How do you clear the cervical (c) spine clinically in trauma patients?

Clinical Clearance of the Cervical Spine in Trauma Patients

The cervical spine can be safely cleared clinically in alert, cooperative trauma patients who meet all four criteria: GCS 15 with normal alertness, no intoxication, no neck pain/tenderness, and no distracting injuries. 1

Patient Classification for C-Spine Clearance

Trauma patients can be divided into four categories when considering cervical spine clearance:

1. Alert and Asymptomatic Patients

   • GCS 15, fully alert and oriented
   • No intoxication from drugs or alcohol
   • No neck pain or midline tenderness on examination
   • No distracting injuries
   • Full range of active neck movement
   • No neurological deficits referable to the spine

2. Temporarily Non-Assessable Patients

   • Expected to be clinically evaluable within 48-72 hours
   • Examples: intoxicated patients, those with minor head injuries, or post-operative patients requiring brief ventilation
   • Maintain immobilization until proper clinical evaluation possible

3. Symptomatic Patients

   • Neck pain, tenderness, or neurological symptoms
   • Require imaging regardless of mental status

4. Obtunded/Unconscious Patients

   • Unlikely to be evaluable within 48-72 hours
   • Examples: severe head injuries, multiple injuries, organ failure

Clinical Clearance Algorithm

For Alert, Asymptomatic Patients:

• If all four clinical criteria are met (GCS 15, no intoxication, no neck signs, no distracting injuries), the cervical spine can be considered stable and cleared without imaging 1, 2
• This approach has been shown to be highly sensitive and specific, potentially more so than radiographic screening alone 1

For Temporarily Non-Assessable Patients:

• Maintain immobilization until proper clinical evaluation is possible (typically within 48-72 hours)
• Perform baseline three-view cervical radiographs
• Re-evaluate clinically when the patient becomes assessable 1

For Symptomatic Patients:

• Require imaging regardless of mental status
• Three-view cervical radiographs (lateral, anteroposterior, odontoid)
• Consider CT for areas not well visualized on plain films

For Obtunded/Unconscious Patients:

• Three-view cervical radiographs
• High-resolution CT of entire cervical spine (1.5-2mm slices) with sagittal reconstructions
• If interpreted as normal by a senior radiologist, the cervical spine may be assumed stable 1, 2
• MRI should be considered for patients with neurological deficits referable to the spine 2

Important Considerations

Risks of Prolonged Immobilization:

• Pressure ulcers (up to 55% of patients)
• Increased intracranial pressure
• Respiratory complications
• Venous thromboembolism (7-100% in patients with tetraparesis)
• Increased nursing requirements and cross-contamination risk 1

Pitfalls in Clinical Clearance:

1. Missed Injuries: Up to 4.3% of cervical fractures can be missed, with 67% of these patients suffering neurological deterioration as a result 2
2. Isolated Ligamentous Injuries: These occur in approximately 0.1-0.7% of blunt trauma patients and may not be detected on plain films or CT 1
3. Inadequate Radiographs: Up to 49% of lateral cervical spine films fail to visualize the cervicothoracic junction, where up to 60% of injuries may occur 1

Imaging Considerations:

• Plain radiographs alone miss approximately 15% of cervical injuries 1
• CT is highly sensitive (99.75%) for detecting clinically significant C-spine injuries in obtunded patients 3
• The debate continues about whether MRI is necessary after a negative CT in obtunded patients 4, 5, 6
• Recent evidence suggests CT with sagittal and coronal reconstructions may be sufficient for clearance in patients without motor deficits 6

Special Situations

Patients with Neurological Deficits:

• MRI is indicated for any patient with neurological signs or symptoms referable to the spine 2
• Management of detected injuries should involve a senior neurosurgeon or orthopedic surgeon 2

Intubated Patients:

• Manual in-line stabilization should be maintained during intubation procedures
• The anterior portion of the cervical collar can be removed during intubation 2

By following this evidence-based approach to cervical spine clearance in trauma patients, clinicians can minimize both the risk of missed injuries and the complications associated with unnecessary prolonged immobilization.