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Home > Articles > Initial Assessment of Spinal Injury

Introduction

The diagnosis of an unstable spinal injury and its subsequent management can be difficult, and a missed spine injury can have devastating long-term consequences. Spinal column injury must therefore be presumed until it is excluded.

Some studies of spinal trauma have recorded a missed injury rate as high as 33%. Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inadequate cervical spine radiology and incorrect interpretation of radiographs. An appropriate procedure for the evaluation of the potentially unstable spine must be robust and easy to implement, with a high sensitivity, given the potential importance of such injuries. It must also address the main issues raised by the modalities available for diagnosis.

For spinal trauma, the main concerns are which patients can be cleared by clinical exam alone, how many plain X-rays are necessary and when should additional imaging using Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) be used. An assessment for ligamentous injury in the absence of a fracture is also important, especially in unconscious patients who are unable to complain of neck pain or tenderness.

While it is tempting to focus on the cervical spine, it is important to assess and clear the entire spinal column. The thoracolumbar spine, while more protected, is at risk in major trauma and must be assessed both clinically and radiologically. Additionally, 5% of spinal injuries have a second, possibly non-adjacent, fracture elsewhere in the spine.

These pages discuss the initial assessment and management of the potentially spine injured patient. The actual protocol implemented at any given institution will depend on the expertise and facilities available. Where the required expertise or imaging are not available in a given institution, the protocol should encompass criteria for expeditious transfer of patients to specialist care.

Spinal Stabilization & Management

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

Indications for spinal immobilization

Very few studies define the criteria used to decide who is at risk from cervical spine injury.

Blunt Injury All patients with sufficient mechanism of injury to lead to a spinal injury should be considered to have a spinal injury until proven otherwise. What constitutes 'sufficient mechanism' is undefined.

Penetrating Injury Gunshot wounds that have traversed the spinal column may produce unstable injuries and caution should be exercised. Gunshot wounds to the cranium alone are not associated with a risk of cervical spine trauma. It is not necessary to immobilize stab injuries. Spinal immobilization devices may interfere with the recognition and management of life-threatening conditions.

Techniques of immobilization and patient handling

The spine should be protected at all times during the management of the multiply injured patient. The ideal position is with the whole spine immobilised in a neutral position on a firm surface. This may be achieved manually or with a combination of semi-rigid cervical collar, side head supports and strapping. Strapping should be applied to the shoulders and pelvis as well as the head to prevent the neck becoming the centre of rotation of the body.

Prehospital

Manual spinal protection should be instituted immediately. The application of definitive immobilisation devices should not take precedence over life-saving procedures.

If the neck is not in the neutral position, an attempt should be made to achieve alignment. If the patient is awake and co-operative, they should actively move their neck into line. If unconscious or unable to co-operate this is done passively. If there is any pain, neurological deterioration or resistance to movement the procedure should be abandoned and the neck splinted in the current position.

Long spine (rescue) boards are valuable primarily for extrication from vehicles. Repeated transfers to and from the board may compromise spinal protection and induce a significant amount of spinal movement. Patients may also be transferred on a scoop stretcher and/or vacuum mattress. There is little place for the short spine board or spinal extrication devices in the prehospital environment.

In-hospital

The spine board should be removed as soon as possible once the patient is on a firm trolley. Prolonged use of spine boards can rapidly lead to pressure injuries. Full immobilisation should be maintained. Manual protection should be reinstated if restraints have to be removed for examination or procedures (eg. intubation).

The log-roll is the standard manoeuvre to allow examination of the back and transfer on and off back boards. Four people are required, one holding the head and coordinating the roll, and three to roll the chest, pelvis and limbs. The number and degree of rolls should be kept to an absolute minimum. Rigid transfer slides (eg. Patslide) are useful for transferring the patient from one surface to another (eg CT scanner, operating table).

Patients who are agitated or restless due to shock, hypoxia, head injury or intoxication may be impossible to immobilise adequately. Forced restraints or manual fixation of the head may risk further injury to the spine. It may be necessary to remove immobilisation devices and allow the patient to move unhindered.

