Cervical spine clearance after blunt trauma: current state of the art

Abstract

No definite consensus exists for the clearance of the cervical spine (C-spine) after blunt trauma, despite many validated algorithms, recommendations and guidelines. We intend to answer the most relevant questions with which physicians are confronted when clearing C-spines after blunt trauma in emergency departments (EDs). To exclude significant C-spine injuries we designed an algorithm to be compatible with clinical practice, to simplify patient management and avoid unrewarding evaluation.We conducted an exploratory PubMed search including articles published from January 2000 to October 2018. Keywords used were "cervical spine", "injury", "clearance", "Canadian C-spine Rule", "CCR" and "national emergency x-radiography utilization study". Clinical and experimental studies were included in a detailed review.We based our literature review on 33 articles. While answering fundamental triage questions from daily clinical practice, the current literature is discussed in detail. We designed an algorithm for the C-spine clearance suitable for any trauma centre with a high-quality multiplanar reconstruction computerized tomography (CT) scan continuously available.The high sensitivity of the Canadian C-spine Rule (CCR) prevents missing C-spine injuries while limiting the amount of unnecessary radiologic examinations. Plain radiographs were fully abandoned for C-spine clearance. A negative CT scan is sufficient to clear the majority of C-spine injuries and allows for collar removal. In case of motor symptoms or radio-clinical discrepancy, the advice of a specialized spine surgeon must be requested. Magnetic resonance imaging must not be routinely used. Neck pain despite negative imaging is not a reason to delay removal of stiff cervical collars. Cite this article: EFORT Open Rev 2020;5:253-259. DOI: 10.1302/2058-5241.5.190047.

Keywords: algorithm; c-spine clearance; cervical spine; collar; diagnostics; trauma.

Fig. 1

Alert patients with Glasgow Coma Scale of 15 or patients showing a potential recovery during the following hours are cleared through the Canadian C-spine Rule (CCR). Clearing by CCR allows removal of the cervical stiff collar. Patients without inclusion criteria, obtunded patients as well as patients who were not cleared by the CCR must undergo multiplanar reconstruction CT scan. If the imaging excludes an unstable injury and a reliable examination excludes any gross motor function deficiency or radio-clinical discrepancy, the cervical stiff collar is removed. Otherwise, collar immobilization is maintained until advice from a spinal surgeon is obtained.