Clearing the cervical spine

Dr Claudia AY Cheng
Senior Medical Officer
Department of Anaesthesia and
Intensive Care
 Objectives

 Spinal immobilization and airway management

 Reading cervical spine X-rays
 Guidelines on clearing the cervical spine
 Cases
“Spinal immobilization is a
priority in multiple trauma,
spinal clearance is not”
 Who needs spinal immobilization?

 All at risk patients:

 Blunt injury
• All patients with sufficient mechanism of injury to lead to a
spinal injury should be considered to have a spinal injury until
proven otherwise
• What constitutes “sufficient mechanism” remains unclear
 Penetrating injury
• Gunshot wounds to the spinal column – necessary
• Gunshot wounds to head and stab wounds – probably not
necessary
 Vandemark criteria for high-risk
patients
 High velocity blunt trauma
 Multiple fractures
 Evidence of direct cervical injury (cervical pain, spasm,
obvious deformity)
 Altered mental status (LOC, alcohol/drug use)
 Drowning or diving accident
 Fall of > 10 feet
 Significant head or facial injury
 Thoracic or lumbar fracture
 Rigid vertebral disease (AS)
 Parasthesias or burning in extremities
 Spinal immobilization

 Whole spine immobilisation is required

 Neutral position
 Firm surface
 Can be achieved manually or with semi-rigid
cervical collar, spinal board
 Anaesthesia
Neck Collars
Moving the patient
Spinal Board
Airway management
Airway obstruction
 Open airway - Head tilt-chin lift
 Pulls the base of the
tongue away from the
back of the throat

 Only perform if there is

no possibility of cervical
spine injury
 Airway management
 Jaw thrust
 Manual in-line immobilization
 Oro- or naso-pharyngeal airways
 Intubation with rapid sequence induction with
cricoid pressure
 Fibreoptic intubation
 Laryngeal mask airway
 Tracheostomy
 Open airway - Jaw thrust
 Use the jaw thrust
technique in patients
with cervical spine
injuries
Manual in-line immobilization
Oropharyngeal airway
Nasopharyngeal airway
Fibreoptic intubation
Laryngeal Mask Airway –
“LMA”
 How many plain X-rays are necessary?

 Note: there is no statistically valid prospective

or retrospective study addressing the issue of
how many plain X-rays are necessary
 Experts have different opinions
 Time-consuming if many views. Open-mouth view
most commonly repeated. Radiation exposure, cost
 CT scan quicker (eg 6-view series = 22 minutes vs
CT = 12 minutes)
 CT more and more important as a screening tool;
but cannot completely abandon plain x-ray series
 Plain X-rays

3 views necessary:
Lateral: occiput to top of T1
AP: spinous process of C2-C7
Open mouth – entire dens and lateral
masses of C1
Sensitivity 92-99%
If lateral only:
Sensitivity 82-85%
 Flexion/extension views
 Not helpful except for ensuring that minor
degrees of anterolisthesis or retrolisthesis in
patients with cervical spondylosis are fixed
deformities
 Muscle spasm in acute stage precludes
adequate examination
 It’s use is whether patient has ligamentous
instability
 MRI is procedure of choice
 Role of MRI
Reserve for patients with clear-cut
neurologic findings
Patients with suspected ligamentous
instability
Us as screen for multiple noncontiguous
injuries (occurs in about 20% of patients)
 3 views

Lateral AP Open mouth

3 imaginary columns
Anterior vertebral line
Posterior vertebral line

 
Spinolaminar line

Disruption of more than one

column = unstable injury                                       
Soft tissue shadow
Above C4: , 50% width of
vertebral body. Pharyngeal

 
and prevertebral tissues
Below C4: 1 full vertebral
body width. Posterior larynx
and oesophagus thickening
                                      

Does not apply to intubated

patients; invariably associated
with soft tissue swelling
  
Intubated patients;
Invariably will have soft tissue swelling.
Cannot interpret accurately

                                      
Open mouth view
Must see the lateral
masses of C1
Odontoid peg
Odontoid peg

 
Atlanto-Dens Interval in adults <
3mm
Upper c-spine distances
Occiput-Atlas < 5 mm
                                      

