Outline your approach  to the initial and  subsequent  management  of the cervical spine after major trauma.

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College Answer

Management of patients with potential cervical spine injuries is still controversial, despite a number  of  major  groups  attempting to  provide  evidence  based  guidelines  (eg.  ATLS, Eastern Association for the Surgery of Trauma). Delayed clearance of the cervical spine can result in many potential problems, related to requirements for immobilisation as well as the cervical collar (eg. pressure areas, airway access, delayed mobilisation etc.).   Candidates often failed to discuss the “subsequent management” component.

Patients with major trauma are at increased risk of having associated spinal injuries (including those related to the cervical spine).  All patients should be treated as if they have cervical spine injuries (ie. appropriately immobilised) until further information is available. The conscious patient without distractors can be assessed and managed clinically (National Emergency  X-radiography Utilization  Study,  Hoffman  NEJM  2000),  but  the  scenario usually seen in ICU is one where one or more pre-conditions for clinical clearance are not met (eg. distracting injuries, or presence of intoxicants).   In this scenario the usual recommendation is three view cervical spine radiographs (AP, lateral and open mouth view) supplemented by high resolution CT (especially directed to suspicious areas).  Debate still surrounds the need for lateral fluoroscopic flexion/extension to decrease the injuries missed by plain films and CT (EAST J Trauma 1998, www.east.org, Morris BMJ 2004).

Routine MRI is problematic because of ferromagnetic compatibility.

Discussion

The issue of clearance of the C-spine in the unconscious patient is covered elsewhere. And in any case, that is not what the question is asking.

The key points the college wanted to see seem to have been pragmatic ones.

Some adjustments must be made to correct for the age of this question, and recent findings.

  • All trauma patients to be treated as potential C-spine trauma
  • C-spine collars and precautions should remain in situ until the C-spine is cleared
  • The C-spine in conscious patients should be cleared according to the NEXUS criteria
  • In unconscious patients, a normal CT excludes an overwjhelming majority of clinically significant ligamentous and bony injuries
  • Plain radiographs and flexion-extension views are no longer recommended
  • Routine MRI is not recommended
  • C-spine clearance should be prompt as there is a significant risk from pressure areas and increased intracranial pressure.

Thus, "subsequent management" should include the following:

  • Attention to pressure area care
  • Immobilisation of the C-spine for airway manipulation and patient mobility
  • Conversion to a comfortable collar
  • Attention to central venous access
  • Monitoring of ICP

References

The Alfred Spinal Clearance Protocol

 

Lien, D., T. Jacques, and K. Powell. "Cervical spine clearance in Australian intensive care units." Critical Care and Resuscitation 5.2 (2003): 91.

 

Cooper, D. J., and H. M. Ackland. "Clearing the cervical spine in unconscious head injured patients-the evidence." Critical Care and Resuscitation 7.3 (2005): 181.

 

Hennessy, Deirdre, et al. "Cervical spine clearance in obtunded blunt trauma patients: a prospective study." The Journal of Trauma and Acute Care Surgery68.3 (2010): 576-582.

 

Como, John J., et al. "Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?." Journal of Trauma-Injury, Infection, and Critical Care 63.3 (2007): 544-549.

 

Tran, Baotram, Jonathan M. Saxe, and Akpofure Peter Ekeh. "Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?." Journal of Surgical Research 184.1 (2013): 411-413.

 

Sierink, J. C., et al. "Systematic review of flexion/extension radiography of the cervical spine in trauma patients." European journal of radiology 82.6 (2013): 974-981.