Cervical spine clearance in polytrauma

1. Cervical Spine Assessment &
Clearance in Emergency
Dr.PONNILAVAN

2. Injuries to c- spine are common and are among the few skeletal injuries that carry a high
likelihood of death.
They are often difficult to diagnose on initial imaging studies
A thorough understanding of the complex anatomy of c spine is essential for accurate
diagnosis of injury and for proper planning of Rx.
Anatomy of subaxial lower cervical spine is almost consistent, whereas anatomy of upper
cervical spine is unique at each level, hence the injuries of cervical spine is best described in
the two headings of craniovertebral and subaxial cervical spine injuries separately

3. • Goals for management of cervical injuries are
- prompt recognition of the problem and
- prevention of secondary neurological damage.
Missed diagnoses are common because of the difficulty in
identification of cervical spine trauma, particularly in polytrauma
patients with altered level of consciousness.

4. Estimate-
all trauma patients- 2 to 3%
serious head injuries- 10% sustain cervical spine injuries,
& of those, between 3 & 25% suffer extension of those injuries from
delay in diagnosis or unwarranted manipulation in the emergency
department.

5. When will u suspect a cervical spine
injury????

6. How to Obtain Radiographs
Radiographic clearance of
c- spine begins with the std
three-views.
- cross-table lateral, AP &
open-mouth views.

7. A swimmer’s view is added
when the initial lateral
projection fails to
demonstrate C7-T1 junction.
The swimmer’s lateral view
may be somewhat limited
secondary to the overlapping
shadows of the clavicle and
ribs.

8. Fuch view / closed
mouth odontoid view
Standard Fuch view
not to be used in a
trauma setting &
modified fuch can be
used

9. supine-oblique projections, in
which only the X-ray beam is
angled 45 degree from the
sagittal plane aimed at the
anterior margin of middle of
sternomastoid muscle, &
radiographic cassette is slid under
the scapulae without moving the
patient.

10. When an occult spinal injury is strongly suspected, i.e. due to the mode
of injury or because of suggestive findings on plain film, cervical CT
scanning is indicated.
Injury identified in one spinal region mandates plain film screening of
the remainder of the spine.

11. Interpretation of Radiographs
ATLS guidelines, assess the lateral
X-ray for alignment of four vertical
lines,
(i) anterior soft tissue line
(ii) anterior vertebral body line,
(iii) posterior vertebral body line,
(iv) a line joining the tips of spinous
processes.

13. Prevertebral soft tissue thickness varies
anterior to the C1 arch.
• This plane narrows to 2-3 mm anterior to
C2 to C4.
• At C5 and below, the thinner
retropharyngeal space widens to the
retrotracheal space, which approximates
the width of the vertebral body.

14. Webb et al described a tetrad of signs that should warn
the clinician of a possibility of unstable hyperflexion
cervical spinal injury, which includes
(i) Interspinous widening,
(ii) anterior subluxation exceeding 3 mm in adult or 4 mm in children,
(iii) tear drop fracture, and
iv)focal Kyphosis exceeding 11° or widening of the interspinous
distance relative to the adjacent levels.

16. • Conversely, a hyperextension injury may show anterior disc space
widening, focal lordosis, extension tear-drop fracture at C-2, and
posterior subluxation.

17. • In upper cervical region, anterior
atlantodens interval exceeding 3
mm in adult & 5 mm in children
indicate damage to transverse
ligament.
• In the elderly patients with
degenerative disc disease
presence of some degree of
retrolisthesis is common and may
be less likely to predict injury.
• X-ray is uncommon and is more
likely to indicate a hidden injury.

18. Flexion-Extension Radiographs, CT and MRI
• Flexion-extension views are not used to determine stability of known
cervical spine injuries.
• Dynamic films are best used when assessing a suspected hyperflexion
sprain when routine radiographs are equivocal.
• Their purpose is to assess the integrity of the posterior ligament
complex.

19. Degree of flexion-extension must be limited to the point of the
patient’s pain tolerance. These may be safely performed in awake and
alert patients in the emergency room.
Dynamic Films produce unacceptably high false positive and false
negative rates in an acute setting because pain and spasm limit cervical
spine motion.
This examination is best performed when the patient comfortably
exhibits a more normal arc of motion, usually after 1 to 2 weeks.

20. Multiple studies have shown that cervical spine clearance based on
plain radiographs alone misses spine fractures in 15 to 30% cases.
The limitations of plain radiography have led to the widespread use of
flexion-extension radiographs, CT, and MRI to evaluate for subtle
cervical spine injuries.