C1-C2 interspinous space <+ 10

mm
NTEC/PWH Trauma Advisory
Committee
Guidelines for Cervical Spine
Clearance
Management flow chart for cervical spine clearance
Injury mechanism having the potential
for causing a C-spine injury

Immobilization

YES E
Altered mental status / intoxicated
No
YES
Neurological deficit D
No

Spinal pain or palpation tenderness YES C

No
YES
A distracting painful injury B
No

Clearing of C-spine clinically

clear documentation A

Satisfactory

Off immobilization
declare C-spine is clear
Can you clear the cervical spine
without performing any X-rays?
 A

C spine can be cleared if ALL conditions listed below are satisfied

 Alert, not intoxicated
 No neurological symptom or sign
 No midline neck pain or tenderness (needs removal of
immobilization device temporarily, but continue to keep in-line
immobilization manually)
 Painless, full range of motion – have the patient actively flex
and rotate his/her neck with instructions to stop immediately
should pain or paraesthesia develop
 Absence of a distracting painful injury (eg. long bone extremity
fracture)
 Cervical spine X-rays NOT necessary
Can you clear the cervical spine
without performing any X-rays?

YES
Injury mechanism having the potential
for causing a C-spine injury

Immobilization

Altered mental status / intoxicated

No

Neurological deficit
No

Spinal pain or palpation tenderness

No

A distracting painful injury

No

Clearing of C-spine clinically

clear documentation A

Satisfactory

Off immobilization
declare C-spine is clear
How to clear the cervical spine if
patient has a painful, distracting
injury somewhere in the body?
 B

Presence of a painful distracting injury, patient is fully

conscious & alert, no symptom or sign referring to the
cervical spine
 Perform 3 views cervical spine X-rays
 Failure to visualize the entire C spine will mandate
additional studies eg. swimmer’s view or CT scan
 Make sure clinical examination is done & documented
 If negative, cervical spine cleared
Injury mechanism having the potential
for causing a C-spine injury

Immobilization

YES E
Altered mental
metal status
status/ /intoxicated
intoxicated
No
YES
Neurological deficit D
No

Spinal pain or palpation tenderness YES C

No
YES
A distracting painful injury B
No

Clearing of C-spine clinically

clear documentation A

Satisfactory

Off immobilization
declare C-spine is clear
 How to clear the cervical spine if
patient has pain on palpation of the
cervical spine?
 C

Patient is fully conscious & alert, complaining of neck pain or tenderness on

palpation
 3 views C spine X rays
 Axial CT at 3 mm intervals thru’ suspicious areas identified on these X rays
 If lower C spine not adequately visualized, consider
 Swimmer’s view
 Axial CT at 3 mm intervals through lower C spine with sagittal reconstruction
 If X-rays are normal, movement unrestricted and mild to moderate pain only,
there is no need to perform any further investigations
 For patient suspected to have significant c-spine injury, obtain flexion &
extension views:
 Voluntary & painless excursion must exceed 300
 C spine cleared if no abnormality found
 If voluntary, painless excursion does NOT exceed 30 0, neck collar is
replaced and repeat X-rays in 2 weeks
Injury mechanism having the potential
for causing a C-spine injury

Immobilization

YES E
Altered mental
metal status
status/ /intoxicated
intoxicated
No
YES
Neurological deficit D
No

Spinal pain or palpation tenderness YES C

No
YES
A distracting painful injury B
No

Clearing of C-spine clinically

clear documentation A

Satisfactory

Off immobilization
declare C-spine is clear
 D

Presence of neurological deficits compatible with a

spinal cord injury
 3 views X rays and supplemented by axial CT as
necessary
 MRI cervical spine
 Manage according to the injury
 High dose methylprednisolone started within 8 hours of
injury shown to improve outcome (30 mg/kg bolus,
followed by 5.4 mg/kg infusion over the next 23 hours)
Injury mechanism having the potential
for causing a C-spine injury

Immobilization

YES E
Altered metal status / intoxicated
No
YES
Neurological deficit D
No

Spinal pain or palpation tenderness YES C

No
YES
A distracting painful injury B
No

Clearing of C-spine clinically

clear documentation A

Satisfactory

Off immobilization
declare C-spine is clear
Injury mechanism having the potential
for causing a C-spine injury

Immobilization

YES E
Altered mental
metal status
status/ /intoxicated
intoxicated
No
YES
Neurological deficit D
No

Spinal pain or palpation tenderness YES C

No
YES
A distracting painful injury B
No

Clearing of C-spine clinically

clear documentation A

Satisfactory

Off immobilization
declare C-spine is clear
How to clear the cervical spine if
patient has altered mental status
that affects neuro assessment?

