take clinical examination to the extreme - do you wait
until your ICU patient has documented sub-therapeuric levels of
benzodiazepine, propofol, morphine and as returned to normal psychomotor
function before examining them?  It's all very hazy - and a lot of hysteria
is propogated about the subject of cervical spine clearance.

PPS.  The lateral cervical spine film in the above patient group had a
sensitivity of 29%.

-----Original Message-----
From: trauma-list-admin@trauma.org
[mailto:trauma-list-admin@trauma.org]On Behalf Of DocRickFry@aol.com
Sent: 25 April 2003 15:58
To: trauma-list@trauma.org
Subject: Re: C-spine clearance

In a message dated 4/24/2003 8:25:15 PM Eastern Standard Time,
mmcbridemd@yahoo.com writes:

> Now, you do mention concensus opinion, which is helpful. But are there
data to demonstrate that this approach would be contraindicated? It seems as
though the data about CT
> concludes no missed injuries - ligamentous or otherwise.
I am not aware of any studies or data indicating CT alone allows removal of
collar--if you know of such could you share it with us?  All studies of
which I am aware indicate that imaging is only a first step to excluding
c-spine injury, not the final step. The only thing that allows "clearance"
of the c-spine in the initial evaluation is no cervical spine tenderness on
exam in an awake and responsive patient.
 Obviously there are still many holes in our knowledge of this, and still
many issues persist, which is why so many protocols still exist

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