The process of spinal
clearance can be accomplished safely, in a
systematic way, as outlined in the
algorithm chart.
Two questions ought
to be answered in the beginning:
1.
The first question
is whether the patient is fully conscious
or not.
2. If the patient is
conscious, the second question addresses
the presence, or lack thereof, of symptoms attributable to cervical
spinal injury.
Accordingly, a
patient is put into one of the following
three categories:
I
The
conscious asymptomatic patient.
II The
conscious symptomatic patient.
III The unconscious
or obtunded patient.
The
clearance process in each of these
categories then takes a different route as
outlined in the algorithm chart. Further
detail is given below
I.
The conscious asymptomatic patient
Not all trauma
patients need to undergo radiological
examination of the cervical spine. Selective radiological evaluation of the
symptomatic patients, and those who do not
meet the criteria for clinical clearance,
would avert unnecessary exposure of many
individuals to ionising radiation, besides
endorsing resources allocation policies.(47)
In that line, many authors
proposed that radiographic examination of
the cervical spine after trauma is not
necessary in asymptomatic patients. Certain prerequisites must be fulfilled to
consider a patient eligible for clinical
clearance.(48, 49, 50, 51, 52, 53)
All of the following
criteria must be present. The lack of any
of them disqualifies the patient from
clinical clearance and puts him into the
radiological clearance group. Thus, the
patient must be:
1.
Fully alert and
awake, with a Glasgow Coma Scale score of
15/15.
2.
Adult.
3.
Sane.
4.
Cooperative.
5.
Not intoxicated by
alcohol or drugs. (One should beware of
the sedative effect of strong
analgesics and sedatives prescribed to alleviate
the patient's
symptoms).
6.
No other
distracting injury. This includes any type
of injury that would affect the patient's
ability to concentrate and cooperate
in the clinical assessment. Examples are:
visceral injuries,
long bone fractures
and large lacerated wounds.
Based on the above, a
patient could be cleared on clinical
grounds alone (clinical clearance),
without the need for radiological
examination, provided he has all of the
following:
1.
No neck pain.
2.
No neck deformity
or bruising noted on inspection.
3.
No tenderness on
palpation of the back of the neck.
4.
No neurological
symptoms or signs.
5.
Pain-free full
range of active neck movement.
It is to be noted
that the exemption of asymptomatic
patients from radiological examination is
one of the few agreed upon practice
standards in the management of acute
cervical spinal injury and is supported by
Class I evidence driven from numerous
large prospective studies.(15, 48, 49,
50, 51, 52, 53)
II.
The conscious symptomatic patient
Radiological
clearance as outlined earlier is indicated
in the symptomatic patients as well as in
those who fail to meet the criteria for
clinical clearance referred to above.
The
main symptoms and signs are:
1.
Neck pain .
2.
Deformity or
bruising noted on inspection of the neck.
3.
Midline tenderness
on palpation of the back of the neck.
4.
Neurological
symptoms or signs attributable to cervical
spinal injury.
III.
The unconscious or obtunded patient
Trauma victims who are unconscious, or
obtunded due to associated head injury, or
those who are under the sedative effects
of medications, alcohol or drug
intoxication are naturally excluded from
the clinical clearance category. The
radiological clearance process here is
somewhat different from that applicable to
the conscious symptomatic patients who are
able to cooperate and participate in the
clinical and radiological assessments. As
such, open-mouth films can not be
performed adequately, passive
flexion-extension views carry risks as
explained earlier, CT screening of the
entire cervical spine is not always
feasible and MRI examination is
usually difficult in the unconscious
ventilated patients.
Accordingly, the
unconscious patient should undergo:
1.
Lateral and
anteroposterior x-rays of the entire spine
including cervical, dorsal and lumbar
segments .
2.
CT occiput-C2
(C0-C2) at the time of CT head scan.
3.
CT of C7-T1 if
this could not be seen on prior plain
x-ray films.
4.
CT scan of
fracture sites or suspicious areas.
5. MRI scans as indicated.
Conclusion
The review of
evidence-based practice parameters for
cervical spine clearance after trauma
identifies only two standard
recommendations generated from Class I
evidence. These are:
1.
The exemption from
radiological assessment of patients who
meet the criteria for clinical clearance
and
2.
Radiological
clearance using three-view x-ray series
supplemented with targeted CT scanning of
suspicious areas or areas not
adequately visualized on the x-rays in
symptomatic patients.
Most of the medical
practice parameters have not yet been
universally standardized because of
ethical reasons encountered, and practical
and technical hitches faced in formulating
supportive Class I evidence. While
research continues to bridge this gap,
practice guidelines and options can still
be generated from the best available
medical literature. Agreed-upon
parameters, supplemented by logical
judgement, and best use of available
facilities and experience, form the basis
of good medical practice. The current
guidelines for cervical spine clearance
follow a similar systematic approach to
problem solving and should assist those
responsible for the care of the acutely
injured.
