Journal of the International Society of Head and Neck Trauma (ISHANT)

Original Article

Clearing Cervical Spine Injury in the Awake Adult Patient

Mohammad A Fallaha

Imperial College School of Medicine, London, UK

mohammad.fallaha13@imperial.ac.uk

Received August 2016. Accepted following peer review October 2016. Published December 2016

JISHANT 2016:11

Introduction “Clearing” the cervical spine involves the confident exclusion of injuries to both

the bones and the supporting soft tissues of the neck (notably the ligaments). In many patients this may be possible following careful clinical examination. However in many other cases imaging is also required. It is now widely accepted that if imaging is necessary a normal appearing lateral cervical spine (“C Spine”) view, although encouraging, is not enough to confidently exclude all injuries. In many patients, clearance involves both clinical and radiological evaluation. .

What guidance exists?

A number of good sources provide guidance. These include:

• The Canadian C-spine rule (1)

• The NEXUS (National Emergency X-Radiography Utilization Study) criteria (2)

• National Institute of Clinical Excellence (NICE)(3)

• Eastern Association for the Surgery of Trauma (EAST)(4)

• The College of Emergency Medicine (5)

Journal of the International Society of Head and Neck Trauma (ISHANT)

• ATLS (Advanced Trauma and Life Support) Cervical Spine guidelines (6)

Other guidelines also exist.

How do these guidelines differ?There is some difference in the criteria used to determine whether a patient needs radiological imaging. They also differ in the recommend choice of imaging.

SCOPE OF GUIDANCE

This summary guidance applies to patients who:

i) Have a Glasgow Coma Scale (GCS) of 15

ii) Are 16 years or older

This summary guidance does not apply to patients who:

i) Have sustained a penetrating neck injury

SUMMARY OF GUIDANCE

1. Patients who present following blunt trauma to the neck and who need to have their cervical spine cleared should have their neck immobilised by a collar.

2. If there are “high-risk factors”, radiographic imaging is mandatory. Keep the patient immobilised and obtain imaging (proceed directly to point 6) (1).

“High-risk factors” include:

i) Age of patient >65 years old

ii) Symptoms of paresthesia in the extremities

iii) The mechanism of injury was “dangerous” (see Box 1)

Journal of the International Society of Head and Neck Trauma (ISHANT)

3. For those who do not have any “high-risk factors”, determine if the patient is at “low-risk” of cervical spine injury. This can be done by either the Canadian C-Spine Rule (a) or using the NEXUS criteria (b) (Box 2).

4. If a patient is determine to be at “low-risk” of cervical spine injury using either of the above criteria then the neck should be examined for range of motion. Proceed directly to point 6 if the patient has not been determined to be at “low-risk” of cervical spine injury.

5. Range of motion is demonstrated by active rotation of the neck left and right, a minimum of 45 degrees regardless of pain. If range of motion is demonstrated, the patient does not require radiological imaging (1).

6. If “high-risk factors” are present (see point 2) or patients placed in the “low risk” category for cervical spine injury are unable to demonstrate range of motion (see points 3-5), then a CT scan should be performed in adults (3,4)

7. CT scanning is superior to plain films in sensitivity and time-efficiency (7-9) and therefore plain films should not be used (4)

8. MRI is indicated if

Box 1

Dangerous mechanisms indicating radiography in the alert and stable Trauma Patient (from the Canadian C-Spine Rule - video 1)

• Fall from ≥ 1 metre height / 5 stairs

• Axial load to head e.g. diving

• Motor vehicle collision at high speed (>100km/h)

• Rollover motor vehicle accident

• Ejection from a motor vehicle

Journal of the International Society of Head and Neck Trauma (ISHANT)

i) There is a neurological abnormality which could be attributable to spinal cord injury (3,4) or

ii) The patient is neurologically intact, awake and alert complaining of neck pain with a negative CT (4)

9. Remember also the possibility of a thoracic or lumbosacral injury(11).

Box 2

Determining “low risk” of cervical spine injury

(a) (“Canadian C-Spine Rule”) If ANY of the following criteria are met, then the patient is at a very low risk of injury and can be safely assessed for range of motion (1)

• Simple rear-end motor vehicle collision

• Found to be in sitting position in ED

• Ambulatory status at any time after injury

• Delayed onset of neck pain

• Absence of midline C-spine tenderness

(b) (“NEXUS Criteria”)If the following 5 criteria are all met then the patient is at

low risk of cervical spine injury and radiographic imaging of the cervical spine is

unnecessary (see Video 2) (2)