Anaesthesia may be necessary to allow adequate diagnosis and therapy. Intubation of the trauma victim is best achieved via rapid sequence induction of anaesthesia and orotracheal intubation, though the technique used should ultimately depend on the skills of the operator. The collar should be removed and manual, in-line protection re-instituted for the manoeuvre. The routine use of a gum elastic bougie is recommended, minimising cervical movement by allowing intubation with minimal visualisation of the larynx.

Transfer to Secondary Units

Patients may require transfer to other units for definitive care of other injuries such as head or pelvic trauma. There should be no unnecessary delays in the transport of these patients. Transfer should not wait for unnecessary diagnostic procedures that will not alter management. This includes radiological imaging of the spine.

The spine should be immobilised and protected for the transfer. Split-scoop stretchers and vacuum mattresses are more appropriate for transfer than rigid spinal (rescue) boards, which should be reserved for primary extrication from vehicles, rather than as devices for transporting patients.

Spinal Clearance

  1. Spinal immobilisation is a priority in multiple trauma, spinal clearance is not.
  2. The spine should be assessed and cleared when appropriate, given the injury characteristics and physiological state.
  3. Imaging the spine does not take precedence over life-saving diagnostic and therapeutic procedures.

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

  1. Radiological evaluation of the cervical spine is indicated for all patients who do not meet the criteria for clinical clearance as described above.
  2. Imaging studies should be technically adequate and interpreted by experienced clinicians.

Plain Film Radiology

The standard 3 view plain film series is the lateral, antero-posterior and open-mouth view.

The lateral cervical spine film must include the base of the occiput and the top of the first thoracic vertebra. The lateral view alone is inadequate and will miss up to 15% of cervical spine injuries. The lower cervical spine may be difficult to examine and caudal traction on the arms should be used to improve visualisation. Repeated attempts at plain radiography are usually unsuccessful and waste time. If the lower cervical spine is not visualised a CT scan of the region is indicated. How to read the lateral cervical spine film.

The antero-posterior view must include the spinous processes of all the cervical vertebrae from C2 to T1.

The open-mouth view should visualise the lateral masses of C1 and the entire odontoid peg. Bite blocks may improve the open-mouth view. In the unconscious, intubated patient the open mouth view is inadequate and should be replaced by a CT scan from the occiput to C2.

The addition of two oblique views to the standard 3-view series does not increase the sensitivity of plain film evaluation. Some centres use two supine or trauma-oblique views to replace the antero-posterior view. These views can provide excellent visualisation of the posterior elements of the cervical spine and provide significantly more information than the antero-posterior view. Lateral

CT Scanning

Thin-cut (2mm) axial CT scanning on specific bone windows, with sagittal and coronal reconstruction should be used to evaluate abnormal, suspicious or poorly visualised areas on plain radiology. With technically adequate studies and experienced interpretation, the combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%. The scan should include the entire vertebral body above and below the region of interest, as these must be undamaged for subsequent internal fixation.

Assessment of soft tissue injury in the awake patient

The patient with normal radiological evaluation as described above who has persistent symptoms requires an evaluation of soft tissue injury with static flexion and extension imaging of the neck at the extremes of the active range of motion. Pure disc or ligamentous disruption can produced unstable cervical spine injuries and will usually be detected by such imaging. The movements are safe provided the patient performs them actively and halts if there is an increase in pain or neurological symptoms.

Magnetic Resonance Imaging

All patients with an abnormal neurological examination should be evaluated in a specialist unit and have an MRI scan of the spine. Patients who report transient neurological symptoms (the 'stinger' or 'burner') but who have a normal exam should also undergo an MRI assessment of their spinal cord.

Unconscious, Intubated Patients

  1. The odontoid view is unreliable in intubated patients.
  2. Clinical examination is impossible in the unconscious patient.
  3. Plain film radiology cannot exclude ligamentous instability.

