Are any of the following present such that clinical clearance is inappropriate? Yes: radiography. No: proceed
Glasgow coma scale (GCS) <15
Presence of distracting injuries
Intoxication
Are ≥1 high-risk factors present that mandate radiography? Yes: radiography. No: proceed
Age >65 years
Dangerous mechanism*
Paraesthesia in extremities
Are ≥1 low-risk factors present which allow clinical clearance to be attempted? No: radiography. Yes: proceed
Simple rearend motor vehicle collision (MVC)**
Sitting in Emergency Department
Ambulatory at any time since
Delayed onset of neck pain
Absence of midline cervical spine tenderness
Able to actively rotate neck 45 degrees left and right? No: radiograph. Yes: cervical spine cleared clinically
*Dangerous mechanism includes:
Fall from height ≥1 metre or 5 stairs
Axial loading to head e.g. diving
MVC involving
High speed (≥60 mph)
Rollover
Ejection
Pedestrian or cyclist struck by a motor vehicle
**Simple rearend motor vehicle collision excludes:
Pushed into oncoming traffic
Collision with bus or large truck
Rollover
High speed
National Emergency X-Radiography Utilization Study (NEXUS) criteria:
Provided all of the following are absent, cervical spine can be cleared clinically; if ≥1 are present then radiography is required
Focal neurological deficit
Midline spinal tenderness
Reduced level of consciousness
Intoxication
Distracting injury
Which rules to use?
Both have their advantages and disadvantages
The Canadian C-spine rules are useful in the context of midline tenderness because clinical clearance can still be attempted provided ≥1 other low-risk factors are present
The NEXUS criteria are useful in the context of age >65 and dangerous mechanism because these do not mandate radiography
Ultimately, the decision of whether or not imaging is required is a clinical one; if in doubt, it is best to ere on the side of caution and proceed to imaging
However, remember that imaging is not without its disadvantages such as radiation, discomfort and pressure sores from ongoing immobilisation, inconvenience to the patient, increased workload for radiographers
Primary imaging modality
CT cervical spine should be used if any of the following are present
Elderly patients
Patients with known or presumed cervical spine degenerative disease
GCS <13
Intubated patients
Inadequate plain film series
Suspicion or certainty of abnormality on plain film series
Patients being scanned for head trauma and/or multi-region trauma as well
In the absence of the above, 3-view plain radiographs (lateral, anteroposterior and odontoid peg) should be adequate
Cervical spine radiograph interpretation
ABCD approach
Adequacy and alignment
Bones
Cartilage and other soft tissues
Dens and disc spaces
Lateral view
Identify C1-7 and the superior border of T1
If the superior border of T1 cannot be identified, the film is inadequate and a swimmer’s view should be requested
Check the alignment of the following three lines; each should be smooth and unbroken
Anterior vertebral line (along the anterior margins of the vertebral bodies)
Anterior spinal line (along posterior margins of the vertebral bodies)
Posterior spinal line (along the bases of the spinous processes); this may show a step at C2 but should not be >2 mm posterior to line
Check that Wackenheim’s line drawn along the clivus passes posterior to the peg; if it intersects the peg, suspect atlanto-occipital dislocation
Check that the anterior cortex of the peg
Closely opposes the anterior arch of C1; this gap should be <3 mm in adults and <5 mm in children
Is continuous with the anterior cortex of the C2 body; displacement implies a fracture
Check that the posterior cortex of the peg is continuous with the posterior cortex of the C2 body; displacement implies a fracture
Check that Harris’ ring (white ring projected over the base of the peg and part of the C2 body) is normal; it is normal for this ring to appear incomplete over its superior and/or inferior borders but disruption of the anterior and/or posterior margins implies a fracture through the base of the peg or the body of C2
Examine all vertebrae for preservation of height, width and integrity of the bony cortex; joints spaces should be uniform
Check that the vertebral soft tissues are normal (C1-4 <7 mm and C5-7 <22 mm); any bulges indicate haemorrhage and suggest injury
Anteroposterior (AP) view
Check that the spinous processes are in a straight line
Check that the space between adjacent spinous processes is approximately equal
Odontoid peg view
Check that the lateral margins of C1 align vertically with those of C2; lateral displacement of the former compared to the latter implies a burst fracture, or Hangman’s fracture
Check that the spaces on each side of the peg are approximately equal; if not, suspect C1 rotary subluxation
Check for a fracture line across the base of the peg; it is very common to see a thin black line (Mach band) across the top or base of the peg which is an optical illusion from superimposition; the gap between the two upper incisors can also cause an apparent vertical fracture
Thoracic and lumbar spine radiograph interpretation
Lateral view
Identify three columns
Anterior
Anterior longitudinal ligament
Anterior annulus fibrosus
Anterior 2/3 vertebral body
Middle
Posterior longitudinal ligament
Posterior annulus fibrosus
Posterior 1/3 vertebral body
Posterior
Facet joints
Pedicles
Posterior ligaments
Ligamentum flavum
Interspinous ligament
Supraspinous ligament
Examine all vertebrae for preservation of height, width and integrity of the bony cortex; joints spaces should be uniform
Check for loss of height or wedging of the vertebral bodies which suggests a compression fracture
The posterior margin of each vertebral body should be slightly concave; loss of this concavity may be associated with a wedge fracture
AP view
Examine all vertebrae for preservation of height, width and integrity of the bony cortex; joints spaces should be uniform
Check that the spinous processes are in a straight line
Check that the space between adjacent spinous processes is approximately equal
Check the width between pedicles; normally pedicles gradually splay apart but sudden widening suggests a fracture
Check the paraspinal lines on a thoracic spine radiograph
Right paraspinal line should not be visible
Left paraspinal line should be closely applied to vertebral bodies with the vertical shadow of the descending aorta lateral to it
Any displacement or bulging should be regarded as a haematoma from a vertebral body fracture
Initial management of spinal trauma:
Manage patients with a dangerous mechanism of injury from an ABCDE perspective
Patients with suspected or confirmed spinal trauma should have their spine immobilised in a neutral position
This can be with manual inline stabilisation (MILS) initially followed by triple immobilisation (collar, blocks and tape) at the earliest opportunity
If airway compromise is suspected, a jaw thrust can be applied simultaneously with MILS; head-tilt and chin-lift manoeuvres are contraindicated as these may exacerbate spinal trauma
Patients requiring intubation and ventilation may have their triple immobilisation removed but this must be substituted with MILS applied by an assistant
Further management of spinal trauma
Give analgesia for pain e.g. morphine 1-10 mg IV
For agitated patients who are unable to cope with immobilisation, every effort should be made to relieve the cause of agitation e.g. analgesia for pain; sedation with or without intubation and ventilation may be necessary
Patients should not be forcibly restrained by immobilisation as this is likely to exacerbate injury
Spinal boards are for extrication and transport purposes only; on arrival to the Emergency Department, patients should be log-rolled for removal from the board and examination of the back with or without digital rectal examination
During prolonged immobilisation consider IV maintenance fluid and toileting with bedpans