• Absence of tenderness at the posterior midline of the cervical spine

• Absence of focal neurological deficit

• Normal level of alertness

• No evidence of intoxication

• Absence of clinically apparent pain that might distract patient from the pain

of a cervical spinal injury

Journal of the International Society of Head and Neck Trauma (ISHANT)

Indications for CT

1 The patient demonstrates “high-risk factors” which include:

i) Age of patient >65 years old

ii) There is paresthesia in the extremities

iii) The mechanism of injury was “dangerous”:

• Fall from ≥ 1 metre height / 5 stairs

• Axial load to head e.g. diving

• Motor vehicle collision at high speed (>100km/h)

• Rollover motor vehicle accident

• Ejection from a motor vehicle

• Motorised recreational vehicles

• Bicycle collision

2 The patient cannot be placed into the “low-risk” category using either the Canadian C-Spine or NEXUS criteria

Indications for MRI

There is a neurological abnormality which could be attributable to spinal cord injury or

The patient is neurologically intact, awake and alert complaining of neck pain with a negative CT

Journal of the International Society of Head and Neck Trauma (ISHANT)

Figure 1 – A summary of guidance on clearing the cervical spine in the awake patient based on previous guidance (1-4)

Journal of the International Society of Head and Neck Trauma (ISHANT)

Video 1 – The Canadian C-Spine Rule (courtesy of EM Ottawa) https://www.youtube.com/watch?v=k0cqlYvpv1o

Video 2 – The NEXUS Criteria (courtesy of MEDZCOOL) https://www.youtube.com/watch?v=wjUDJAGzGPQ

Journal of the International Society of Head and Neck Trauma (ISHANT)

References

(1) Stiel IG et. al, The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients, Journal of the American Medical Association, 2001, 286(15):1841-1848, Available at: http://jamanetwork.com/journals/jama/fullarticle/194296

(2) Hoffman JR et. al, Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma, New England Journal of Medicine, 2000, 343:94-99. Available at: http://www.nejm.org/doi/full/10.1056/NEJM200007133430203

(3)NICE, Spinal Injury: assessment and initial management, NICE guidelines [NG41], February 2016, Available at: https://www.nice.org.uk/guidance/NG41/chapter/recommendations#assessment-for-spinal-injury [Date accessed 12/06/2016]

(4) Como JJ et. al, Cervical Spine Injuries Following Trauma, Journal of Trauma, 2009, 67(3):651-659, Available at: https://www.east.org/education/practice-management-guidelines/cervical-spine-injuries-following-trauma [Date accessed 12/06/2016]

(5) Clinical Effectiveness Committee, Guideline on the management of alert, adult patients with potential cervical spine injury in the Emergency Department, London, The College of Emergency Medicine, 2010. Available at: https://heeoe.hee.nhs.uk/sites/default/files/cervical_spine_cem5718.pdf

(6) American College of Surgeons, ATLS Student Course Manual, 9th Edition, United States of America, 2012.

(7) Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. Journal of Trauma and Acute Care Surgery. 2005, 58(5):902-905, Available at: http://journals.lww.com/jtrauma/Abstract/2005/05000/Computed_Tomography_Versus_Plain_Radiography_to.4.aspx

(8) Daffner RH, Cervical radiography for trauma patients: a time effective technique? American Journal of Roentgenology, 2000, 175(5):1309-1311, Available at: http://www.ajronline.org/doi/abs/10.2214/ajr.175.5.1751309

(9) Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. American Journal of Roentgenology, 2001, 177(3):677-679, Available at: http://www.ajronline.org/doi/abs/10.2214/ajr.177.3.1770677

Journal of the International Society of Head and Neck Trauma (ISHANT)

(10) NICE, Spinal Injury: assessment and initial management: Methods, evidence and recommendations, NICE guidelines, February 2016, Available at: https://www.nice.org.uk/guidance/ng41/evidence/full-guideline-2358425776 [Date accessed 21/07/2016]

(11) 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. Journal of Trauma and Acute Care Surgery, 1999, 47:896-903, Available at: https://www.ncbi.nlm.nih.gov/pubmed/10568719

(12) Widder S, Doig C, Burrowes P, et al. Prospective evaluation of computed tomographic scanning for the spinal clearance of obtunded trauma patients: preliminary results. Journal of Trauma 2004, 56(6):1179-84. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15211122

Learning points

1 Clearing the cervical spine following blunt trauma does not always require imaging

2 Current guidelines still differ in their recommendations whether imaging is required. If unsure, always follow your agreed local protocol.

3 Clinical assessment and mechanism of action of injury are important in determining whether imaging is required

4 If imaging is required, CT scanning should be performed and is superior to plain film radiography.

5 Plain films alone are now rarely indicated

Accepted October 2016

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