Cervical spine clearance lecture given to 1st-year emergency medicine residents at Duke University. Covers indications for applying cervical collar, types of collars, types of imaging of the spine, and when to remove the collar.

1. Cervical Spine Clearance
in Trauma
Duke Emergency Medicine Residency, PGY1 Lecture Series
Joseph M Reardon, MD
with thanks to Sarah Crosby, MBBS; Hunter New England Health, New South Wales

2. Disclosure Statement
• I have no financial conflicts of interest to disclose.
Special Thanks
• Josh Broder
• Sam Francis
• Steve Barmach
• Steph Eucker

3. Case
• Jethrow Williams, farmer injured on Yates Store Road, 1943
• C-spine injury
• Brought to Duke Hospital (recently opened)

4. Original C-collar

5. Overview
• When to collar
• How to collar
• When to image
• When to take it off

6. Overview
• When to collar
• American Association of Neurological Surgeons Guidelines
• Current Evidence
• Clinical Practice
• How to collar
• When to image
• When to take it off
• Other spinal trauma

7. Overview
• When to collar
• American Association of Neurological Surgeons Guidelines
• Current Evidence
• Clinical Practice
• How to collar
• When to image
• When to take it off
• Other spinal trauma

8. When to collar - AANS
• “all trauma patients with a cervical spinal column
injury or with a mechanism of injury having the
potential to cause cervical spinal injury should be
immobilize
• “A combination of a rigid cervical collar and
supportive blocks on a backboard with straps is very
effective in limiting motion of the cervical spine and is
recommended”
AANS, 2001

9. When to collar - AANS
• “As many as 20% of
spinal column injuries
involve multiple non-
continuous vertebral
levels”
• Immobilize whole
spine if truly concerned
AANS, 2001

10. Overview
• When to collar
• American Association of Neurological Surgeons Guidelines
• Current Evidence
• Clinical Practice
• How to collar
• When to image
• When to take it off
• Other spinal trauma

11. When to collar – Current Evidence
• 2001: Fresno/Kings/Madera Protocol
• 99% sensitive
• 5 fractures missed: 1 adverse outcome
• All patients missed by the protocol were >67yo or <1yo
• 2005: University of Michigan EMS Protocol Study
• 92% sensitive
• 33 fractures missed; no adverse outcomes

12. When to collar – Current Evidence, contd
• 2010: Natl Trauma Data Bank Study
• Penetrating trauma pts with doubled risk of death if collared
• Mult sources of confounding
• 2011: EMJ
• Collaring on scene associated with critical scene delays

13. Overview
• When to collar
• American Association of Neurological Surgeons Guidelines
• Current Evidence
• Clinical Practice
• How to collar
• When to image
• When to take it off

14. When to Collar – Clinical Practice
• Durham County EMS Protocol:
• Immobilize spine by either long board, scoop board, or Kendrick extrication
device, based on paramedic’s assessment
• C-collar using portable Ambu c-collar device
• No need for spinal immobilization for isolated penetrating trauma

15. Overview
• When to collar
• How to collar
• Miami J
• Philadelphia
• Portable EMS Collar
• Lab!
• When to image
• When to take it off
• Other spinal trauma

16. Poll
• When do you use a Miami J versus Philly?
• 70mph rollover, GCS 6
• Penetrating injury to spine
• Fall from standing, 20y healthy male
• Fall from standing, 80y female with multiple myeloma and osteoporosis
• Resident of Fort Lauderdale
• Resident of Camden, New Jersey

17. How to collar – Miami J vs Philadelphia
• Miami J superior to Philadelphia in flexion, extension, rotation and
lateral tilt
• Philadelphia has not been rigorously studied in clinical trials although
subjectively more comfortable
• Cost:
• Miami J: Approx $300
• Philadelphia: Approx $150
• “But Doctor, do we really need to spend the extra money for an
uncomfortable collar?”
• Yes. Askins, Eismont, Spine 1997

18. How to collar – Miami J

19. How to collar: Philadelphia, Ambu
• Ambu: EMS Standard
• Philadelphia:
• Not currently evidence-supported.
• Soft collar:
• Use for patients with definite muscular (aka NON-traumatic) neck pain for
whom neck support will reduce pain medication requirements

20. Overview
• When to collar
• How to collar
• When to image
• American Association of Neurological Surgeons Guidelines
• Eastern Association for Surgery of Trauma Guidelines
• Current Evidence
• Clinical Practice
• When to take it off
• Other spinal trauma

21. When to Image - Guidelines
• AANS:
• “Radiographic assessment of the cervical spine is not recommended in
trauma patients who are awake, alert, and not intoxicated, who are without
neck pain or tenderness, and who do not have significant associated injuries
that detract from their general evaluation.”
• EAST:
• Same as AANS

