Outline and justify your approach to “clearing” the cervical spine in an adult multi-trauma patient with a severe closed head injury.
This is a controversial area with no consensus. Aim is to test understanding of literature on cervical spine injury, sensitivity and limitations of imaging, risk Vs benefits, understanding of institutional protocols and systems issues. A well reasoned and an appropriate approach would score high marks.
A suggested approach is
1. Detailed history and clinical exam with review of mechanism of injury, speed, other injuries
2. 3 view (AP, lateral and peg view) or 5 view( 3 + right and left obliques) cervical spine with focussed CT to missed areas or CT scan of neck from base of skull to upper thoracic vertebrae with reconstructions.
3. If CT scan normal after interpretation by specialist radiologist and ortho spine/neurosurgeon/ICU specialist then neck is “clear”.
4. MRI if clinically suspected spinal neurological injury or abnormal CT scan or very high risk cord injury ( high speed, ejection from vehicle, high ISS)
5. Transfer to specialised trauma centre.
1. 5-10 % of patients with a severe head injury have an associated unstable cervical fracture.
2. Clinical clearance not possible here.
3. Maintaining cervical/spinal immobility via a cervical collar until clinical clearance increases the risk of pressure areas, pneumonia and raised intracranial pressure.
4. 3 and 5 view cervical X rays are frequently of inadequate quality and detect 75-
90% of unstable injuries even when of adequate quality and correctly interpreted.
5. Multislice CT scan from the base of skull to upper thoracic spine with sagittal and coronal reconstructions will detect most injuries. It may miss an unstable ligamentous injury without bone fracture (risk 1/1000). It is convenient to image the neck at the same time as the CT brain scan or other CT scans
6. MRI will detect spinal cord and soft tissue pathology such as ligamentous injury, spinal cord injury and epidural haematoma.
• Role of flexion extension views
• Requirements for clinical clearance
• Timing of clearing cervical spine Vs attending to other life threatening injuries
• Institutional Protocols
Details regarding the clearance of the C-spine in the unconscious patient are discussed elsewhere.The rules seem to have changed somewhat since this answer was written, and these days we dont tend to ask for flexion-extsnion views and lateral C-spine Xrays very often.
In short, the algorithm one should follow ought to resemble the excellent Alfred algorithm, which incorporates evidence from the post-CT era. Remember that many of the early studies were done on CT scanners with 2.5mm slices, or thicker - these days the resolution is substantially better than that.
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.