The document outlines management guidelines and considerations for cervical spine injury clearance, emphasizing the importance of adequate radiographic evaluations and awareness of potential missed injuries. It discusses the etiology of missed injuries, the role of various imaging techniques, and the significance of clinical practice guidelines to reduce inappropriate care. Key takeaways include maintaining suspicion for cervical injuries in patients with persistent symptoms and understanding pediatric anatomical differences in injury assessments.

5. CLEARING THE CERVICAL SPINE THE 2002 ORTHOPAEDICS AND SPINE LECTURE SERIES

6. LECTURE OUTLINE “ CLINICAL CLEARANCE” - THE LATEST MANAGEMENT GUIDELINES ETIOLOGY OF MISSED CERVICAL SPINE INJURY THE QUESTIONS AND CONTROVERSIES - IS THERE A CONSENSUS?

7. LECTURE OUTLINE THE 3-VIEW RADIOGRAPH - A REVIEW OF THE APPROACH CERVICAL FRACTURES - NONSKELETAL INJURIES THE PEDIATRIC C-SPINE -- THE ANATOMIC DIFFERENCES CONCLUSION/PEARLS WHAT IS IT?

8. “ CLINICAL CLEARANCE” - THE LATEST ALERT, AWAKE, NO AMS NO NECK PAIN NO DISTRACTING INJURY NO NEURO DEFICITS NO MIDLINE C-SPINE TENDERNESS

9. THE NEXUS STUDY , NEJM 7/00 P ROSPECTIVE O BSERVATIONAL S TUDY - 34,000 P ATIENTS I DENTIFIED A LL B UT 8 O F 818 C SI 99% S ENSITIVE , N EGATIVE P REDICTIVE V ALUE 99.8% A PPLICATION O F T HIS D ECISION I NSTRUMENT W OULD H AVE D ECREASED O VERALL O RDERING O F X RAYS B Y 12.6% == 100,000 C -SPINE R ADIOGRAPHS I N T HE U.S. P ER Y EAR

10. MANAGEMENT GUIDELINES - WHY? CSI: 2-4% OF ALL TRAUMA PATIENTS CSI: MOST COMMONLY MISSED SEVERE INJURY RAMIFICATIONS OF MISSED OR DELAYED DIAGNOSIS = NEURO INJURY OF PROGRESSON OF INCOMPLETE ONE AS WELL AS MEDICOLEGAL

11. MANAGEMENT GUIDELINES - WHY? CLINICAL PRACTICE GUIDELINES ARE USED TO: “ REDUCE INAPPROPRIATE CARE, CONTROL GEOGRAPHIC VARIATIONS IN PRACTICE PATTERNS, AND MAKE MORE EFFECTIVE USE OF HEALTH CARE RESOURCES”

12. Classification of Scientific Evidence and Formulation of Recommendations

13. QUESTIONS & CONTROVERSIES WHO NEEDS XRAYS? WHAT VIEWS? XRAYS NEGATIVE BUT NECK PAIN PERSISTS ROLE OF FLEX/EXT, CT, MRI “ DISTRACTING INJURY”?? OBTUNDED PATIENT -- WHAT TO DO?

14. DISTRACTING INJURY?

15. IS THERE A CONSENSUS? ACR ATLS EAST VVMC

16. VVMC MANAGEMENT GUIDELINES

17. Awake & Alert Awake & Alert Altered Mental Status with Neurological deficit No neuro deficit Possible C-Spine Injury Immobilize 3 or 5 View C-Spine X – rays Abnormal Consult Spine/Ortho Service Continue hard collar Cervical spine CT and/or MRI Traction /Alignment per Spine/Ortho. Service Normal

18. Awake & Alert No neuro deficit Significant Neck Pain CT Cervical Spine Positive Negative Consult Spine/Ortho Service C-spine Cleared C-spine Cleared Flexion Extension Films No neck pain or tenderness with full range of motion Positive Negative Consult Spine/Ortho Service Normal C-Spine X-rays

19. Consult Spine/Ortho Service Continue hard collar CT or MRI C-Spine Awake & Alert With neurological deficit Normal C-Spine X-rays

20. Continue hard collar If patient becomes awake and cooperative proceed with Awake & Alert Guidelines If patient remains uncooperative obtain cervical spine CT scan Positive Negative Consult Spine Ortho C-spine Cleared when Awake & Alert Normal C-Spine X-rays Altered Mental Status

