There is a lot of angst out there among trauma professionals when it comes to clearing the cervical spine and possible distracting injuries. I’ve written about this before, and the most important technique I use is to try to see if the patient is aware of pain in areas distant from the suspected distraction.
A recent prospective study looked at injury patterns and c-spine clearance in over 9,000 trauma patients at a single Level I trauma center. Of those, 101 were evaluable (not intoxicated, no head injury) and actually had a cervical fracture. 96% of them were symptomatic, despite the majority having what would normally be considered a distracting injury (87%). Of the 4 who did not have pain or tenderness on examination of the neck, every one of them had a distraction.
There was a pattern as to which “distracting” injuries were really a distraction. All four of the asymptomatic patients had bruising or tenderness to the upper anterior chest, which diverted their attention away from their neck. Other injuries caused pain in some of these patients, but it was outweighed by the chest wall pain.
Bottom line: Distracting injury is currently defined too liberally, which results in lots of patients getting lots of unneeded cervical spine imaging. Although this study is small, it adds one more piece of information to the c-spine clearance puzzle. I personally will add this to my current practice and clear the cervical spine if:
- The patient is aware of multiple sources of pain
- Subjective pain scale overall is less than 6 (otherwise provide better pain control!)
- There is no pain/tenderness/injury to the upper chest
Reference: The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma 71(3):528-532, 2011.
Algorithm For Clearing the Pediatric Cervical Spine
I previously wrote about a straightforward way to clear the cervical spine in children. Click here to see the article. Alfred I. DuPont Children’s Hospital has condensed their clearance technique into a relatively simple algorithm that can be used in conjunction with my previous tips.
Some notes on this algorithm:
- Can be performed only by attending physicians or a trauma resident in consultation with the attending trauma surgeon
- Clinical clearance alone may be carried out in select cases
- If radiographs are required, cross-table lateral, anterior/posterior, and odontoid views should be obtained (age 8 and above, non-intubated)
- Flexion / extension views should only be ordered in consultation with neurosurgery
Download a print version of the protocol here
Related post: How Do I Clear The Pediatric Cervical Spine?
Image and protocol courtesy of the Alfred I DuPont Children’s Hospital
Eight months ago I blogged about inline stabilization vs inline traction of the cervical spine. Click here to read the post. A reader recently asked what the optimal method for inline stabilization is.
We’ve been pondering this question for nearly 30 years. In 1983, trauma surgeons at UCLA looked at a number of devices available at that time and tested them on normal volunteers. They measured neck motion to see which was “best."
Here’s what they found:
- Soft collar – In general, this decreased rotation by 8 degrees but insignificantly protected against flexion and extension. Basically, this keeps your neck warm and little else.
- Hard collars – A variety of collars available in that era were tested. They all allowed about 8% flexion, 18% lateral movement, and 2% rotation. The Philadelphia collar allowed the least extension.
- Sandbags and tape – Surprisingly, this was the best. It allowed no flexion and only a few percent movement in any other direction.
The Mayo clinic compared four specific hard collars in 2007 (Miami J, Miami J with Occian back, Aspen, Philadelphia). They found that the Miami J and Philadelphia collars reduced neck movement the best. The Miami J with or without the Occian back provided the best relief from pressure. The Aspen allowed more movement in all axes.
And finally, the halo vest is the gold standard. These tend to be used rarely and in very special circumstances.
- For EMS: Rigid collar per your protocol is the standard. In a pinch you can use good old tape and sandbags with excellent results.
- For physicians: The Miami J provides the most limitation of movement. If the collar will be needed for more than a short time, consider the well-padded Occian back Miami J (see below).
- Efficacy of cervical spine immobilization methods. J Trauma 23(6):461-465, 1983.
- Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. J Trauma 63(5):1120, 1126, 2007.
So far, I’ve posted more than 200 items during the past year and a half. There’s a lot of good stuff in the archives, and I am going to periodically provide a list of links to them so they are not forgotten. To see a full index of the archive by subject, click here.
Today, I’m going to focus on cervical spine imaging. Here are four interesting posts from the archives:
As always, I welcome suggestions for new posts!
The number of motorcyclists has been increasing over the past decade. At the same time, the number of states repealing their helmet laws is increasing. The evidence is convincing that the number and severity of brain injuries is decreased with helmet use. But what about spine injury?
Many arguments against wearing helmets given by riders are derived from a report in 1986 by Goldstein*. One of the issues cited in this paper is the potential increase in cervical spine injuries due to the weight of the helmet. A recently published study using the National Trauma Data Bank (NTDB) corroborates several smaller studies which show that this just isn’t so.
All motorcycle collisions in the NTDB involving adults were analyzed by logistic regression. Missing data was compensated for using standard statistical techniques. Nearly 41,000 cases had complete records for analysis. About 77% of riders were wearing helmets, and the overall mortality was 4%.
Nonhelmeted riders suffered the following statistically significant differences:
- A higher proportion of severe head injury (19% vs 9% with helmets)
- Higher incidence of shock on admission (6% vs 5% with helmets)
- Higher injury severity score (ISS) (14.7 vs 13.4 with helmets)
- Higher crude mortality (6.2% vs 3.5% with helmets)
- Higher incidence of cervical spine injury (5.4% vs 3.5% with helmets)
Bottom line: Motorcyclists wearing helmets had a 22% reduction in the likelihood they would sustain a cervical spine injury in a crash. This is in addition to decreases in shock, injury severity and death. These data need to be considered when the future of helmet laws is considered in any state looking at repealing them.
- Motorcycle helmets associated with lower risk of cervical spine injury: debunking the myth. J Amer Col Surgeons 212(3):295-300, 2011.
- *The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injury. Evaluation Rev 10:355-375, 1986.