Clearing the cervical spine in the

unconscious patient
Paul Harrison MB ChB FRCA
Chris Cairns MB ChB FRCA DICM

This article describes the issues concerning the Presentation Key points

Downloaded from http://ceaccp.oxfordjournals.org/ by Syed Zeeshan Javaid Hashmi on November 5, 2014

common problem of safely excluding potentially Cervical spine injury is a
Patients who are fully immobilized after trauma
unstable cervical spine injury in patients who relatively common and
are commonplace in Emergency Departments. In
cannot be assessed clinically because of their potentially devastating
the vast majority, no spinal column injury will injury.
depressed level of consciousness. It includes a
eventually be identified. In the awake patient,
summary of the epidemiology of cervical spine Delay in diagnosis increases
diagnosis of spinal injury is greatly aided by the
injury, a critique of the relevant guidelines, and the risk of permanent
ability of the patient to report pain, comply with
a discussion of more recent evidence, which neurological deficit.
instructions, and allow detailed clinical examin-
may be used to guide clinical practice. Prolonged spinal
ation. However, in the unconscious patient, no
immobilization is associated
pain or tenderness may be reported, and the clini-
with significant morbidity
cian may have no idea about neurological signs
and mortality.
and symptoms (unless these were recorded before
Epidemiology In the comatose patient, the
the coma ensued). Therefore, spinal immobiliz-
Cervical spine trauma occurs most frequently clinician must decide when
ation is continued until injury can be ruled out
the risks of continued collar
in males between the ages of 20 and 30 yr. The and the spinal column ‘cleared’. This can only be
usage outweigh the risks of
most common aetiologies are road traffic acci- fully performed after the patient has woken and a missed injury without
dents, falls, assaults, and sporting injuries. by asked about symptoms; however, as this may undue delay.
Cervical spinal cord injury is a devastating not be for a significant period of time, conclusive
Helical computed
event both for both the patient and society. The radiological investigations are sought to rule out
tomography scans with 3D
financial cost for tetraplegic individuals may injury. These rely on adequate, complete imaging reconstruction will provide
run into millions of pounds for lifetime of the entire cervical spine (C1–T1) and accurate adequate radiological
medical care. In England in 2004–5, cervical reporting by an experienced radiologist; without ‘evidence’ to clear the
spinal cord injury was recorded in 637 cases.1 this, subtle signs may be missed, with potentially cervical spine in the
Cervical spine injury has an incidence of 5% devastating consequences. The stability of any majority of comatose
in association with blunt polytrauma. Factors injury must also be estimated to allow further patients.
making injury more likely include focal neuro- treatment decisions.
logical deficit, concurrent head injury, and a
Glasgow Coma Scale (GCS) of ,8. The
appreciation of the increased risk of cervical
Assessment of the unconscious
patient Paul Harrison MB ChB FRCA
spine injury in trauma victims with neurological
Specialist Registrar in Anaesthetics
impairment prompted the development of ATLS Assessment of the spinal column in the uncon- Southern General Hospital
guidelines for the management of trauma scious patient presents a significant challenge. Glasgow
patients.2 The standard pre-hospital practice for This is two-fold: (i) to identify significant cervi- UK
any patient who has suffered injury or trauma cal spine pathology promptly, recognizing that Chris Cairns MB ChB FRCA DICM
(often this may only have been relatively minor) delay in diagnosis increases the risk of neurologi- Consultant Anaesthetist
is to have full spinal immobilization at the scene cal deficit 10-fold3 and (ii) to ‘clear’ the cervical Honorary Senior Lecturer
Department of Anaesthesia, Critical
of the incident. Properly applied, this requires spine in the remainder of patients because pro-
Care and Pain Management
both a rigid collar and a spinal board with sand- longed, unnecessary spinal immobilization rep- Stirling Royal Infirmary
bags and tape, to keep the head completely still resents significant risks to the patient. Livilands
Stirling FK8 2AU
and the spinal column ‘in-line’. In other words, The exclusion of spinal injury can be made
UK
the patient is assumed to have a neck injury by clinical or radiological investigation. The Tel/Fax: þ44 1786 434 476
until proven otherwise, and is transported to required criteria to clinically exclude a spinal E-mail: chris.cairns@fvah.scot.nhs.uk
(for correspondence)
hospital and managed as such. fracture are listed in Table 1. If these criteria
doi:10.1093/bjaceaccp/mkn022
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 8 Number 4 2008 117
& The Board of Management and Trustees of the British Journal of Anaesthesia [2008].
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Clearing the cervical spine in the unconscious patient
Table 1 EAST clinical criteria
GCS of 15 and is alert and orientated
No intoxicants or drugs have been consumed
No significant distracting injuries
No signs or symptoms on clinical examination of the C-spine
No midline tenderness or pain
