Evaluation of the cervical spine in the polytrauma patient

Abstract

Study design: Two-part study. Part One: the analysis of surveys distributed to members of the Orthopaedic Trauma Association (OTA) and 1000 surgeon members of NASS. Part Two: a prospective clinical study evaluating a new algorithm to evaluate the cervical spine in polytrauma patients.

Objectives: To determine if there is a consensus of the optimal method for "clearing the cervical spine"; to assess the safety and efficacy of a newly proposed algorithm.

Summary of background data: There is no uniformly accepted algorithm for "clearing the cervical spine" in the polytrauma patient or those patients with altered mental status secondary to the influence of alcohol, drugs or a closed head injury.

Methods: All members of the OTA and 1000 surgeon members of NASS were sent questionnaires to assess their methods of "clearing the cervical spine" in the polytrauma patient. Their answers were collated, analyzed and compared to standard ATLS protocol guidelines. A new protocol, which includes a surgeon, controlled stretch test and flouroscopically visualized flexion-extension views, was initiated and evaluated for safety and efficacy.

Survey: Fifty-five percent of the members of the OTA and 31% of the NASS surgeons responded to the questionnaire. Among the responses from the NASS members, the ratio of orthopaedic spine surgeons to neurosurgeons accurately parallels the society's membership (77% ortho, 23% neuro). Sixty-nine of the OTA and 54% of the NASS responders replied that they followed ATLS guidelines. Analysis of their responses showed only 40% compliance. Eighty-one percent of the OTA respondents utilize the standard three view cervical spine trauma series, only 31% of the NASS members adhere to this guideline. Nearly 90% of all respondents identified the presence of neck pain or retropharygeal soft tissue swelling as an indicator to expand their initial radiographic evaluation. There was no consensus as to management of the polytrauma patient with a closed head injury. Eighty-two percent of all respondents has seen or treated a purely ligamentous injury of the c-spine. SPECTIVE STUDY: Prospective clinical protocol. 35-month period: enrolled 153 patients, 12,000 patients seen in trauma unit. Completed data 149/153. 8/153 unable to be cleared due to poor visualization of cervical-thoracic junction. 3/153 positive findings identified during fluoro examination. All three instability patterns verified in surgery (true positives). No untoward events to date.

Conclusions: A standardized protocol to safely and effectively clear the cervical spine has yet to be established. Preliminary results of a new protocol to safely evaluate the cervical spine in the polytrauma patient are promising.