21. Computed tomography (CT) scans
- However, CT scans are limited their ability to demonstrate axially oriented
fractures (like type II odontoid fractures) or ligamentous injures.
- If CT scans are used as a substitute for a 3-view spine series, then coronal
and sagittal reconstructions are essential.
Thin slice CT scan (2mm or less) & multiplanar reconstructed images will
show fractures that are oriented purely in the axial plane, subluxation of
facet joints and vertebral bodies, as well as angular and rotational
abnormalities.
Sensitivity of CT scans for detection of fractures ranges from 97 to 100%

22. MRI scan
MRI scan provides direct visualization of the posterior ligament
complex and is therefore, the definitive imaging examination for
anterior subluxation.
Cost and limited availability preclude its use as a screening study.
Patients with significant neck pain but normal radiographs should be
evaluated with an MRI scan, or treated presumptively with a hard
cervical orthosis until flexion-extension views can be obtained at a later
date

23. For comatose patients
Passive flexion-extension views under fluoroscopic guidance has been
recommended.
• While controversial, this may be an acceptable method for clearing
the spine for ligamentous injury when MRI scanning is
contraindicated.
• Care must be exercised to assure that adequate motion occurs. This
maneuver may be performed with the patient log-rolled onto his side,
taking extra care to protect the spine

24. Case Scenario

25. A 12-month-old female infant
presented with nausea,
vomiting, and drowsiness to
emergency room after falling
from a height of less than
30 cm.
She had no neurological deficit
at presentation, and cervical
spine plain radiographs (a) and
CT with 3D reconstruction (b)
showed no abnormal findings.

26. c) 7 days after the injury the patient
developed right sided hemiparesis &
cervical MRI revealed increased
intensity (arrows) in the T2-weighted
images at the level of C6.
(d) Repeat cervical MRI one month
later shows that increased signal
intensity has disappeared.
The patient continued to improve
neurologically until 24 months after
the injury and returned to near-
normal

27. • SCIWORA, first described by Pang and Wilberger in 1982 occurs in
approximately 2-4% of spinal injures.
• They described the clinical profile of the SCIWORA syndrome in
• 55 children, of which there were
- 10 upper cervical (C1-C4),
- 33 lower cervical (C5- C8), and
- 12 thoracic cord injuries.

28. SCIWORA
Absence of radiological evidence confirming a spinal injury should not lead to a relaxation of
precautions until the patient is lucid & cooperative enough to move all limbs & report any
areas of excessive tenderness.
Spinal cord may be injured even though vertebral column is spared from disruption, because of
the inherent elasticity of the juvenile spine, which permits selfreduction but significant
intersegmental displacements when subjected to flexion, extension & distraction forces.
This vulnerability is most evident in children younger than 8 years.

29. Hendey et al
Using the database of the National Emergency X-Radiography
Utilization Study (NEXUS).
Studied the incidence & characteristics of patients with
SCIWORA

30. What is NEXUS??
NEXUS criteria
National Emergency X radiography Utilisation Group

31. • Remember Nexus by NSAID
N - Neurodeficit
S - Spine tenderness
A - Alertness
I - Intoxication
D - Distracting injuries

32. NEXUS criteria (5 N)
• No posterior midline cervical tenderness
• No evidence of intoxication
• Normal alertness level
• No focal neurological deficit
• No painful distracting injuries
If any one N is missing request for
a radiograph

33. SCIWORA
-defined as SCI demonstrated by MRI, when a complete, technically adequate plain
radiographic series revealed no injury.
All the SCIWORA cases were identified with adults.
There were over 3000 children enrolled, including 30 with cervical spine injury, but
none had SCIWORA.
The most common MRI findings among SCIWORA patients were
- central disc herniation,
- Spinal stenosis, and
- cord edema or contusion.
Central cord syndrome was described in 10 cases.
They concluded that SCIWORA was an uncommon disorder that occurred only in
adults.

34. Steroids (Methylprednisolone) in Spinal Cord
Injury
National Acute Spinal Cord Injury Studies (NASCIS) I and II published in
the 1990s demonstrated significant benefit in administering high doses
of methylprednisolone early after a spinal cord injury (within 8 h).
Recommended dose is 30 mg/kg IV over 15 minutes, followed by 5.4
mg/kg/h via continuous intravenous infusion over 24 hours.
• The NASCIS I & II trials have received significant criticism with regards
to both their design & possible benefit-to-risk ratio.
• No full consensus has been reached on the use of
methylprednisolone in person with acute cord injury. Management
should be guided based on local guidelines.

