Clearing the cervical spine

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Clearing the cervical spine after blunt multitrauma is an important part of emergency medical care, aiming to avoid preventable quadriplegia due to undiagnosed unstable cervical spine injuries.

Excluding an unstable cervical injury requires at least clinical judgement and training and often sophisticated medical imaging. If any doubt exists the patient’s spine must be immobilised before transport to a hospital or other facility.

After blunt multitrauma, a doctor may consider a patient’s cervical spine to be stable if the patient has:

  1. no signs or symptoms on cervical examination:
    1. no midline tenderness or pain
    2. full range of active movement
    3. no referable neurological deficit
  2. not consumed or been given intoxicants or drugs
  3. no significant distracting injuries
  4. a Glasgow Coma Scale (GCS) of 15, and the patient is alert and oriented

If the patient does not meet all the above criteria then they require a three view cervical x-ray series, and thoracolumbar AP and lateral plain films.

If the patient has a head injury with altered sensorium, is drunk or has been given potent analgesics, then the cervical spine must remain immobilised until the clinical examination becomes possible.

If the patient is not expected to be clinically evaluable within 48-72 hours because of severe head or multiple injuries, he should remain immobilized until a time when such an examination is possible. A high resolution CT (1.5-2 mm slices) with sagittal reconstructions is not a viable alternative, since it does not rule out ligamentous injury leading to instability.

Neurological deficit referable to the spine may require an urgent MRI scan.

Senior neurosurgeons or orthopaedic surgeons manage any detected injury. Today, most large centers have Spine Surgery specialists, that have trained in this field after their Orthopedic or Neurosurgical residency.

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Reference

  1. Morris CGT, McCoy E. Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening Anaesthesia, 2004, 59 pp 464–482
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