Clearing the cervical spine
Encyclopedia
Clearing the cervical spine is the process by which medical professionals determine whether cervical spine injuries exist. This process can take place in the emergency department
or take place in the field by appropriately trained EMS
personnel. The following is based on the NEXUS (National Emergency X-Radiography Utilization Study) criteria. There are other clinical criteria in common use, such as the Canadian C-spine rule.
Excluding a cervical spinal injury requires clinical judgement and training.
When a significant mechanism of injury is present, a cervical spine is determined to be stable if:
If the patient does not meet all the above criteria then they require a three view cervical x-ray series, adding a swimmer's view if the lateral doesn't include the C7/T1 interface. In those with degenerative disease of the cervical spine, a plain film series is often inadequate to assess for injury.
If the patient has a head injury with altered sensorium
, is intoxicated, or has been given potent analgesics, then the cervical spine must remain immobilised until the clinical examination becomes possible.
If the patient is not expected to be clinically evaluable within 48–72 hours because of severe head or multiple injuries, they should remain immobilized until a time when such an examination is possible. A 64-slice CT with reconstructions does not entirely rule out ligamentous injury leading to instability, but is a practical means of identifying the majority of C-spine injuries in obtunded patients. MR C-spine suffers from frequent false-positives, limiting its usefulness.
The indication for MR spine is a focal neurological deficit.
Senior neurosurgeons or orthopaedic surgeons manage any detected injury. Today, most large centers have Spine Surgery specialists, that have trained in this field after their Orthopedic or Neurosurgical residency.
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
or take place in the field by appropriately trained EMS
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
personnel. The following is based on the NEXUS (National Emergency X-Radiography Utilization Study) criteria. There are other clinical criteria in common use, such as the Canadian C-spine rule.
Excluding a cervical spinal injury requires clinical judgement and training.
When a significant mechanism of injury is present, a cervical spine is determined to be stable if:
- There is no posterior midline cervicalNeckThe neck is the part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk. The adjective signifying "of the neck" is cervical .-Boner anatomy: The cervical spine:The cervical portion of the human spine comprises seven boney...
tenderness - There is no evidence of intoxication
- The patient is alert and oriented to person, place, time, and event
- There is no focalFocalFocal may refer to:*Focal , an Irish lexicographical website*FOCAL **FOCAL-69**Focal *Focal Radio, a radio station based in Stoke-on-Trent, England-See also:*Focus...
neurological deficit (see focal neurological signs) - There are no painful distracting injuries (e.g., long bone fracture)
If the patient does not meet all the above criteria then they require a three view cervical x-ray series, adding a swimmer's view if the lateral doesn't include the C7/T1 interface. In those with degenerative disease of the cervical spine, a plain film series is often inadequate to assess for injury.
If the patient has a head injury with altered sensorium
Sensorium
The term sensorium refers to the sum of an organism's perception, the "seat of sensation" where it experiences and interprets the environments within which it lives. The term originally enters English from the Late Latin in the mid-17th century, from the stem sens-...
, is intoxicated, or has been given potent analgesics, then the cervical spine must remain immobilised until the clinical examination becomes possible.
If the patient is not expected to be clinically evaluable within 48–72 hours because of severe head or multiple injuries, they should remain immobilized until a time when such an examination is possible. A 64-slice CT with reconstructions does not entirely rule out ligamentous injury leading to instability, but is a practical means of identifying the majority of C-spine injuries in obtunded patients. MR C-spine suffers from frequent false-positives, limiting its usefulness.
The indication for MR spine is a focal neurological deficit.
Senior neurosurgeons or orthopaedic surgeons manage any detected injury. Today, most large centers have Spine Surgery specialists, that have trained in this field after their Orthopedic or Neurosurgical residency.