The standard radiological examination of the cervical spine in the unconscious, intubated patient is :

  • Lateral cervical spine film
  • Antero-posterior cervical spine film
  • CT scan of occiput - C3

The open-mouth odontoid radiograph is inadequate in intubated patients and will miss up to 17% of injuries to the upper cervical spine.

Thin-cut (2mm) axial CT scanning on specific bone windows, with sagittal and coronal reconstruction should be used to evaluate abnormal, suspicious or poorly visualised areas on plain radiology. With technically adequate studies and experienced interpretation, the combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%. The scan should include the entire vertebral body above and below the region of interest, as these must be undamaged for subsequent internal fixation.

Ligamentous Instability

Clearance of the spine in unconscious patients is limited by the lack of clinical information. The incidence of unstable spinal injury in adult, intubated trauma patients is around 10.2%. The incidence of unstable, occult spinal trauma (not visible on plain films is around 2.5%. The options for full clearance of cervical spine injury are:

  • Continue precautions until fully conscious
  • Magnetic Resonance Imaging
  • Dynamic Flexion-Extension Fluoroscopy
  • CT Scan whole cervical spine

Continue spinal precautions until fully conscious.

Where the patient is expected to regain full consciousness in the following 24-48 hours, patients can be nursed with full spinal precuations. Once the patient has returned to full consciousness, clinical examination can exclude significant ligamentous injury.

Prolonged spinal immobilisation in critically ill patients leads to decubitus ulcers and deep venous thromboses while compromising nursing care, respiratory support and the management of traumatic brain injury.

A semi-rigid collar is not necessary in the adequately sedated, ventilated patient, and may increase intracranial pressure in patients with traumatic brain injury.

Magnetic Resonance Imaging

MRI is extremely sensitive at detecting soft tissue injuries without stressing the cervical spine. However the significance of such injuries with regards to the clinical stability of the spine is not clear, and the number of false positive examinations is high. MRI of ventilated patients is a significant undertaking requiring special non-ferromagnetic equipment. However the increasing use of MRI for critically ill patients is making this equipment cheaper and more widely available. Possibly because of the difficulties associated with undertaking routine MRI scans in these patients, there have been few good studies on the use of MRI in clearing the cervical spine in unconscious patients.

Dynamic Flexion-Extension Fluoroscopy

Fluoroscopy Passive dynamic flexion/extension stressing of the cervical spine, performed by an experienced clinician, should reveal most significant ligamentous injuries. Several centres have reported their results, and some guidelines give primary support to the use of dynamic fluoroscopy in clearance of the spine in unconscious patients.

However, there are significant difficulties in performing flexion/extension imaging routinely on the intensive care unit, and many spinal surgeons are unwilling to perform the study due to safety & resource implications. Of 625 patients currently reported in the literature, dynamic fluoroscopy has a sensitivity of 92.3% and specificity of 98.8%. Two cases of neurological deterioration during the study have been reported, including one complete quadriplegia.

CT Scan whole Cervical Spine

In recent years, the concept of full cervical spine CT for assessment of spinal injury has emerged. There are several studies that have demonstrated the robustness of the full CT scan, with sagittal and coronal reconstructions, for the exclusion of significant spinal injury. Widening, slippage or rotational abnormalities of the cervical vertebrae suggest soft tissue injury. An absence of such signs appears to exclude significant instability. Abnormal findings on the CT scan are evaluated by a spinal surgeon and additional modalities, such as MRI, can be employed. No study has missed a cervical spine injury, and no study has identified an injury on plain films that was not apparent on the CT scan.

Helical or multislice CT scanning from the Occiput to T1 is performed at 2-3mm collimation and 1.5mm pitch. Sagittal and coronal reconstructions are must be closely examined for indications of ligamentous instability. When whole cervical spine CT scanning is performed, the antero-posterior plain film becomes redundant.

Thoracic & Lumbar Spine Injury

  1. Thoracolumbar spine imaging is indicated if there is pain, bruising, swelling, deformity or abnormal neurology attributable to the thoracic or lumbar spinal regions.
  2. The presence of a fracture anywhere in the spine mandates full spinal imaging.
  3. Unconscious patients who cannot be assessed clinically also require radiological clearance of the whole spine.

