What are the criteria for cervical spine clearance?

From the Guidelines

Cervical spine clearance should be performed using a combination of clinical evaluation and imaging, with CT being the preferred imaging modality for moderate to high-risk patients, as it provides superior sensitivity and can help identify potentially catastrophic injuries. For alert, oriented patients without distracting injuries, intoxication, or neurological deficits, clinical clearance can be performed using the NEXUS criteria or Canadian C-spine rules, as suggested by 1. If the patient has no midline cervical tenderness, no focal neurological deficits, normal alertness, no intoxication, and no painful distracting injuries, the cervical spine can be cleared clinically without imaging. However, for patients who don't meet these criteria, a three-view cervical spine series (anteroposterior, lateral, and odontoid views) or CT scan is recommended, with CT being preferred for moderate to high-risk patients due to its superior sensitivity, as noted in 2. Some key points to consider when evaluating cervical spine clearance include:

• Documenting movement of limbs at first presentation, as suggested by 2
• Avoiding routine plain radiographs and dynamic flexion/extension views, as they are no longer recommended, according to 2
• Using MRI if there is a positive neurological examination referable to the spinal cord (myelopathy), as recommended by 2
• Getting images reported by a senior radiologist who is skilled in musculoskeletal/neuro-radiology, as suggested by 2
• Considering the potential consequences of removing spinal precautions after CT and combined CT and MRI, as noted in 2
• Being vigilant for developing neurological signs despite a spine having been ‘cleared’, as recommended by 2. For unconscious or uncooperative patients, maintaining cervical spine precautions until clinical clearance is possible or until CT and possibly MRI can rule out injury is crucial, as it helps balance the need to identify potentially catastrophic injuries while avoiding unnecessary immobilization, which can lead to pressure ulcers, aspiration risk, and increased intracranial pressure, as discussed in 1 and 2.

From the Research

Cervical Spine Clearance Protocols

• Cervical spine injury is relatively rare, occurring in only 2% to 3% of patients with blunt trauma who undergo imaging studies 3
• Evaluation of cervical spine injuries should begin in the emergency department and involves a combination of pediatric, trauma, orthopedic, and neurosurgeons for definitive management 3
• Implementation of guidelines will decrease time for cervical spine clearance and incidence of missed injuries 3

Comparison of CT and MRI Findings

• CT had a sensitivity of 0.875 and a specificity of 1.000 in detecting all cervical spine injuries compared to MRI 4
• If only unstable injuries are considered, CT had a sensitivity of 1.00 and a specificity of 1.000 compared to MRI in obtunded patients with GCS of 14 or less in the absence of high impact trauma 4
• CT is highly sensitive in detecting unstable injuries in obtunded patients with GCS of 14 or less in the absence of high impact trauma 4

Intensive Care Physician-Led Clearance

• A normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department 5
• Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met 5
• The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%) 5

Cervical Spine Clearance in Trauma Patients

• Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS 6
• As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity 6

Role of MRI in Cervical Spine Clearance

• In the obtunded blunt trauma patient with unreliable clinical examination and a normal CT scan, there is still a role for CS-MRI in detecting clinically significant injuries when MRI resources are available 7
• However, when a reliable clinical exam reveals intact gross motor function, CS-MRI may be unnecessary 7