21. HOW IS A C-SPINE INJURY MISSED??? INADEQUATE CERVICAL SPINE SERIES MISINTERPRETATION OF STANDARD XRAY FILMS LACK OF APPROPRIATE INDEX OF SUSPICION

22. 32,000 PTS, 740 CSI - 34 PTS (4.6%) MISSED OR DELAYED “ MISSED” = IF PT DISCHARGED AND DX MADE IN F/U “ DELAY” = IF SPINAL PRECAUTIONS REMOVED, YET CSI DISCOVERED PRIOR TO DISCHARGE “ THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS” - J. O F T RUAMA , 1993

23. “ THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS” - J. O F T RUAMA , 1993

24. “ THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS” - J. O F T RUAMA , 1993

25. “ THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS” - J. O F T RUAMA , 1993

26. “ THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS” - J. O F T RUAMA , 1993 CONCLUSION: 94% OF THE ERRORS LEADING TO A MISSED/DELAYED DX OF CSI WERE FUNDAMENTAL – 1. FAILURE TO OBTAIN CLINICALLY ADEQUATE 3-VIEW 2. MISINTERPRETATION OF XRAYS

27. 3-VIEW RADIOGRAPH: AP, LATERAL, ODONTOID COMBINATION OF AP AND ODONTOID WITH LATERAL INCREASES SENSITIVITY FROM 85% TO 92% 3-VIEW PLUS CT WITH SAGITTAL RECONSTRUCTION THROUGH SUSPICIOUS AREAS == FALSE NEGATIVE OF .1% IF TECHNICALLY ADEQUATE AND PROPERLY INTERPRETED

28. THE X-TABLE LATERAL THE UNDISPUTED MAINSTAY OF THE CERVICAL SPINE SERIES 85% SENSITIVITY NEGATIVE PREDICTIVE VALUE: .97 -- BUT NOT SUFFICIENT TO BE ONLY SCREENING STUDY

29. THE X-TABLE LATERAL TO BE ADEQUATE: OCCIPUT ALL 7 VERTEBRAE SUP. ENDPLATE OF T1

30. ABC’S OF THE LATERAL XRAY A: ALIGNMENT B: BONY C: CARTILAGE S: SOFT TISSUE

31. LATERAL C-SPINE: A-ALIGNMENT

32. ANTERIOR SPINAL LINE

33. POSTERIOR SPINAL LINE

34. SPINOLAMINAR LINE

35. LATERAL C-SPINE: CLIVUS LINE AKA “ BASILAR LINE OF WACKENHEIM ” MEANS OF VERIFYING ATLANTO-OCCIPITAL RELATIONSHIP SHOULD INTERSECT POST. 1/3 OF DENS OR LIE TANGENT TO POST. CORTEX BASION-DENTAL INTERVAL > 1.2 CM = ATLANTO-OCCIPITAL DISSOCIATION

36. #13, P. 6 FIG 2

38. LATERAL C-SPINE: B-BONY ASSESS FOR: VERTEBRAL BODY CONTOUR AND AXIAL HEIGHT LATERAL BONY MASS -PEDICLES, FACETS, LAMINA, TP SPINOUS PROCESS

39. #28 FIG 2-36 -

43. ASSESS FOR: INTERVERTEBRAL DISC FACET JOINTS LATERAL C-SPINE: C-CARTILAGE

44. LATERAL C-SPINE: S-SOFT TISSUE ASSESS FOR: PREVERTEBRAL SPACE PREVERTEBRAL FAT STRIPE SPACE BETWEEN SPINOUS PROCESSES

46. FLEXION TEARDROP FRACTURE POSTERIOR SPINAL LINE PREVERTEBRAL SWELLING SPINOUS PROCESS WIDENING

47. AP XRAY ASSESS FOR: ALIGNMENT SYMMETRY OF PEDICLES CONTOUR OF BODIES HEIGHT OF DISC SPACES CENTRAL POSITION OF SPINOUS PROCESSES

48. AP XRAY FACET JOINTS ORIENTED AT 45 DEGREE ANGLE FROM CORONAL PLANE -- THUS NOT SEEN ON AP IF FACET IS CLEARLY IDENTIFIED ON AP, ARTICULAR PILLAR OR PEDICLE FX WITH ROTATION IS LIKELY