<24 hours
> 24 hours
 If mental status is expected to return
within 24 hours
a. Leave collar on and reassess when mental
status returns or at 24 hours (whichever is
earlier)
b. After patient regain consciousness
i. Consider flexion-extension cervical X-ray if
there are symptoms related to the neck despite
normal radiological examination
ii. If there is pain and muscle spasm, flexion-
extension cervical X-ray may be delayed for 2
weeks
If mental status is expected to return
within 24 hours
i. For MRI spine if neurological signs detected
ii. Cervical spine is cleared if no signs and
symptoms related to cervical spine
 Clearing the cervical spine in the
unconscious, intubated patient

Problems of the intubated, unconscious patient:

Unable to give history, unable to display symptoms
of pain, neurological deficit
Lateral C-spine not accurate to demonstrate soft
tissue shadows
Cannot perform open mouth view adequately
 Clearing the cervical spine in the
unconscious, intubated patient
 Incidence of unstable spinal injury in adult,
intubated patients is 10.2%
 Odontoid view is unreliable, miss up to 17% of
injuries to upper cervical spine
 If lateral + AP + CT C1/2 with sagittal
reconstruction, still does not rule out
ligamentous injury
Guidelines for clearing the c-spine in the
unconscious, intubated ICU patient
 Wide variation in methods after the initial
screening X-rays
 Aim for early clearance to avoid prolonged
immobilization
 > 24 hours - decubitus ulcers esp occiput
 Increased risk of DVT
 PWH ICU guidelines

Radiological assessment MUST include:

Lateral c-spine – the best quality lateral X-ray possible,
ideally demonstrating the base of occiput to upper
border of T1
Thin-cut (3 mm) CT of whole cervical spine with sagittal
reconstruction

NB. Lateral X-ray – if views inadequate, swimmer’s view or should

pull technique may be attempted
 PWH ICU guidelines

Notes:
If possible and time allows, should also get an AP
(+/−) odontoid peg
CT whole cervical spine – will rule out major bony
and ligamentous injuries. Emergency
management take priority over this investigation.
Keep cervical collar on in the meantime. Perform
CT within 48 hours post-injury to avoid
prolonged and unnecessary spinal
immobilization and pressure sores
 PWH ICU guidelines

C-spine is cleared and neck collar can be

removed when
 CT and X-rays seen by a specialist,
neurosurgeon or orthopaedic surgeon and
reported by a specialist radiologist to be
normal
 Further investigations should be decided by
specialist team looking after the spine
Cases
 Case 1
Male 38
Fall from height
R basal ganglia haematoma
Comminuted and displaced fracture of
C2. Anterior subluxation of C2 on C3
C7 pathology
Fracture C6 spimous process and L
lamina
Fracture C7 vertebral body and
bilateral lamina
T8 comminuted fracture
Burst fracture of L2 with retropulsed fragment
and narrowing of spinal canal
 Delayed or missed diagnosis

 Failure to suspect an injury to cervical spine

 Inadequate cervical spine radiology
 Incorrect interpretation of radiographs
 Case 2
14 year old boy
Hit by taxi
On arrival in PWH:
GCS 7/15 (E1V2M4)
Spontaneous breathing, RR 14/min, SPO2 100%
on 6L oxygen
HR 105/min
BP 140/90 mmHg
Bleeding L leg
You are the leader of the trauma team.
You received a call to Trauma Room 1
in A&E. What are you going to do?
 ABCs
A = intubation with manual in-line
immobilization
B = mechanical ventilation
C = compression bandage, 2 large bore
IV drips, blood for crossmatch, Hb,
coags, RFT, LFT etc
 Trauma Series
CXR: unremarkable
X-ray pelvis: fracture (L) superior pubic
ramus
X-ray lower limbs: fracture (L)
femur/tibia/fibula
C-spine series: lateral, AP, open mouth?
 LATERAL view

Abnormalities?
Is this an adequate film?
AP view
What else would you do?
The End