A presentation given in the AOTrauma Regional Advances in Fracture Management Course, Dubai, October 19, 2010

1. Spine “Clearance” in Trauma
Sohail Bajammal
Makkah, Saudi Arabia
Acknowledgement: M Harris & W Taha

2. Recent Trauma
• 56 y/o F, restrained MVC
• Hard collar and board
• Intubated in the field
• No neuro exam
• Open ankle #
• BB Forearm #
• Closed head injury
• Chest contusion
L R

3. She is expected to be intubated for 3 weeks.
What would you do to clear her cervical spine?
1. Keep the hard collar
2. Remove the hard collar
3. Put a soft collar
4. Do floroscopy flexion/extension
5. Order MRI
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4. Spine “Clearance” in Trauma
Sohail Bajammal
Makkah, Saudi Arabia

5. Spine “Protection” in Trauma

6. Learning Outcomes
• When to suspect spine injury
• Initial assessment of spine in trauma patient
• Radiological assessment of spine in trauma
• How to clear spine
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7. At least 5% of patients with
spinal cord injuries
worsen neurologically
at the hospital
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8. Primum non nocere
“Do No Harm”
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9. Every trauma patient
has cervical spine injury
until proven otherwise
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10. Protection is priority
Detection is secondary
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11. When should you suspect
spine fracture?
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12. When should you suspect
spine fracture?
• Mechanism of injury
• Unconscious/obtunded patient
• Neurological deficit
• Spine pain/tenderness
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13. How to protect the spine?
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14. Kid on an Adult Board?
Sohail Bajammal

15. Protecting the Spine
• Cervical spine: Stiffneck Hard Collar
• Thoracolumbar spine: Log rolling
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16. Spine Board for Transfer
Remove spine board ASAP
Log roll until spine is cleared
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17. 17

18. Stiffneck Hard Collar
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✔ ✗

19. Protection is priority
Detection is secondary
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20. Categorizing Patients
• Level of consciousness
• Conditions masking cervical injuries:
• Intoxication
• Distracting injuries:
• Major injury above the shoulder
• Pelvic fracture
• Long bone or periarticular fracture
• Thoracolumbar spine injury
• Severe soft-tissue injury
• Major visceral cavity injury
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21. Trauma Patient
1. Asymptomatic 2. Symptomatic
3. Temporarily
4. Obtunded
Non-assessable
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22. 1. Asymptomatic
1. Awake, alert, sober (no intoxication)
2. No spine pain (no distracting pain)
3. No history of transient neurological deficits
4. No tenderness
5. No neurological deficits
6. No pain with full range of motion:
First: 45° right and left rotation
If OK: Flexion and extension
ATLS C-spine is cleared
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23. 23

24. NEXUS Criteria
• Validated on 34,069 patients in 21 centers
• Sensitivity: 99%
• Negative predictive value: 99.8%
Anderson et al, JAAOS 2010
Hoffman et al, NEJM 2000
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25. 2. Symptomatic
1. Spine pain
2. Spinal tenderness, step-off, gap, hematoma
3. Neurological deficits, even transient
4. Pain with range of motion of the neck
(do this only if the previous negative)
CT C-spine & Spine Consult
ATLS
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26. 3. Temporarily
Non-assessable
Intoxication or distracting injuries
1. Keep the cervical collar
2. Re-assess in 24-48 hours
3. Follow one of the symptomatic or
asymptomatic algorithms
Anderson et al, JAAOS 2010
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27. Long Term Immobilization
✔ ✔
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28. C-spine X-rays
• Cross-table lateral, AP & Open mouth view
• Sensitivity: 52 – 85%
• Difficulty with O-C & C-T junctions
• If any pathology  CT
Anderson et al, JAAOS 2010
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29. High Index of Suspicion
• 10% of patients with c-spine fracture
have a 2nd spine fracture
• Identify one abnormality  Look for
another!
• Radiographic screening of entire spine
required in this situation
ATLS
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30. 30

31. 31

32. 32

33. 33

34. Flexion-Extension
• Contraindicated if there is fracture
• No value & possibly harmful in acute setting
• Helpful in the subacute setting (2 weeks)
Anderson et al, JAAOS 2010
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35. CT C-spine
• Helical multi-detector CT
• Sensitivity: 99.3% for fractures
• Does not detect ligamentous injuries
Brown et al, J Trauma 2005
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36. 36

37. MRI C-spine
• Detects neural, ligamentous, or disk injuries
• Fat suppression sequence, STIR
• Not for screening
• Indicated if:
• Neurological deficits
• Suspected ligamentous injuries
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38. 4. Obtunded
• One of the following:
• Altered mental state
• Prolonged intubation
• Psychiatric disturbance
• Unable to cooperate
• Clearing the C-spine is controversial
• Balance between keeping & removing
collar
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39. Avoiding the Collar!!
• Collar alters normal
management:
• Skin ulcers
• Impaired patient
mobilization
• ICP and respiratory
challenges

40. 4. Obtunded
• CT C-spine:
• 99.3% sensitivity for fractures
• If +ve  treat
• If –ve  MRI
• MRI C-spine:
• 20-30% of negative CT showed MRI
abnormalities in obtunded patients
Anderson et al, JAAOS 2010
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41. Dynamic Floroscopy
• Physician-supervised, bed-side or OR
• Disadvantages:
• 1% of ligamentous injuries missed
• Risky
• Does not visualize C-T junction
• Not recommended anymore
Anderson et al, JAAOS 2010
41

42. Recent Trauma
• 56 y/o F, restrained MVC
• Hard collar and board
• Intubated in the field
• No physical exam
• Open ankle #
• BB Forearm #
• Closed head injury
• Chest contusion
L R

43. She is expected to be intubated for 3 weeks.
What would you do to clear her cervical
spine?
1. Keep the hard collar
2. Remove the hard collar
3. Put a soft collar
4. Do floroscopy flexion/extension
5. Order MRI
43

44. T2 Weighted STIR sequence
Increased ADI with hemorrhage and disruption of transverse ligament

46. Summary
• Suspect spine injury
• Protection is priority, Detection is secondary
• Complete immobilization of spine
• Clearance by physical and/or radiological
exams
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