50. AP XRAY - OTHER FINDINGS AIR COLUMN TRANSVERSE PROCESSES DISPLACED SPINOUS PROCESS FRACTURE MAY GIVE APPEARANCE OF “DOUBLE SPINOUS PROCESS” ABRUPT SIDE-TO-SIDE DISPLACEMENT OF SP CAN INDICATE UNILATERAL FACET SUBLUXATION/DISLOCATION

51. ODONTOID FILM ATLAS, ODONTOID, SUPERIOR FACETS OF AXIS ATLAS-AXIS RELATIONSHIP == JEFFERSON FX, C1-2 ROTATORY SUBLUXATION, ODONTOID FRACTURES

53. WHAT IS IT?

58. WHAT IS IT?

62. WHAT IS IT?

69. NONSKELETAL INJURIES - MUST CONSIDER IN “CLEARANCE” LIGAMENTOUS INSTABILITY SCIWORA CENTRAL CORD INJURY

70. Panjabi and White : Dx of Clinical Instability in the Lower Cervical Spine Anterior elements Destroyed or Unable to Function 2 Posterior Elements Destroyed of Unable to Function 2 Relative Sagittal Plane Translation > 3.5mm 2 Relative Sagittal Plane Rotation > 11deg 2 Positive Stretch Test 2 Medullary (Cord) Damage 2 Root Damage 1 Abnormal Disc Narrowing 1 Dangerous Loading Anticipated 1 TOTAL OF 5 OR MORE = UNSTABLE

71. SCIWORA : spinal cord injury without radiographic abnormality DEFINED BY PANG AND WILBERGER, 1982: “ Objective Signs Of Myelopathy As A Result Of Trauma With No Evidence Of Fracture Or Ligamentous Instability On Plain Xray And Tomography ” FINDING OF FRACTURE, SUBLUXATION, OR ABNORMAL INTERSEGMENTAL MOTION AT LEVEL OF NEUROLOGICAL INJURY EXCLUDES SCIWORA AS A DIAGNOSIS

72. SCIWORA EXPERIMENTALLY, OSTEOCARTILAGINOUS STRUCTURES IN SPINAL COLUMN CAN STRETCH 2 INCHES WITHOUT DISRUPTION -- SPINAL CORD RUPTURES AFTER 1/4 INCH ANATOMICALLY, CERVICAL SPINAL CORD IS RELATIVELY TETHERED - SPINAL NERVES, DURAL ATTACHMENT TO FORAMEN MAGNUM, AND BRACHIAL PLEXUS

73. SCIWORA: LATENT PERIOD PANG AND WILBERGER: 13 OF 24 CHILDREN WITH SCIWORA WITH LATENT PERIOD OF 30 MIN TO 4 DAYS (MEAN 1.2 DAYS) BEFORE ONSET OF OBJECTIVE SENSORIMOTOR DEFICITS ALL 13 HAD TRANSIENT SUBJECTIVE COMPLAINTS AT TIME OF INITIAL TRAUMA THAT CLEARED WITHIN 1 HOUR OTHER STUDIES: 22%, 23%, AND 27% INCIDENCE OF SAME

74. SCIWORA PRESENTING NEURO EXAM CORRELATES TO OUTCOME MRI FINDINGS (OR LACK OF) MAY BE MORE PREDICTIVE OF OUTCOME NO CHILD HAS BEEN DOCUMENTED TO DEVELOP SPINAL INSTABILITY AFTER DX OF SCIWORA

75. SCIWORA - TREATMENT NO CONSENSUS: BUT HARD COLLAR IMMOBILIZATION FOR 12 WEEKS AND AVOIDANCE OF FLEX/EXT ACTIVITIES FOR ANOTHER 12 WEEKS HAS NOT BEEN ASSOCIATED WITH RECURRENT INJURY

76. MYELOPATHY PATHOPHYSIOLOGY -- CORRELATIVE ANATOMY THE SPINAL CANAL: WHAT IS THE SHAPE? PREPATHOLOGY FOR MYELOPATHY TO EXIST HOW DOES THE DEGENERATIVE CASCADE CAUSE STENOSIS?

