Clearing the cervical spine
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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. It is based on the NEXUS (National Emergency X-Radiography Utilization Study) criteria.
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 cervical tenderness
- There is no evidence of intoxication
- The patient is alert and oriented to person, place, time, and event
- There is no focal neurological deficit
- 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, and thoracolumbar AP and lateral plain films.
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 high resolution CT (1.5-2 mm slices) with sagittal reconstructions is not a viable alternative, since it does not rule out ligamentous injury leading to instability.
Neurological deficit referable to the spine may require an urgent MRI scan.
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.
[edit] References
- Morris CGT, McCoy E. Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening Anaesthesia, 2004, 59 pp 464–482