The standard imaging for the thoracic and lumbar spine are antero-posterior and lateral radiographs.

CT scanning is carried out for any abnormal, suspicious or inadequately visualised ares. The scan should include the entire vertebral body above and below the level of injury, as these need to be uninjured if used for operative fixation.

Patients with abnormal neurology attributable to the thoracic or lumbar spine should undergo an MRI scan to visualise the spinal cord.

Paediatric Spine Injury

  1. Spinal evaluation in the paediatric population is similar to those in adults.
  2. Clinical and radiological evaluation of the immature anatomy requires particular care, with attention paid to X-ray variants.
  3. Spinal cord injury without radiographic plain film abnormality is more common in this age group and a thorough neurological examination is important.

Immobilization

Children have a disproportionately larger head size than adults, and when supine on a firm surface will be in a position of slight flexion. This slight degree of flexion is rarely a problem, though it can give rise to difficulties in X-ray interpretation. This can be corrected by placing a folded towel or sheet under the patient's shoulders to bring the cervical spine into the neutral position.

It may be difficult to immobilize a child adequately. Distress and discomfort may require that manual in-line stabilization is used instead of a semi-rigid collar, blocks and tape. Collar sizing may be difficult and there are no collars that adequately fit infants aged 6 and below.

Clinical Clearance

Clinical clearance of the spine is less well established in the paediatric population. While the NEXUS study (Vicellio) has shown promise in this area, of 3065 patients there were only 4 cervical spine injuries in patients under 9 years of age, and none below 2 years old.

Radiology

The immature anatomy of the paediatric cervical spine requires some expertise and familiarity to interpret and to avoid missed injuries. Due to the paediatric patients' larger head size, pseudosubluxation of C2 on C3, and anterior translations may appear as injuries rather than as consequences of mild flexion.

References

Incidence of Cervical Spine Injury

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Associated Injuries

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Multiple Level Injuries

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Penetrating trauma

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Missed Injuries

Davis JW, Phreaner DL, Hoyt DB, et al: The etiology of missed cervical spine injuries. J Trauma 34:342-6, 1993

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Protocols

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Stabilization

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Watts D, Abrahams E, MacMillan C, et al Insult after injury: pressure ulcers in trauma patients. Orthop Nurs. 1998 Jul-Aug;17(4):84-91

Clinical Clearance of Cervical Spine Injury

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

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Kreipke DL, Gillespie KR, McCarthy MC, et al: Reliability of indications for cervical spine films in trauma patients. J Trauma 29:1438-9, 1989

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McNamara RM, O'Brien MC, Davidheiser S: Post-traumatic neck pain: A prospective and follow-up study. Ann Emerg Med 17:906-11, 1988

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Mirvis SE, Diaconis JN, Chirico PA, et al: Protocol-driven radiologic evaluation of suspected cervical spine injury: Efficacy study. Radiology 170:831-4, 1989

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Conscious, Symptomatic Patient Evaluation

Plain Film Radiology

Clark CR, Igram CM, el-Khoury GY, et al: Radiographic evaluation of cervical spine injuries. Spine 13:742-7, 1988

Fischer RP: Cervical radiographic evaluation of alert patients following blunt trauma. Ann Emerg Med 13:905-7, 1984

el-Khoury GY, Kathol MH, Daniel WW: Imaging of acute injuries of the cervical spine: Value of plain radiography, CT, and MR imaging. AJR Am J Roentgenol 164:43-50, 1995

Hoffman JR, Schriger DL, Mower W, et al: Low-risk criteria for cervical-spine radiography in blunt trauma: A prospective study. Ann Emerg Med 21:1454-60, 1992

Jacobs LM, Schwartz R: Prospective analysis of acute cervical spine injury: A methodology to predict injury. Ann Emerg Med 15:44-9, 1986

Jergens ME, Morgan MT, McElroy CE: Selective use of radiography of the skull and cervical spine. West J Med 127:1-4, 1977

