The University of Kansas Hospital
Trauma Policy Manual
Practice Management Guideline
Cervical Spine Clearance
Signature _________________________________________________________
Michael Moncure, MD Medical Director, Trauma Program
Signature _________________________________________________________
Christopher Ruder, RN Vice President, Patient Care Services
Formulation 12/1998
Date
Revised 1/2005, 5/2008
Date
Reviewed 1/2005, 5/2008
Date
Position Responsible for Policy Updates ______________________________________
Elizabeth Carlton, RN Trauma Program Manager
Purpose: To assure that all patients with a mechanism of injury that might include possible spine
injuries are immobilized until cervical spine injuries are ruled out. To promote the timely
identification and treatment of cervical spine fractures and dislocations in those patients
harboring such injuries.
1) Patient Arrival:
a) Patients arriving with suspected spinal injury and immobilization by an extrication rigid
cervical orthosis (e.g.: Stiff Neck collar) and/or spine board will not have them removed
until appropriate clinical and radiographic evaluations are obtained.
b) If the patient is not immobilized upon presentation, appropriate immobilization will be
applied.
c) The patient should not remain on a rigid spine board for longer than two (2) hours from
injury. The patient should not remain immobilized in an extrication rigid cervical collar
for longer than two (2) hours from injury. A rigid cervical collar intended for long-term
immobilization (e.g. Philadelphia collar) will re-place the extrication rigid cervical collar
prior to transfer from the Emergency Department.
2) Radiographic requirements:
a) If the patient is alert, awake, not intoxicated, neurologically normal, and has no midline
neck pain or tenderness even with full range of motion of neck and palpation of the
cervical spine
i)
Cervical spine x-rays are not necessary
ii)
An attending physician or the trauma nurse practitioner (ED, Trauma, Orthopedic,
or Neurosurgery) must complete a full neurologic examination including
motor/sensory/reflexes. The physician must document the exam findings in the
medical record. If physical exam is negative, the c-spine can be cleared and the
cervical collar removed.
Page 1 of 4
This must be done by an attending (Optimal timing – within 2 hours after arrival
to the Emergency Department)
b) If the patient is alert, awake, and complains of neck pain
i)
3-view cervical spine x-rays are obtained or Axial CT images at 3 mm intervals
with sagittal and coronal reconstruction are obtained if any CT study is ordered.
ii)
If the lower cervical spine is not adequately visualized on the lateral cervical
spine x-ray, obtain a Swimmers view
iii)
If the Swimmers view is inadequate, axial CT at 3mm intervals through the lower
cervical spine with sagittal reconstruction
iv)
If above radiographs are normal, the cervical collar is removed and a clinical
examination is done to determine whether the patient can flex and extend the neck. If
the patient can flex and extend the neck, then flexion/extension lateral cervical spine
x-rays are obtained with the patient sitting and voluntarily flexing and extending their
neck. Voluntary and painless excursion must exceed 30 degrees. Physician or the
trauma nurse practitioner must be present during flexion extension exam.
v)
If voluntary, painless excursion during flexion/extension does not exceed 30
degrees, the cervical collar should be replaced and patient should be reassessed in 48
hours. If patient continues to experience pain, maintain patient in long-term
immobilization collar and reevaluate as indicated.
vi)
Optimal timing – within 4 hours of admission to the Emergency Department.
c) If the patient has neurological deficits referable to a spine injury
i)
Consult spine specialists
ii)
Obtain plain films and CT images as described above
iii)
Obtain a MRI of the cervical spine if necessary. The MRI is important if the plain
films and CT do not demonstrate an injury.
iv)
Optimal timing – within 2 hours of admission to the Emergency Department.
d) If the patient has altered mental status and return of normal mental status is not
anticipated for 2 days or more, e.g., severe traumatic or hypoxic, ischemic brain injury
i)
Axial CT images at 3mm intervals are obtained through the lower cervical spine
with sagittal reconstruction from the occiput through T1 within 24 hours of
admission.
ii)
If radiographs do not reveal any suspicion for cervical spine injury and patient
does not exhibit any signs of neuro deficit consistent with a spinal cord injury
discontinue cervical collar
iii)
If either radiograph suggest evidence of injury, obtain cervical spine MRI as soon
as clinical condition allows and maintain cervical immobilization.