22. Overview
• When to collar
• How to collar
• When to image
• NEXUS
• Canadian C-spine Rule
• Clinical Practice
• When to take it off

23. Poll
• When do you use Canadian C-spine rule vs NEXUS criteria?
• Canadian C-spine rule all the time
• NEXUS all the time
• Canadian only in foreigners
• None of the above, it’s simply too high risk. Scan them all.
• Gestalt

24. When to image - Evidence
• NEXUS

26. Clinical Clearance of the C-Spine in the Awake Patient
NEXUS
Sensitivity 90.7%
Specificity 36.8%
Radiography Rate 66.6%
CCR
Sensitivity 99.4%
Specificity 45.1%
Radiography Rate 55.9%
Stiell IG, et al. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma.
NEJM 2003;349:2510-2518
When to image - Evidence

27. When to Image: One perspective
• Patient obtunded or you are concerned  Image
• Borderline, pressed for time, rolling to the scanner (trauma surgeon
breathing down your neck)  NEXUS
• Less concerned, patient flunks NEXUS but you really don’t think they
have an injury  Canadian C-spine
• You’re a hotshot with an 8 GHz processor in your head  Canadian
every time

28. Overview
• When to collar
• How to collar
• When to image
• When to take it off
• Evidence
• Clinical Practice
• Other spinal trauma

29. Poll
• When do you use?
• X-ray c-spine?
• Flex/ex films?
• CT c-spine?
• MRI c-spine?
• Ultrasound?
• X-man vision?

30. C-collar Removal: Imaging
• The Primary screening modality is axial CT from
the occiput to T1 with sagittal and coronal
reconstructions (Level II)
• Plain radiographs contribute no additional
information and should not be obtained (Level II)
• If there is neurological deficit attributable to a c-
spine injury an MRI should be obtained

31. C-Collar Removal: Neck Pain with negative CT in
the neurologically intact patient
3 options (Level III)
1. Continue collar
2. Remove collar after negative MRI (<72h)
3. Remove collar after negative and adequate
flexion extension films
• Picks up c-spine instability in 6.75-8% of normal c-spine
films
• Incidence of isolated ligamentous injury is rare (0.6% of
traumatic c-spine injuries)

32. C-Collar Removal: Obtunded Trauma Patient with a
Negative CT C-Spine
EAST Recommendations 2009
• Flexion/Extension radiographs should NOT be performed
(Level II)
• The risk/benefit ratio of obtaining an MRI in addition to
CT is not clear (individualise to each institution) (Level III)
• Options are:
1. Continue cervical collar immobilisation until a clinical
examination can be performed
2. Remove the cervical collar on the basis of CT alone
3. Obtain an MRI and if negative the collar can be safely removed
(Level II)

33. ? MRI in addition to CT?
• Incidence of ligamentous injury with negative CT c-spine is very low
(<5%)
• Incidence of clinically significant injury is even lower (<1%)
• Difficult
• More sensitive for identification of soft tissue injuries (Gold standard
for spinal cord injury)
• Not reliable for identifying bony injury

34. Albrecht et al.
Evaluation of cervical spine in
intensive care patients following blunt
trauma. World J Surg 2001
150 Patients (150 obtunded)
Retrospective, blunt trauma ICU patients.
25% of patients with negative x-rays or CT C-spine had
extradural soft tissue or ligamentous injury on MRI
(only 1 required operative stabilisation)
Ghanta et al.
An analysis of Eastern Association for
the Surgery of Trauma Practice
guidelines for cervical spine evaluation
in a series of patients with multiple
imaging techniques. Am Surg. 2002
124 patients (51 obtunded)
Retrospective, trauma patients.
All had plain C-spine x-ray, CT and MRI.
19% of patients had injuries only evident on MRI
Horn et al.
Cervical magnetic resonance imaging
abnormalities not predictive of cervical
spine instability in traumatically injured
patients J. Neurosurg Spine
314 patients (22 obtunded)
Retrospective, c-spine MRI patients.
42% of patients with no injury detected on CT or C-ray
had abnormality detected on MRI.
No cervical instability detected on MRI that wasn’t evident
on CT or flexion/extension
Holmes et al.
Variability in computed tomography
and magnetic resonance imaging in
patients with cervical spine injuries.
J Trauma 2002
688 patients
Prospective multicenter study, blunt trauma patients.
MRI superior to CT for detection of cervical spine
ligamentous and cord injuries. CT was superior for
skeletal and facet joint injuries.