Ross SE, Schwab CW, David ET, et al: Clearing the cervical spine: Initial radiologic evaluation. J Trauma 27:1055-60, 1987

Shaffer MA, Doris PE: Limitation of the cross table lateral view in detecting cervical spine injuries: A retrospective analysis. Ann Emerg Med 10:508-13, 1981

Streitwieser DR, Knopp R, Wales LR, et al: Accuracy of standard radiographic views in detecting cervical spine fractures. Ann Emerg Med 12:538-42, 1983

West OC, Anbari MM, Pilgram TK et al. Acute cervical spine trauma: diagnostic performance of single-view versus three-view radiographic screening. Radiology 204:819-23, 1997

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Obliques vs AP

Holliman CJ, Mayer JS, Cook RT, et al: Is the anteroposterior cervical spine radiograph necessary in initial trauma screening? Am J Emerg Med 9:421-5, 1991

Ireland AJ; Britton I; Forrester AW Do supine oblique views provide better imaging of the cervicothoracic junction than swimmer's views? J Accid Emerg Med, 1998 May, 15:3, 151-4

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How many X-rays?

Doris PE, Wilson RA. The Next Logical Step in the Emergency Radiographic Evaluation of Cervical Spine Trauma : The Five-view Trauma Series. J Emerg Med 1985; 3: p. 371-375

Freemyer B, Knopp R, Piche J, et al: Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med 18:818-21, 1989

MacDonald RL, Schwartz ML, Mirich D, et al: Diagnosis of cervical spine injury in motor vehicle crash victims: How many x-rays are enough? J Trauma 30:392-7, 1990

Flexion-Extension Views

Lewis LM, Docherty M, Ruoff BE, et al: Flexion-extension views in the evaluation of cervical-spine injuries. Ann Emerg Med 20:117-21, 1991

Computed Tomography

Acheson MB, Livingston RR, Richardson ML, et al: High-resolution CT scanning in the evaluation of cervical spine fracture: comparison with plain film examinations. AJR Am J Roentgenol 148:1179-85, 1987

Borock EC, Gabram SG, Jacobs LM, et al: A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 31:1001-6, 1991

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CT of Occiput-C3

Blacksin MF and Lee HJ. Frequency and significance of fractures of the upper cervical spine detected by CT in patients with severe neck trauma. AJR Am J Roentgenol 165(5): 1201-1204, 1995

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CT of C7-T1

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Unconscious, intubated trauma patients

Computed Tomography of Occiput - C3

Kirshenbaum KJ, Nadimpalli SR, Fantus R, et al: Unsuspected upper cervical spine fractures associated with significant head trauma: Role of CT. J Emerg Med 8:183-98, 1990

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Incidence of Ligamentous Instability

Chiu WC, Haan JM, Cushing BM, Kramer ME, Scalea TM. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma 2001 Mar;50(3):457-63;

Demetriades D, Charalambides K, Chahwan S et al 'Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls' J Trauma. 2000 Apr;48(4):724-7

Magnetic Resonance Imaging

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Goldberg AL, Rothfus WE, Deeb ZL, et al: The impact of magnetic resonance on the diagnostic evaluation of acute cervicothoracic spinal trauma. Skeletal Radiol 17:89-95, 1988

Katzberg RW, Benedetti PF, Drake CM, et al Acute cervical spine injuries: prospective MR imaging assessment at a level 1 trauma center. Radiology 1999 Oct;213(1):203-12

Silberstein M, Tress BM, Hennessy O: Prevertebral swelling in cervical spine injury: Identification of ligament injury with magnetic resonance imaging. Clin Radiol 46:318-23, 1992

Dynamic Fluoroscopy

Ajani AE, Cooper DJ, Scheinkestel CD et al. Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation. Anaesth Intensive Care 26:487-91, 1998

Brooks RA, Willett KM. Evaluation of the Oxford protocol for total spinal clearance in the unconscious trauma patient. J Trauma 2001 May;50(5):862-7

Cox MW, McCarthy M, Lemmon G, Wenker J. Cervical spine instability: clearance using dynamic fluoroscopy. Curr Surg 2001 Jan;58(1):96-100 Cervical spine instability: clearance using dynamic fluoroscopy.

