Tag Archives: Cervical spine

General

How To: Flexion / Extension Views of the Cervical Spine

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Clearance of the cervical spine can often be done using clinical criteria alone (see this video at http://youtu.be/NhjF9kDOcjE). If this is not possible, a combination of radiologic and clinical evaluation is usually carried out. 

In some cases, radiographic studies (usually CT) are normal, but there is pain on clinical exam. Our next step is to send the patient to xray for flexion and extension views. This exam is performed by removing the collar while the patient is sitting, so the thoracic and lumbar spines must be clear before ordering this. The patient then gently flexes and extends the neck to their limits of comfort. Images are then obtained at the limits of flexion and extension. The premise is that a normal, awake patient cannot and will not move their neck beyond their comfort level to the point where they could cause themselves neurologic injury. 

It is very important that you look at the images yourself. The radiologist may review the images and will report that “there is no evidence of subluxation at the limits of flexion and extension.” But the patient may have barely moved their neck!

The question is: how much flexion and extension do you need to have to clear the spine?

The answer is not easy to find, and is buried in literature from the 1980s and 90s. According to the EAST guidelines, the ideal amount is 30 degrees from neutral for both flexion and extension. This is not always achievable in elderly patients, so in those cases you must use your judgment. Talk to the patient to find out if they stopped moving their neck forward or backward due to pain, or because they just can’t move it that far.

Trouble signs to look for are:

  • Subluxation of more that 2mm at any level
  • Angulation of more than 11 degrees

Any abnormality should prompt a spine consult.

If the study is not abnormal but the amount of flexion and/or extension is not adequate, there are two options. First, just leave the collar in place and try again in a week or so and try again. This will allow any soft tissue injuries to get better and may allow a successful repeat study. The alternative is a more costly and less well-tolerated MRI.

References:

  1. EAST Practice Guidelines, Identifying Cervical Spine Injuries Following Trauma – Update (2000).
  2. Defining radiographic criteria for flexion-extension studies of the cervical spine. Robert Knopp et al. Ann Emerg Med. 2001 Jul;38(1):31-5.
General

Inline Stabilization vs Inline Traction of the Cervical Spine

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Members of the trauma team must frequently protect the cervical spine when moving the patient or performing certain procedures. In most cases, a cervical collar is placed which does a fine job of this. Occasionally, though, the collar must be removed to provide access to areas near or under the collar.

When the collar is off, someone must be charged with immobilizing the cervical spine. Sometimes this is incorrectly referred to as providing inline traction and not inline stabilization.There is a big difference!

Inline traction is used to try to realign cervical vertebra that are malpositioned due to fracture or ligamentous injury. This should only be performed under the guidance of a neurosurgeon!

Inline stabilization merely means that the patient (or trauma professional) is restrained from moving the cervical spine. This is commonly needed while intubating the patient, so that the intubator does not extend the neck when trying to visualize the cords.

Why is this important? Check out the images below. If a severe injury has already occurred, traction on the neck may have devastating consequences! Inline stabilization is the only way to go.

Spine injury AO dissociation

General

Cervical Spine Clearance in Obtunded Patients

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Cervical spine clearance in obtunded trauma patients has always been controversial. Most physicians believe that evaluation of bones and ligaments is required, although there is a minority that say that the spine can be cleared purely by radiographs. This would greatly simplify the process and decrease costs.

A prospective study was presented at EAST in January that evaluated the use of CT alone to clear the c-spine in these patients. It was presented by Claridge et al from MetroHealth in Cleveland, and is an expansion of an earlier prospective they performed. Based on the original study, the protocol was revised and the results of this re-study was presented.

The study involved 197 patients who were victims of blunt trauma, obtunded, and were noted to move all extremities. Short term mortality was 13% and long term mortality was 27%, which shows how badly injured this group was. The average ISS was 23 and the initial GCS was 8.

The following radiographic criteria were used to diagnose a significant c-spine injury:

  • Fracture line extending on 2 consecutive CT slices
  • Marked prevertebral soft tissue swelling or hematoma
  • Malalignment not explained by degenerative changes
  • Abnormal facets or posterior malalignment on sagittal reconstruction
  • Occipital condyle injury involving the craniocervical junction

Followup was performed either by re-examination after awakening (62%), followup by phone or chart review (12%), or MRI for persistent c-spine pain (2%). Thirteen percent died before re-evaluation, and 11% were lost to followup.

Using this protocol, the average hospital day of clearance decreased from 7.5 to 3.3, the incidence of decubitus ulcer from the collar decreased from 5% to 0.5%, and the average length of stay decreased from 23 to 14 days. All of these results were statistically significant.

The authors recognized that long term followup was lacking in this study and there was the potential for missed injury. Power calculations show that there are not enough patients enrolled to give a statistically sound result. The issue of spinal cord injury without radiographic abnormality (SCIWORA) is always a possibility.

The bottom line: clearance based on radiographs alone is still not ready for prime time. Some injuries will ultimately be missed, and a fraction of those can cause devastating injury. The real question to be answered is “How many missed injuries is okay?” Until more and better work is done, some combination of radiographic and clinical techniques must be used.

Reference: A normal CT alone may clear the cervical spine in obtunded blunt trauma patients with gross extremity movement – a prospective evaluation of a revised protocol. Claridge et al, MetroHealth Medical Center. Presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 2010.

General

Nursing Policy: Cervical Spine Immobilization

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The following is a sample nursing policy for c-spine immobilization.

Purpose: 

To outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient. 

Policy: 

Application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. This will not be necessary for patients with all of the following:

  • no posterior midline cervical tenderness
  • no evidence of intoxication
  • normal level of alertness (GCS 15)
  • no focal neurological deficit
  • no painful distracting injuries
  1. The MD or RN will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
    * talk to the patient and tell them what you are doing- and not to move their head and neck
  2. Place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head. 
  3. Assistants will help with the rest of the application of the cervical collar and backboard. 
  4. Perform a baseline CMS assessment of the extremities. 
  5. Remove jewelry from the neck and ears. 
  6. Choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. This same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar. 
  7. Cervical collar is assembled by snapping the fastener into the hole on the side of the collar 
  8. Adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted) 
  9. Slide the back of the collar behind the right side of the neck until the Velcro tab is visible on the left side of the neck. 
  10. Slide the chin portion up the chest until the chin fits in the collar. 
  11. Secure the Velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment). 
  12. Place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. Patients already in bed will be log rolled and slider board inserted.
    * Do not obtain a rectal temperature while the patient is turned unless the MD specifically requests this.
  13. Recheck CMS. 
  14. The MD or RN can now remove hands from head. 
  15. Document both CMS checks and procedure in patient’s record.