Full range of active movement
No referable neurological deficit
Table 2 Implications of a suspected cervical spine injury to the anaesthetist
Airway
Basic airway manoeuvres but no neck extension
Maintenance of neutral position
Manual in-line neck stabilization required if hard collar must be removed
Increased risk of difficult intubation
Taped rather than tied endotracheal tube
Cardiovascular
Maintenance of spinal cord perfusion
Staffing
’Log roll’ requires at least five staff
Safe transfers from trolley to bed/CT can require up to seven members of staff
cannot be met, radiological investigation is indicated and, when com-
bined with the clinical appraisal, should allow the removal of immo-
bilization in the majority of patients. However, in obtunded patients
where symptoms and signs are disguised, clinicians must rely on
radiological investigation alone to exclude cervical spine injury. This
group of patients presents a clinical problem to anaesthetists either in
the resuscitation room, the operating theatre, or the intensive care.
The implications of a suspected cervical spine injury are listed in
Table 2 and rigid collar related morbidity is described in Table 3.4
Clearing the cervical spine
The Eastern Association for the Surgery of Trauma (EAST) guide-
lines for cervical spine evaluation published in the USA in 1998
suggest that comatosed patients after trauma who have normal plain
radiography and normal targeted computed tomography (CT) (C1,
C2, lower cervical spine, and any other areas of concern) scans
should be considered to have a ‘stable’ cervical spine. In 2000, this
was updated to include the recommendation that flexion/extension
fluoroscopy should also be performed in this group of patients to
exclude cervical instability5 (Table 4). However, there is a lack of
level 1 evidence to support these guidelines, which were drawn
from a combination of surveys of clinical practice and a literature
review that looked mostly at retrospective studies. They have pro-
vided a useful framework to clinicians for some time, but the large
prospective trials that were recommended at the time have not yet
been performed. To date in the UK, no similar universally adopted
guideline has been agreed, but many have been proposed.6
Radiography
X-ray
The standard investigations for excluding cervical spine injury
traditionally comprised of plain radiographs. This included a
118 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 4 2008
Table 3 Hard collar complications
Increased intracranial pressure
Difficult laryngoscopy and intubation
Difficult central venous cannulae insertion
Increased risk of pulmonary thromboembolism, especially in context of other injuries,
e.g. long bone fractures
Infections
Pressure necrosis leading to ulceration, infection, and ultimately sepsis
Increased rates of ventilator-associated pneumonia
Increased rates of central venous cannulae associated blood stream infections
Prevention of cross-infection difficult due to staffing requirements
Downloaded from http://ceaccp.oxfordjournals.org/ by Syed Zeeshan Javaid Hashmi on November 5, 2014
Table 4 EAST radiology for the obtunded patient
Adequate plain radiography: lateral, AP, and peg views
Targeted thin cut axial CT slices with sagittal reconstruction
C1/C2 levels
Any other areas of concern or poor visualization on plain radiography
Dynamic fluoroscopy to assess cervical spine stability
cross-table lateral view as part of the trauma series with the addition
of an AP and open mouth view (to assess the odontoid peg). The
specificity of the lateral film is quoted as around 85%, but this relies
on the film being adequate, defined as showing the atlanto-axial
joint, all cervical levels, and the cervico-thoracic junction.
The rate of adequate lateral views can be as low as 50%.7
Tracheal intubation makes adequate visualization even more diffi-
cult, and it is now recognized that although plain radiography is
specific, the sensitivity may be as low as 30%.8 This may lead to
multiple attempts at further X-rays to improve visualization of the
entire cervical spine, including views such as oblique or swim-
mers, often without success. Therefore, plain X-rays are now not
considered adequate to clear the C-spine in the comatose patient.
Computed tomography
The introduction of helical CT, multi-detector row scanners, and 3D
reconstruction has led to greatly improved image quality and accurate
visualization of lesions, and this is now recognized to be significantly
superior to plain radiography in elucidating cervical spine trauma.
Therefore, CT has been proposed as the single most important inves-
tigation in this group of patients. Concerns over the use of CT in
relation to radiation exposure have been expressed, but this may be
lowered if multiple plain X-rays are not performed before CT.
Helical CT screening is now often carried out using 1 mm
slices instead of 3 mm, and this has further helped to improve the
diagnostic potential for unstable cervical spine fractures. Such
detailed CT scanning may allow diagnosis of an unstable injury or
suggest evidence of ligamentous involvement as accurately as
magnetic resonance imaging (MRI) in many patients.9
Magnetic resonance imaging
MRI is recognized as the gold standard for imaging of soft tissues,
and it may be used to identify ligamentous injury of the cervical