78. MYELOPATHY -- SPINAL CANAL MEASURMENTS CRITICAL DIAMETER = 13 MM VEIDLINGER PAPER TORG RATIO KINETIC ASPECTS OF COMPRESSION

81. MYELOPATHY: Physical “ LONG TRACT SIGNS” DTRS BABINSKI AND CLONUS INVERTED RADIAL REFLEX HOFFMAN’S L’HERMITTES SIGN

82. PEDIATRICS: A BRIEF OVERVIEW OF THE ANATOMIC DIFFERENCES CSI IS RARE IN CHILDREN: 1% OF ALL PEDS FRACTURES AND 2% OF ALL SPINE FRACTURES BY AGE 8-10 , NO ANATOMICAL OR BIOMECHANICAL DIFFERENCES PEDS < 10 Y.O. ARE FUNDAMENTALLY DIFFERENT DUE TO ANATOMICAL VARIATIONS OF THE DEVELOPING SPINE, AND TO A LESSER EXTENT, THE DIFFERENCES IN MECHANISMS OF INJURY

83. PEDS ANATOMY AND BIOMECHANICS INHERENTLY MORE MOBILE: GENERALIZED LAXITY OF INTERSPINOUS LIGAMENTS AND JOINT CAPSULES THICK CARTILAGINOUS ENDPLATES INCOMPLETE VERTEBRAL OSSIFICATION (WEDGE-SHAPED VERTEBRAL BODIES) SHALLOW ANGLED FACET JOINTS, ESPECIALLY B/W OCCIPUT AND C4 HEAD DISPROPORTIONATELY LARGE

85. INITIAL PEDIATRIC EVALUATION CLINICAL EVALUATION HAMPERED MECHANISMS OF INJURY = RISK FACTORS MOST RELIABLE SIGNS OF CSI IN PEDS ARE NECK PAIN, GUARDING, TORTICOLLIS

86. PEDIATRIC ANATOMIC VARIANTS - NOT TRAUMATIC INJURY PSEUDOSUBLUXATION PERSISTENT SYNCHONDROSES ANTERIOR ANGULATION OF DENS FOCAL KYPHOSIS OF MID-CERVICAL SPINE DIFFERENT SOFT TISSUE MEASUREMENTS

89. PSEUDOSUBLUXATION

90. PEDIATRIC C-SPINE CLEARANCE CLINICAL CLEARANCE IF: AWAKE, ALERT, COOPERATIVE NO SIGNS OF CERVICAL INJURY MECHANISM NOT CONSISTENT WITH CERVICAL TRAUMA

91. PEDIATRIC C-SPINE CLEARANCE: OBTUNDED 5 VIEW PLUS CT OF THE AXIAL REGION FROM OCCIPUT TO C2 PREPONDERANCE OF INJURIES OCCUR FROM OCCIPUT TO C2 IN KIDS < 8 Y.O. TECHNICALLY DIFFICULT REGION TO IMAGE WITH PLAIN RADIOGRAPHS MRI = STUDY OF CHOICE TO EVALUATE CORD AND SOFT TISSUE STRUCTURES

92. CONCLUSIONS/PEARLS 1-5% OF CSI ARE MISSED - MAINTAIN APPROPRIATE LEVEL OF SUSPICION IF SEEING A PATIENT WITH CONTINUED NECK PAIN AFTER BEING “ CLEARED ” -- KNOW THE BASIC MANAGEMENT GUIDELINES FOR CLEARING THE C-SPINE

93. CONCLUSIONS/PEARLS MISSED/DELAYED CSI OCCURS DUE TO LACK OF AN APPROPRIATE INDEX OF SUSPICION, INADEQUATE PLAIN FILMS, AND MISREAD STUDIES

94. CONCLUSIONS/PEARLS IF HAVE HIGH ENOUGH INDEX OF SUSPICION TO GET XRAYS, THEN DO NOT ACCEPT INADEQUATE ONES

95. CONCLUSIONS/PEARLS IN “CLEARING” THE C-SPINE, DO NOT FORGET NONSKELETAL INJURIES: LIGAMENTOUS INSTABILITY, CERVICAL STENOSIS, AND SCIOWRA

96. CONCLUSIONS/PEARLS KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS

97. CONCLUSIONS/PEARLS DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE - CAN ALWAYS LEAVE IN A HARD COLLAR

99. Thank You!