Guidelines for Identification of C-Spine Injuries

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:

1. Continue cervical collar.
2. Cervical collar may be removed after negative MRI (level 3).
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:

1. Continue cervical collar immobilization until a clinical examination can be performed.
2. Remove the cervical collar on the basis of CT alone.
3. Obtain MRI.

• If MRI disclosed nothing abnormal, the cervical collar may be safely removed (level 2). 

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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:

1. No posterior midline neck pain or tenderness
2. No focal neurological deficit
3. Normal level of alertness
4. No evidence of intoxication 
5. No clinically apparent, painful distracting injury

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Canadian C-spine Rules (CCR) 

N Engl J Med. 2003;349:2510 –2518