Practice Management Guidelines for Identification of Cervical Spine Injuries Following Trauma:
Update From the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee
J Trauma. 2009;67: 651–659
Recommendations
a. Removal of cervical collars:
- Cervical collars should be removed as soon as feasible after trauma (level 3).
b. In the patient with penetrating trauma to the brain:
- Immobilization in a cervical collar is not necessary unless the trajectory suggests direct injury to the C-spine (level 3).
c.
In awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion of the C-spine:
- C-spine imaging is not necessary and the cervical collar may be removed (level 2).
d. All other patients in whom C-spine injury is suspected must have radiographic evaluation. This applies to patients with pain or tenderness, patients with neurologic deficit, patients with altered mental status, and patients with distracting injury.
- The primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions (level 2).
- Plain radiographs contribute no additional information and should not be obtained (level 2).
- If there is neurologic deficit attributable to a C-spine injury:
- Obtain spine consultation.
- Obtain MRI.
- For the neurologically intact awake and alert patient complaining of neck pain with a negative CT:
Options:
- Continue cervical collar.
- Cervical collar may be removed after negative MRI (level 3).
- Cervical collar may be removed after negative and adequate F/E films (level 3).
- For the obtunded patient with a negative CT and gross motor function of all four extremities:
- F/E radiography should not be performed (level 2).
- The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its use must be individualized in each institution (level 3). Options are as follows:
- Continue cervical collar immobilization until a clinical examination can be performed.
- Remove the cervical collar on the basis of CT alone.
- Obtain MRI.
- If MRI disclosed nothing abnormal, the cervical collar may be safely removed (level 2).
National Emergency X-radiography Utilization Study Low-Risk Criteria (NEXUS NLC)
N Engl J Med. 2000;343:94 –99
A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are met:
- No posterior midline neck pain or tenderness
- No focal neurological deficit
- Normal level of alertness
- No evidence of intoxication
- No clinically apparent, painful distracting injury
Canadian C-spine Rules (CCR)
N Engl J Med. 2003;349:2510 –2518