35. UPPER CERVICAL SPINE
• The craniocervical junction refers to the osseoligamentous and
neurovascular structures that extend from the skull base to C2.
• It is comprised of highly specialized bony articulations between the
occipital condyles, C1 and C2 and the complex ligamentous system
linking these bones into one functional joint.

36. All high energy injuries should be considered potential for upper
cervical instability.
Cranial nerve function
• should be a part of any examination in patients with possible head or
neck injuries.
• Abducens and hypoglossal nerves are the commonest involved in
craniocervical injuries.
• Patterns ranging from complete pentaplegia to incomplete injuries
such as cervicomedullary syndromes and brainstem disorders.

37. • In view of presence of subluxations or partially reduced injuries ,
clinicians should look for indirect clinical signs such as
-soft tissue swelling and hemorrhage during clinical and X ray
examinations.
• Fractures of upper cervical spine (CO-C2) often present without
neurologic deficit, since there is a proportionally greater space
available for the cord than in the lower cervical spine.

38. • Furthermore, if significant cord damage is caused by a high cervical
fracture, patients are frequently dead on the scene of accident.
• The most common patterns of injury seen in the upper cervical spine
are CO-C-1 disruption, C-1 ring fracture, C1-2disruption, C-2 ring
fracture, and odontoid process fracture

39. Subaxial cervical spine
Accurate classification of injuries speeds the delivery of appropriate
diagnostic & therapeutic intervention.
Compressive Flexion Injuries
Vertical Compression Injuries
Distractive Flexion Injuries
Compressive Extension Injuries
Distractive Extension Injuries
Lateral Flexion Injuries

40. The mechanistic classification proposed by Ferguson and Allen are
bases on the position of the neck at the time of injury and the
dominant mode of force application.
Furthermore, each injury pattern graded in terms of the degree of
injury (bony or ligamentous) to the involved motion segment.
A higher stage of injury is associated with greater amount of
displacement and a greater risk of neurological injury.

41. Injury designation is based on the mechanism of injury & review of
plan radiographs.
Crucial to the differentiation of injury patterns is recognition that
compressive load result in shortening of vertebral elements, while
distraction results in lengthening.
In the Ferguson-Allen classification, the PLL & structures anterior to it
are considered the anterior column of the spine, and the structures
posterior to the PLL are considered the posterior column of the spine.
It cannot be universally applied; patients often present with injuries
that represent a combination of injury patterns.

42. Timing of Surgery
Mx of acute SCI has traditionally concentrated on conservative care.
Pharmacologic interventions, in particular iv methylprednisolone
therapy, have shown modest improvements in clinical trials & are still
undergoing evaluation.
More recent interest has focused on the role of surgical reduction &
decompression, particularly early surgery.

43. • A review of the current evidence available in the literature suggests that there is
no standard of care regarding the role & timing of surgical decompression.
• In a recent study, Dimar et al produced thoracic SCI in rats and an epidural spacer
placed adjacent to the contusion to mimic the effect of persisting compression.
• The effect of decompression at 0, 2, 6, 24, and 72 hours after SCI was then
assessed by quantitative analysis of locomotor recovery, lesion volume, &
electrophysiology.
• Neurologic recovery was significantly dependent on time to decompression, with
significant differences seen in all experimental groups.
• This study provides the strongest experimental evidence to date of a clear
beneficial effect of spinal cord decompression after SCI

44. There is insufficient data to support overall treatment standards or
guidelines for timing of surgery in spinal cord injury.
There are, however, class II data indicating that early surgery (< 24
hours) may be done safely after acute SCI. Furthermore, there are Class
III data to suggest a role for urgent decompression in the setting of
1) bilateral facet dislocation and
2) incomplete spinal cold injury with a neurologically deteriorating
patient.

45. Whereas there is biologic evidence from experimental studies in
animals that early decompression may improve neurologic recovery
after SCI, the relevant time frame in humans remains unclear.
To date, the role of decompression in patients with SCI is only
supported by Class III and limited Class II evidence.
Accordingly, there is a strong rationale to undertake prospective,
controlled trials to evaluate the role and timing of decompression in
acute SCI.

46. Summary
• A total of 4,80,652 road accidents took place in India last year
resulting in the loss of 1,50,785 lives
• Often cervical injury occurs in high speed motor accidents

47. In RTA
• Maintain ABC first
• Strict log rolling and Spine immobilisation
• Other injury related specific treatment

48. Thank you