Cervical Spine Assessment
OVERVIEW
- controversial issue
- 5-10% of severe TBI have an associated unstable cervical fracture
- can be cleared clinically and/or radiologically
- in the patient with TBI clinical clearance is not an option
- until cleared patients must be immobilized (hard collar, in-line stabilisation, log rolling)
Removal of hard collar desirable for a number of reasons:
- increased ICP
- more difficult CVL insertion
- increased VTE
- increased VAP & pressure sores
- increased staffing requirements
CLINICAL
Prerequisite
- GCS 15
- no intoxification
- no distracting injuries
Normal examination
- no midline tenderness
- FROM
- no referable neurological deficit
RADIOLOGICAL
Conservative view requires:
- c-spine xrays + CT + an awake patient who can be examined based on ATLS guidelines
OR
- MRI
- dynamic fluoroscopy
-> until then, collar stays on
Liberal view requires:
- lateral c-spine cleared
-> take off collar
REALITY
- lateral c-spine only misses 15% of injuries
- lateral c-spine, AP and PEG misses 10% of injuries (25-50% of studies being inadequate)
- lateral c-spine, AP, PEG, swimmers (oblique views) still misses 10% and may displace injuries!
- 3 view xrays + CT (high resolution, 1.5-2mm slices with sagittal reconstructions) misses <1% on injuries
- CT alone (misses ligamentous injury without bone fracture, risk 1/1000)
AN APPROACH
(1) Full spinal immobilization care until cleared
(2) Detailed history + examination
-> mechanism of injury
-> speed
-> other injuries
(3) CT c-spine (high resolution, 1mm slices with sagittal reconstructions)
(4) Formal radiologist + Orthopaedic/Neurosurgical expert opinion
(5) Any doubt:
-> High risk injury or neurological deficit -> MRI
-> CT abnormal -> MRI
-> Normal -> clear cervical spine
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Journal articles
- Morris CG, McCoy E. Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening. Anaesthesia. 2004 May;59(5):464-82. [PMID 15096241]
FOAM and web resources
- EAST — Cervical Spine Injuries Following Trauma (2009)
- EMCrit — More on a Diagnostic Strategy for C-Spine Injuries (2012)
- EMCrit — EMCrit Wee – More on C-Spine Imaging (2012)
- ICN — Podcast 96. Clearing the C-Spine (2013)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