35. C-Collar Removal: SCIWORA
Significant Cord Injury without obvious radiological
abnormality
• Higher incidence in pediatric population (34.8%)
• The relatively large size of the head
• inherent skeletal mobility
• cord vulnerable to damage
• Higher incidence above 60 yo
• Posterior vertebral spurs due to spondylosis
• Ligamentum flavum bulging due to loss of disc height
• Risk of central cord syndrome after hyperextension injury

36. SCIWORA: The debate continues…
• 2010 Meta-analysis (1550 pts): 96 pts with negative CT who
underwent MRI had practice-altering findings (6.2%)
• Limitations: Retrospective, only included pts with high provider suspicion,
practice-altering does not equal clinically significant
• 2011 Meta-analysis (14,327 pts): Sensitivity of CT for unstable C-spine
fractures was >99.9%
• Limitations: Ignored stable fractures, heterogeneity of alternative modalities
• Conclusions: Imaging for SCIWORA after negative CT, in the absence of
compelling extenuating circumstances, is unnecessary
Schoenfeld, Bono, J Trauma 2010
Panczykowski, Tomcyz, J Neurosurg 2011

37. Overcoming SCIWORA
• Physical Exam (ATLS Secondary Survey©™®)
• Check multiple dermatomes, assess progression of GCS
• Strength & reflexes as proxies of upper motor neuron damage
• Consider rectal exam if any suspicion for spinal cord injury (as in
ATLS, not mandatory if there is very low suspicion of neurologic
injury)

38. Overview
• When to collar
• How to collar
• When to image
• When to take it off
• Evidence
• Clinical Practice
• Other spinal trauma

39. C-Collar Removal: Clinical Practice
• Persistent pain:
• No study has yet validated a method of risk-stratifying patients with
persistent pain and negative CT C-spine
• Seek your senior resident’s guidance.
• In setting of negative CT C-spine, we assess severity of pain. For mild pain (1-
2/10) that could be attributable to positioning and discomfort of the
immobilization, we generally clear the c-spine. Moderate or severe pain or
consultant concern necessitates MRI
• Obtunded patient:
• Do not remove collar – Defer to SICU
• Consider MRI if recommended by radiologist

40. Overview
• When to collar
• How to collar
• When to image
• When to take it off
• Other spinal trauma
• Evidence
• EAST Guidelines
• Clinical Practice

41. Thoracolumbar Spine Trauma
• 4.4% of trauma patients have TLS fracture
• 19-50% of these fractures are associated with spinal cord damage
• Higher incidence of neurologic deficit when fracture identification was
delayed (10.5% vs 1.4%)

42. Overview
• When to collar
• How to collar
• When to image
• When to take it off
• Other spinal trauma
• Evidence
• EAST Guidelines
• Clinical Practice

43. EAST Recommendations (2007)
• Level II Guidelines
• Trauma patients should be examined by a qualified attending physician
• Trauma surgeons, emergency physicians or spine surgeons (neurosurgery or
orthopaedics)
• Trauma patients who are awake, without any evidence of intoxication, with
normal mental status, neurologic and physical examinations may be cleared
clinically

44. Mode of Imaging of TLS
• Multidetector CT with axial reconstruction is superior to plain
films for screening of TLS for bony injury (II)
• CT scout films can be used for spine assessment (II)
• CT scan may be associated with less overall radiation exposure
than plain films (III)
• Plain films are adequate for the examination of the TLS if the
patient does not require CT scan for any other reason (III) (Not if
they have a major trauma mechanism)
• MRI is indicated for patients with neurologic deficits, abnormal
CT scans or clinical suspicion despite normal radiographic
evaluation suggesting an unstable injury (III)
• Early decompression of traumatic lesions improves outcome

45. Plain Film vs CT of TLS
• Ballock et al. (1992)
• plain radiography of the thoracolumbar spine would have missed
25% of fractures
• Gestring et al. (2002)- CT protocol for examining TLS
• Anterior, posterior and lateral scout films and axial images
• 100% sensitivity and specificity

46. Plain Film vs CT of TLS, contd
• Hauser et al. (2003)-prospective study 222 patients
• Plain radiography of the TL spine vs Helical CT (5mm images)
• CT scan accuracy 99% vs plain radiographs 87%
• CT could also differentiate acute vs old #
• Sheridan et al. (2003)
• Reformatted helical T (2.5mm images) vs plain x-ray
• Sensitivity for Thoracic #- CT 97% vs x-ray 62%
• Sensitivity for Lumbar #- CT 95% vs x-ray 86%

47. Obtunded Patient
• No level I evidence
• Level II
• Multidetector CT with axial reconstruction is superior to plain films for
screening of the TLS for bony injury

48. Overview
• When to collar
• How to collar
• When to image
• When to take it off
• Other spinal trauma
• Evidence
• EAST Guidelines
• Clinical Practice

49. TLS Spinal Trauma: Clinical Practice
• Concerning mechanism of injury and/or any thoracoabdominal injury
 pan-scan with T/L/S reformats
• Trauma Level One / Two / Three Orderset

51. Overview
• When to collar
• How to collar
• When to image
• When to take it off
• Other spinal trauma
• QUESTIONS