3) Documentation: Following admission to an in-patient unit, documentation of cervical spine
clearance must be in the progress notes. Every attempt should be made to determine the final
outcome regarding cervical spine clearance within twenty-four hours of admission.
iii)
Definitions:
3-view cervical spine x-rays are defined as:
 Lateral Cervical Spine Radiograph – it must be of good quality and adequately
visualize the base of the occiput to the upper part of the first thoracic vertebrae.
 Anteroposterior Cervical Spine Radiograph – it must reveal the spinous process of C2
– C7.
 Open Mouth Odontoid Radiograph – it must visualize the entire dens and the lateral
masses of C1
Page 2 of 4
References:
o Determination of cervical spine stability in trauma patients, 2000, Eastern Association for the
Surgery of Trauma
o Banit, DM, Grau, G, Fisher, R. (2000) Evaluation of the acute cervical spine: A management
algorithm. The Journal of Trauma Injury, Infection, and Critical Care; 49: 45-456
o Barba, CA, Taggert, J, Morgan, A, et al. (2001) A new cervical spine clearance protocol
using computed tomography. The Journal of Trauma Injury, Infection , and Critical Care;
51:652-6573
o Blackmore, CC, Mann, FA, Wilson, AJ, (2000) Helical CT in the primary trauma evaluation
of the cervical spine: an evidence-based approach. Skeletal Radiology 29:632-639
o Widder, S., Doig, Christopher, et al. Prospective evaluation of Computed Tomographic
scanning for the spinal clearance of obtunded trauma patients: Preliminary results. The
Journal of Trauma Injury, Infection , and Critical Care 2004;56:1179-1184.
o Brooks, RA & Willet, KM. Evaluation of the Oxford protocol for total spinal clearance in the
unconscious trauma patient. The Journal of Trauma Injury, Infection , and Critical Care
2001;50:862-867.
o Bolinger, B, Shartz, M & Marion, D. Bedside fluoroscopic flexion and extension cervical
spine radiographs for clearance of the cervical spine in comatose trauma patients. The
Journal of Trauma Injury, Infection , and Critical Care. 2004;56:132-136.
o Webber-Jones, J et al. (2002) The management and prevention of rigid cervical collar
complications. Orthopaedic Nursing. Pitman: Jul/Aug 2002. Vol. 21, Iss. 4; pg. 19, 9 pgs
Page 3 of 4
C-Spine Clearance in Trauma Patients
December 2004
PATIENT IN
CERVICAL SPINE
IMMOBILIZATION
-4-
Patient Presentation
Awake alert & oriented. No
distracting injuries, no
intoxication, no complaints of
neck pain or tenderness with
ROM, neurologically intact
NO
C-Spine
X-Rays
Neuro Deficits
Convert to extrication collar to
a Philadelphia collar
Complaints of Pain?
Convert to extrication collar
to a Philadelphia collar
3 view C-spine
X-rays. Obtain
swimmers view as
needed
OR
Obtunded or otherwise
neurologically compromised
Convert to extrication collar
to a Philadelphia collar
Axial CT of C-spine
through T-1 @ 3mm
intervals with Sagital &
Coronal Reconstruction
Neg
Axial CT of C-spine
through T-1 @ 3mm
intervals with
Sagital & Coronal
Reconstruction
Pos
Neg
1.
1.
2.
3.
4.
5.
Staff physician must complete
neuro exam including
moto/sensory/relflexes.
Clear C-Spine
Remove Collar
Document all findings
Optimal time: With in 2 hours of
arrival to ED
2.
3.
4.
5.
6.
Physician must be in
attendance.
Remove Collar
Obtain flexion extension
lateral c-spine films
Voluntary painless
excursion must exceed
30 degrees to clear cspine
Document all findings
Optimal time: within 4
hours of arrival
1.
2.
Pos
Consult spine
service
Consider MRI
1.
2.
1.
2.
3.
4.
Altered mental
status expected to
be > 2 days
DC collar
Document all
findings
Optimal time:
within 24 hours of
admission.
Every attempt should be made to determine the final outcome regarding cervical
spine clearance within twenty-four hours of admission
D:\219572231.doc
Axial CT of C-spine
through T-1 @ 3mm
intervals with
Sagital & Coronal
Reconstruction
Consult spine
service
Consider MRI