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:

  1. increased ICP
  2. more difficult CVL insertion
  3. increased VTE
  4. increased VAP & pressure sores
  5. 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

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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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