142 CHAPTER 7 ■ Spine and Spinal Cord Trauma
box 7-1 guidelines for screening patients with suspected spine injury
Because trauma patients can have unrecognized
spinal injuries, be sure to restrict spinal motion until
they can undergo appropriate clinical examination
and imaging.
suspected cervical spine injury
1. The presence of paraplegia or quadriplegia/tetraplegia is
presumptive evidence of spinal instability.
2. Use validated clinical decision tools such as the Canadian
C-Spine Rule and NEXUS to help determine the need for
radiographic evaluation and to clinically clear the c-spine.
Patients who are awake, alert, sober, and neurologically
normal, with no neck pain, midline tenderness, or a
distracting injury, are extremely unlikely to have an
acute c-spine fracture or instability. With the patient in
a supine position, remove the c-collar and palpate the
spine. If there is no significant tenderness, ask the patient
to voluntarily move his or her neck from side to side and
flex and extend his or her neck. Never force the patient’s
neck. If there is no pain, c-spine films are not necessary,
and the c-collar can be safely removed.
3. Patients who do have neck pain or midline tenderness
require radiographic imaging. The burden of proof
is on the clinician to exclude a spinal injury. When
technology is available, all such patients should undergo
MDCT from the occiput to T1 with sagittal and coronal
reconstructions. When technology is not available,
patients should undergo lateral, AP, and open-mouth
odontoid x-ray examinations of the c-spine. Suspicious
or inadequately visualized areas on the plain films may
require MDCT. C-spine films should be assessed for:
• bony deformity/fracture of the vertebral body
or processes
• loss of alignment of the posterior aspect of the
vertebral bodies (anterior extent of the vertebral canal)
• increased distance between the spinous processes at
one level
• narrowing of the vertebral canal
• increased prevertebral soft-tissue space
If these films are normal, the c-collar may be removed to
obtain flexion and extension views. A qualified clinician
may obtain lateral cervical spine films with the patient
voluntarily flexing and extending his or her neck. If the
films show no subluxation, the patient’s c-spine can be
cleared and the c-collar removed. However, if any of
these films are suspicious or unclear, replace the collar
and consult with a spine specialist.
4. Patients who have an altered level of consciousness or
are unable to describe their symptoms require imaging.
Ideally, obtain MDCT from the occiput to T1 with sagittal
and coronal reconstructions. When this technology is
not available, lateral, AP, and open-mouth odontoid
films with CT supplementation through suspicious or
poorly visualized areas are sufficient.
In children, CT supplementation is optional. If the
entire c-spine can be visualized and is found to be
normal, the collar can be removed after appropriate
evaluation by a doctor skilled in evaluating and
managing patients with spine injuries. Clearance of the
c-spine is particularly important if pulmonary or other
management strategies are compromised by the inability
to mobilize the patient.
5. When in doubt, leave the collar on.
suspected thoracolumbar spine
injury
1. The presence of paraplegia or a level of sensory loss
on the chest or abdomen is presumptive evidence of
spinal instability.
2. Patients who are neurologically normal, awake, alert,
and sober, with no significant traumatic mechanism
and no midline thoracolumbar back pain or tenderness,
are unlikely to have an unstable injury. Thoracolumbar
radiographs may not be necessary.
3. Patients who have spine pain or tenderness on
palpation, neurological deficits, an altered level of
consciousness, or significant mechanism of injury
should undergo screening with MDCT. If MDCT is
unavailable, obtain AP and lateral radiographs of the
entire thoracic and lumbar spine. All images must be of
good quality and interpreted as normal by a qualified
doctor before discontinuing spine precautions.
4. For all patients in whom a spine injury is detected or
suspected, consult with doctors who are skilled in
evaluating and managing patients with spine injuries.
5. Quickly evaluate patients with or without neurological
deficits (e.g., quadriplegia/tetraplegia or paraplegia) and
remove them from the backboard as soon as possible. A
patient who is allowed to lie on a hard board for more
than 2 hours is at high risk for pressure ulcers.
6. Trauma patients who require emergency surgery before
a complete workup of the spine can be accomplished
should be transported carefully, assuming that an
unstable spine injury is present. Leave the c-collar in
place and logroll the patient to and from the operating
table. Do not leave the patient on a rigid backboard
during surgery. The surgical team should take particular
care to protect the neck as much as possible during the
operation. The anesthesiologist should be informed of
the status of the workup.