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Clinical Hub,References,Level I Adult Trauma Center Manual,Spine

Cervical, Thoracic and Lumbar Spine Clearance

Cervical, Thoracic and Lumbar Spine Clearance - Clinical Hub, References, Level I Adult Trauma Center Manual, Spine

Focus

Objective

  1. To define patients in which evaluation of the spine must be undertaken.
  2. To define early intervention of spine injuries and prevent neurologic deterioration

Defintions

Stable Spine injury: Those injuries not associated with a neurologic deficit and not at risk for development of neurologic deficit and not prone to late collapse.

Unstable spine injury: Any fracture pattern associated with a neurologic deficit and those that are prone to develop a neurologic deficit or those prone to late collapse (e.g., fracture subluxation and dislocation, severe burst fractures). 

Screening radiologic studies:

Guideline

** Prior to any clinical decision making a final interpretation of the CT scan by the attending radiologist must be obtained. 

  1. In -Hospital spine immobilization will include flat, supine, positioning and cervical collar placement with further work up/evaluation *(see algorithm). Patients who are high aspiration risk or who will require cervical spine immobilization after the initial assessment period will be placed in a reverse Trendelenburg position at 30 degrees.
  2. Removal of spine immobilization:
    1. Cervical Collars:
      1. Cervical collars should be removed as soon as feasible, as long as the criteria listed in the algorithm are met (See algorithm).
      2. Backboards: Backboard should be removed as soon as feasible
    2. In the patient with penetrating trauma without concomitant blunt trauma mechanism:
      1. Immobilization in a cervical collar is not necessary unless the trajectory suggests direct injury to the spine.
      2. Immobilization in spinal precautions is not necessary unless the trajectory suggests direct injury to the spine.
    3. In awake, alert, communicating trauma patients without evidence of alcohol/drugs, neurologic deficits, distracting injuries:
      1. Examination of cervical spine should be performed for neck pain, tenderness or paresthesia’s with full range of motion of the cervical spine
        1. If at any time the exam is positive for findings, the exam should end, the collar should be replaced, and the patient should have a radiographic evaluation.
        2. If negative, cervical spine imaging is not necessary and the cervical collar may be removed.
    4. All other patients in whom cervical spine injury is suspected must have radiographic evaluation. This applies to patients with pain or tenderness, patients with neurologic deficit, patients with altered mental status, and patients with distracting injuries.
      1. The primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions.
      2. Plain radiographs contribute no additional information and should not be obtained for screening.
      3. If CT of the cervical spine demonstrates injury:
        1. Obtain spine consultation
      4. If there is neurologic deficit attributable to a cervical spine injury or an unexplained neurologic deficit:
        1. Obtain spine consultation
        2. Obtain MRI if possible, if MRI not possible, utilize CT C-spine images as above.
      5. For the neurologically intact awake and alert patient complaining of neck pain with a negative CT, options include:
        1. Continue cervical collar
        2. Cervical collar may be removed after MRI or CT
        3. Cervical collar may be removed after negative and adequate Flexion/extension films, determined by spine consult team.
      6. For the obtunded patient with a negative CT and gross motor function of all extremities, options include:
        1. Flexion/extension radiography should NOT be performed
        2. Cerviccal collar may be removed after negative MRI or CT
        3. If MRI is not obtainable, remove the cervical collar on the basis of a negative CT alone.
  3. Level of radiology physician interpretation required for clearance of spine:
    1. Patients with neurologic deficits should maintain spinal precautions regardless of negative CT findings and have spine consultation
    2. Patients with neurologic deficits who have negative MRI findings with final attending radiologist interpretation should have spinal clearance in conjunction with spine consultation.
      1. CT cervical spine – Final attending radiologist interpretation.
      2. CT thoracic/lumbar spine- final attending radiologist interpretation
  4. Beware of ileus in patients with Thoracic and lumbar spinal fractures.