Clearing the cervical spine

The cervical spine continues to cause problems. Once we understand the basics, clearance of the cervical spine is not a mystery.

A Recent Case

An 8 year old child was brought into the emergency department following being involved in a motor vehicle accident. There was a closed head injury of significance and the GCS was 4. Cervical spine precaustions were in place.

The child was intubated with in-line immobilization and stabilized, then had a pan scan.

Head CT showed subarachnoid blood.

Cervical spine CT was normal

CT chest and abdo was normal.

Following review of the CT scan, a senior doctor, proceeded to remove the cervical hard collar. I stopped him, unsure of what was happenning. He responded that there were no fractures on the CT cervical spine. That was correct. Could he clear the spine?

No, No, No. Cervical fracture was excluded, but ligamentus injury and cord injury were not.

In order to clear the spine completely, we need to have an awake and alert patient, that we can question about cervical spine pain and that we can examine to ensure that they are neurologically intact.

So there are two subgroups:

The UNCONSCIOUS and the CONSCIOUS patient.

Let’s look at both of these.

THE UNCONSCIOUS PATIENT

Try as we might, it is difficult to clear the cervical spine of the unconscious patient.

Certainly these patients require a CT cervical spine at the same time as a head CT.

If there is no fracture, it doesn’t mean the spine is cleared. They can be placed in an ‘aspen’ collar, with full spinal precautions and Neurosurgery at your hospital or the nearest centre,  (if in a rural centre) needs to be consulted. These patients may be required to have an MRI as well.

So beware, if they are unconscious with no evidence of fracture on the CT, we still can’t clear the C-spine.

What if you do find a fracture in the cervical spine? Then you need to look for another spinal fracture. In 10% of cases, there is a second fracture in the spine. Some plain films will suffice.

THE CONSCIOUS PATIENT

This means a GCS of 15. If it is <15, then cannot clear the cervical spine clinically, nor by X-ray.

The first question to ask is: IS THE PATIENT UNCOOPERATIVE, HAVE A DISTRACTING INJURY, OR IS INTOXICATED?

What we are trying to do here is apply nexus criteria which require:

1. Normal level of consciousness
2. No neurology
3. No midline neck pain
4. No intoxication
5. No distracting injury

If all these are present then the spine can be cleared clinically, with no need for an Xray. I personally also look at two other things:

• Is the patient >65 yo and
• Has there has been a significant mechanism of injury?

WHAT IF THERE IS MINOR NECK PAIN?

If the neck pain is minor and there is no distracting injury and all other nexus criteria apply, then I do a plain 3 series X-ray.

If  this is normal, I will remove the collar and test the patient for any limitation of movement, by asking them to turn their head from side to side. If all is normal, the collar comes off. If there is limitation through pain, the collar stays on.

WHAT IF THERE IS SIGNIFICANT MIDLINE NECK PAIN?

If the neck pain is significant, then that patient will require a CT of the cervical spine.

The radiologist may ask if a plain X-ray can be done first. Here is the way I usually respond:

“OK, I’m happy to do a plain series Dr Radiologist, but can I ask you to help me a little with my reasoning. If the plain X-ray is normal, I can’t clear the C-spine because the pain is significant and will need a CT, yes?”

The answer is usually “Yes”.

“OK then, please help me out Dr Radiologist. If the X-ray is abnormal, I’ll need a CT, won’t I?”

The answer is usually,“Well of course!”

“Then Dr Radiologist, given that the pain is significant, I will need to do a CT if the X-ray is normal or abnormal, so why don’t we just go ahead and do the CT?”

“Send the patient down.”

….SO THERE IT IS

If the patient is unconscious, you need the CT, but still can’t clear the C-spine.

If the patient is concious and meets all NEXUS criteria, you can clear the C-spine clinically.

If they don’t meet the criteria, or if they have significant C-spine tenderness, then they will also need a CT.

So the only people that really get plain X-rays are:

• patients with minor midline neck pain that meet all other NEXUS criteria
• normal neurology
• not intoxicated
• normal conscious state
• no distracting injury

Once you know this approach, it’s quite straightforward to look after these patients.

Only one more thing be said. These are literature based reviews but if you want to do something more because no matter what the literature says, you think there’s a fracture and you want a CT. That is for you as a clinician to decide. Do more, not less.

See you soon.