Croft AC; Krage JS; Pate D; Young DN Videofluoroscopy in cervical spine trauma: an interinterpreter reliability study. J Manipulative Physiol Ther, 1994 Jan, 17:1, 20-4

Davis JW, Kaups KL, Cunningham MA et al: Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma 2001 Jun;50(6):1044-7

Davis JW, Parks SN, Detlefs CL, et al: Clearing the cervical spine in obtunded patients: The use of dynamic fluoroscopy. J Trauma 39:435-8, 1995

Hino H, Abumi K, Kanayama M, Kaneda K Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine 1999 Jan 15;24(2):163-8

Robert KQ 3rd, Ricciardi EJ, Harris BM. Occult ligamentous injury of the cervical spine. South Med J 2000 Oct;93(10):974-6

Sees DW, Rodriguez Cruz LR, Flaherty SF. The use of bedside fluoroscopy to evaluate the cervical spine in obtunded trauma patients. J Trauma 45:768-71, 1998

Computed Tomography of Complete Cervical Spine

Barba CA, Taggert J, Morgan AS et al 'A new cervical spine clearance protocol using computed tomography.' J Trauma. 2001 Oct;51(4):652-6

Berne JD, Velmahos GC, El-Tawil Q et al 'Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.' J Trauma. 1999 Nov;47(5):896-902

Daffner RH. 'Helical CT of the cervical spine for trauma patients: a time study.' AJR Am J Roentgenol. 2001 Sep;177(3):677-9

Keenan HT, Hollingshead MC, Chung CJ et al 'Using CT of the cervical spine for early evaluation of pediatric patients with head trauma.' AJR Am J Roentgenol. 2001 Dec;177(6):1405-9

Thoracolumbar spine injury

Durham RM, Luchtefeld WB, Wibbenmeyer L, Maxwell P, et al. Evaluation of the thoracic and lumbar spine after blunt trauma. Am J Surg 170(6): 681-684, 1995

Frankel HL, Rozycki GS, Ochsner MG, Harviel JD, et al. Indications for obtaining surveillance thoracic and lumbar spine radiographs. J Trauma 37(4): 673-676, 1994

Meldon SW and Moettus LN. Thoracolumbar spine fractures: clinical presentation and the effect of altered sensorium and major injury. J Trauma 39(6): 1110-1114, 1995

Spivak JM, Vaccaro AR and Cotler JM. Thoracolumbar Spine Trauma: I. Evaluation and Classification. J Am Acad Orthop Surg 3(6): 345-352, 1995

Paediatric spine injury

Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med 17:230-4, 1999

Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg. 2001 Aug;36(8):1107-14

Curran C, Dietrich AM, Bowman MJ, Ginn-Pease ME, et al. Pediatric cervical-spine immobilization: achieving neutral position? J Trauma 39(4): 729-732, 1995

Herzenberg JE, Hensinger RN, Dedrick DK and Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J Bone Joint Surg [Am] 71(1): 15-22, 1989

Jaffe DM, Binns H, Radkowski MA, Barthel MJ, et al. Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med 16(3): 270-276, 1987

Keenan HT, Hollingshead MC, Chung CJ, Ziglar MK. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. AJR Am J Roentgenol. 2001 Dec;177(6):1405-9.

Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001 Jan;36(1):100-5.

Nitecki S and Moir CR. Predictive factors of the outcome of traumatic cervical spine fracture in children. J Pediatr Surg 29(11): 1409-1411, 1994

Patel JC, Tepas JJ 3rd, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001 Feb;36(2):373-6

Rachesky I, Boyce WT, Duncan B, et al: Clinical prediction of cervical spine injuries in children. Radiographic abnormalities. Am J Dis Child 141:199-201, 1987

Skellett S, Tibby SM, Durward A, Murdoch IA. Immobilisation of the cervical spine in children. BMJ. 2002 Mar 9;324(7337):591-3

Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001 Aug;108(2):E20.

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