Question 14

Last updated 19/04/2022 - 02:19
 Topic: Trauma, Burns, Drowning
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With respect to management of the cervical spine in an intubated ICU patient who has suffered a multi- trauma:

a)    What are the advantages and disadvantages of radiological clearance of the cervical spine with MRI compared to CT?    (40% marks)

b)    List the complications of prolonged immobilisation when spinal precautions are used for a suspected cervical-spine injury.    (60% marks)

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College answer

Not available.

Discussion

Modality Advantages Disadvantages
CT
  • Ligamentous injuries could have clinically significant consequences, and these may be missed
  • Only gives limited information about the disc
  •  
MRI
  • Highly sensitive for injured soft tissue structure and spinal cord injury
  • Gold standard for the evaluation of spinal cord trauma
  • No radiation exposure is required
  • May be necessary for surgical planning
  • Loses its sensitivity for ligamenous injury over the first week 9as the oedema diminishes)
  • High false positive rate (as high as 40% in some studies)
  • Availability of MRI, particularly MRI set up to accept intubated patients, is lower than CT
  • May not be possible if the patient has had interventions which have resulted in MRI-incompatible implants
  • Waiting for the MRI may prolong the period of C-spine immobilisation unnecessarily

Complications of prolonged C-spine immobilisation from a 2004 review by Morris and McCoy

  • Pressure areas under the collar
    • Source of sepsis
    • Need for skin grafts
    • Increased hospital stay
  • Increased intracranial pressure
  • Airway is made more difficult by in-line stabilisation
  • Central venous access is made more difficult (IJ is out of bounds)
  • Oral care is made more difficult, increasing the risk of VAP
  • Nutrition is affected:
    • Gastroparesis and ileus results from prolonged immobility
    • Aspiration risk is increased by supine position
  • Physiotherapy is delayed or impossible
  • A greater risk of DVT/PE results from prolonged immobility
  • A minimum of 4 nursing staff are required to turn the patient.

References

The Alfred Spinal Clearance Protocol

Chapter 78 (pp. 795) Spinal injuries by Sumesh Arora and Oliver J Flower

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.

Patel, Mayur B., et al. "Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma." Journal of Trauma and Acute Care Surgery 78.2 (2015): 430-441.

Morris, C. G. T., and E. McCoy. "Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening." Anaesthesia 59.5 (2004): 464-482.

Richards, Paula J. "Cervical spine clearance: a review." Injury 36.2 (2005): 248-269.

Hoffman, Jerome R., et al. "Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma." New England Journal of Medicine 343.2 (2000): 94-99.

Stiell, Ian G., et al. "The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma." New England Journal of Medicine 349.26 (2003): 2510-2518.

Stiell, Ian G., et al. "The Canadian C-spine rule for radiography in alert and stable trauma patients." Jama 286.15 (2001): 1841-1848.

Jo, Alexandria S., et al. "Essentials of spine trauma imaging: radiographs, CT, and MRI." Seminars in Ultrasound, CT and MRI. Vol. 39. No. 6. WB Saunders, 2018.

Malhotra, Ajay, et al. "Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT." European radiology 28.7 (2018): 2823-2829.

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