Clearing the cervical spine

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. The following is based on the NEXUS (National Emergency X-Radiography Utilization Study) criteria.[1] There are other clinical criteria in common use, such as the Canadian C-spine rule.[2]

Excluding a cervical spinal injury requires clinical judgement and training.

Under the NEXUS guidelines, when an acute blunt force injury is present, a cervical spine is deemed to not need radiological imaging if all the following criteria are met:

  • 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 (see focal neurological signs)
  • 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, adding a swimmer's view if the lateral doesn't include the C7/T1 interface. In those with degenerative disease of the cervical spine, a plain film series is often inadequate to assess for injury. Plain radiographs, even when technically optimal, my fail to reveal significant injury. If there is clinical suspicion, a Computerized Tomography (CT Scan) may be needed to rule out a fracture, and flexion-extension radiographs or Magnetic Resonance Imaging to exclude a ligament injury.[3]

If the patient is obtunded, i.e. has a head injury with altered sensorium, is intoxicated, or has been given potent analgesics, the cervical spine must remain immobilized until a clinical examination becomes possible.[4]

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 64-slice CT with reconstructions does not entirely rule out ligamentous injury leading to instability, but is a practical means of identifying the majority of C-spine injuries in obtunded patients. MR C-spine suffers from frequent false-positives, limiting its usefulness. In these cases, a consultation with a Spine Surgery specialist is prudent.

The indication for MR spine is a focal neurological deficit. Another indication for MR of the cervical spine is persistent mid-line neck pain or tenderness despite a normal CT in the awake patient.

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.

Clearing the cervical spine
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See also

References

  1. ^ Hoffman JR, Wolfson AB, Todd K, Mower WR (1998). "Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)". Ann Emerg Med. 32 (4): 461–9. doi:10.1016/s0196-0644(98)70176-3. PMID 9774931.
  2. ^ Canadian CT Head & C-Spine (CCC) Study Group (2004). "Canadian C-Spine Rule study for alert and stable trauma patients: I. Background and rationale". CJEM. 4 (2): 84–90. PMID 17612425.
  3. ^ Jaeseong, Jason (2015). "The utility of flexion–extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine". Emergency Medicine Australasia. doi:10.1111/1742-6723.12525.
  4. ^ Morris CGT, McCoy E (2004). "Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening". Anasthesia. 59: 464–482. doi:10.1111/j.1365-2044.2004.03666.x.

External links

Cervical spine disorder

Cervical spine disorders are illnesses that affect the cervical spine, which is made up of the upper first seven vertebrae, encasing and shielding the spinal cord. This fragment of the spine starts from the region above the shoulder blades and ends by supporting and connecting the Skull.The cervical spine contains many different anatomic compositions, including muscles, bones, ligaments, and joints. All of these structures have nerve endings that can detect painful problems when they occur. Such nerves supply muscular control and sensations to the skull and arms while correspondingly providing our bodies with flexibility and motion.[1] However, if the cervical spine is injured it can cause many minor or traumatic problems, and although these injuries vary specifically they are more commonly known as "cervical spine disorders" as a whole.[1]

Cervical vertebrae

In vertebrates, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull.

Thoracic vertebrae in all mammalian species are those vertebrae that also carry a pair of ribs, and lie caudal (toward the tail) to the cervical vertebrae. Further caudally follow the lumbar vertebrae, which also belong to the trunk, but do not carry ribs. In reptiles, all trunk vertebrae carry ribs and are called dorsal vertebrae.

In many species, though not in mammals, the cervical vertebrae bear ribs. In many other groups, such as lizards and saurischian dinosaurs, the cervical ribs are large; in birds, they are small and completely fused to the vertebrae. The vertebral transverse processes of mammals are homologous to the cervical ribs of other amniotes. Most mammals have 7 cervical vertebrae.In humans, cervical vertebrae are the smallest of the true vertebrae, and can be readily distinguished from those of the thoracic or lumbar regions by the presence of a foramen (hole) in each transverse process, through which the vertebral artery, vertebral veins and inferior cervical ganglion pass.

The remainder of this article focuses upon human anatomy.

Spinal cord injury

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury. Injury can occur at any level of the spinal cord and can be complete injury, with a total loss of sensation and muscle function, or incomplete, meaning some nervous signals are able to travel past the injured area of the cord. Depending on the location and severity of damage, the symptoms vary, from numbness to paralysis to incontinence. Long term outcomes also ranges widely, from full recovery to permanent tetraplegia (also called quadriplegia) or paraplegia. Complications can include muscle atrophy, pressure sores, infections, and breathing problems.

In the majority of cases the damage results from physical trauma such as car accidents, gunshots, falls, or sports injuries, but it can also result from nontraumatic causes such as infection, insufficient blood flow, and tumors. Just over half of injuries affect the cervical spine, while 15% occur in each of the thoracic spine, border between the thoracic and lumbar spine, and lumbar spine alone. Diagnosis is typically based on symptoms and medical imaging.Efforts to prevent SCI include individual measures such as using safety equipment, societal measures such as safety regulations in sports and traffic, and improvements to equipment. Treatment starts with restricting further motion of the spine and maintaining adequate blood pressure. Corticosteroids have not been found to be useful. Other interventions vary depending on the location and extent of the injury, from bed rest to surgery. In many cases, spinal cord injuries require long-term physical and occupational therapy, especially if it interferes with activities of daily living.

In the United States, about 12,000 people a year survive a spinal cord injury. The most commonly affected group are young adult males. SCI has seen great improvements in its care since the middle of the 20th century. Research into potential treatments includes stem cell implantation, engineered materials for tissue support, epidural spinal stimulation, and wearable robotic exoskeletons.

Stabilization (medicine)

Stabilization is a process to help prevent shock in sick or injured people. Stabilization is often performed by the first person to arrive on scene, EMTs, or nurses before or just after arrival in hospital. It includes controlling bleeding, arranging for proper evacuation, keeping patients warm with blankets, and calming them by providing personal attention and concern for their well-being.

It is particularly important in trauma cases where spinal injury is suspected to immobilize the cervical spine, or back. Failure to do so can cause permanent paralysis or death. In the field, spinal stabilization involves moving the person's back as a single unit with as many as five rescuers assisting, then applying a cervical collar (which can be improvised from duct tape and cardboard), and securing victims to a solid-backed stretcher, long spine board, or a vacuum mattress.

Search and rescue technicians trained in wilderness first aid have a protocol for verifying that the spine has not been hurt (clearing the cervical spine) when the victim is several hours or more from the hospital and evacuation may not be indicated. Without this technique, it may be necessary to carry a suspected trauma victim out only to discover that he had no injury worthy of the effort and expense.

Tetraplegia

Tetraplegia, also known as quadriplegia, is paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso; paraplegia is similar but does not affect the arms. The loss is usually sensory and motor, which means that both sensation and control are lost. Tetraparesis or quadriparesis, on the other hand, means muscle weakness affecting all four limbs. It may be flaccid or spastic.

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