Fig. 1 Suggested flow chart for clearing the cervical spine in an
unconscious patient.
spine, with a high sensitivity. The EAST guidelines suggest MRI
imaging should be carried out in cases of neurological deficit.
Some studies have tried to justify MRI as a single investigation
for cervical spine injury but only in comparison with plain radi-
ography.10 The problems with MRI for obtunded patients with
blunt trauma relate to the need for transfer from the ICU and to
the problems with monitoring and management during the rela-
tively long scanning time; in many hospitals, MRI scanners may
not be immediately available or even present.
In light of the improvements in CT resolution, MRI should
probably be reserved for those patients with abnormal neurology
or unsatisfactory CT scans. However, there is a risk that ligamen-
tous injuries may be missed, although these injuries are rare and
the risk of them being unstable low (,0.1%).11, 12
Dynamic fluoroscopy
This is now more commonly performed worldwide because of con-
cerns that targeted CT may not exclude cervical spine instability.
However, its use as a screening tool in obtunded patients is contro-
versial. It is labour intensive and time-consuming, as some studies
may require several hours to obtain adequate images. Compared
with plain radiography and CT, dynamic fluoroscopy may not
always identify new cervical spine injuries in obtunded patients.13
In one study, a patient developed tetraplegia after undergoing
dynamic fluoroscopy, a risk of passively stressing the cervical
spine.14 Dynamic fluoroscopy is not widely practiced in the UK
and is unlikely to become so in unconscious patients for the
reasons outlined above.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 4 2008
Clearing the cervical spine in the unconscious patient
Removing the collar after radiological
investigations
This is the crux of the clinical concern over the potential for a
missed unstable cervical spine injury and the subsequent neuro-
logical deterioration, weighed against the consequences of pro-
longed spinal immobilization in patients who in the majority of
cases have no injury. In recent studies, the majority of cervical
spine ‘critical errors’ have occurred because of protocol violations,
not protocol failures.8 – 11 Therefore, given the lack of national
guidelines and variance of clinical practice in relation to investi-
Downloaded from http://ceaccp.oxfordjournals.org/ by Syed Zeeshan Javaid Hashmi on November 5, 2014
gation and assessment around the country,15 the adoption of a
locally agreed protocol would seem the best option. This protocol
needs to be accepted by emergency, trauma, anaesthetic, and radi-
ology departments. It should include a formal report from a radiol-
ogist who is experienced in interpreting trauma cervical spine CT
images, followed by a two signature agreement between anaesthetist/
intensivist and surgeon that, based on a normal report and the
clinical history, the likelihood of a significant missed cervical
spine injury is negligible. This should not delay the removal of a
hard collar for more than 24 h, which should allow enough time
for intensive care staff to be reasonably confident that the patient’s
clinical condition is unlikely to improve in time to clinically
exclude an injury before the risks of spinal immobilization begin
to increase.
This is not to belittle the consequences of a missed cervical
spine injury, which can result in permanent neurological sequelae,
in a predominantly young population. A consensus approach
between the responsible consultants is paramount and, if any doubt
exists, spinal immobilization should remain.
Conclusion
To date, no prospective, randomized, controlled trial has suggested
a single investigation that will exclude completely a cervical spine
injury. Clinicians must decide what investigation, or combination
of investigations, provides them with enough evidence to either
diagnose a cervical spine injury or exclude it. This should take
into account the risk of a missed injury and the risk of unnecessary
prolonged immobilization. In the last 10 yr, CT technology has
improved to a point that renders other modalities either inferior
( plain X-rays or dynamic fluoroscopy) or initially unnecessary
(MRI). We suggest that all obtunded trauma victims should have a
helical CT scan of their entire cervical spine with 1 mm cuts and
3D reconstruction. This should be done on admission at the same
time as the CT head scan. If these images are reported as normal,
by an experienced radiologist, then the risk of the patient having a
significant, missed injury is small enough to warrant safe removal
of spinal immobilization. A protocol for the management and sub-
sequent ‘clearing’ of the cervical spine (Fig. 1) should be in place
in all centres that receive trauma patients.
119
Clearing the cervical spine in the unconscious patient
References
1. Health Episodes Statistics. Primary Diagnosis Statistics 2004– 2005.
Available from www.nesonline.nhs.uk
2. Advanced Trauma Life Support for Doctors Student Course Manual.
Chicago, IL: American College of Surgeons, 2001
3. Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course
of missed spine fractures. J Trauma 1987; 27: 980 –6
4. Morris CG, McCoy W, Lavery GG. Spinal immobilisation for uncon-
scious patients with multiple injuries. Br Med J 2004; 329: 495–9
5. EAST Determination of Cervical Spine Stability in Trauma Patients. Update
2000. Available from www.east.org
6. McCulloch PT, France J, Jones DL. Helical computer tomography
alone compared with adjuvant computer tomography to evaluate the
cervical spine after high energy trauma. J Bone Joint Surg 2005; 87-A:
2388–94
7. Morris CGT, McCoy E. Clearing the cervical spine in unconscious poly-
trauma victims, balancing risks and effective screening. Anaesthesia
2004; 59: 464–82
8. Gale SC, Garcias VH, Reilly PM, Schwab CW. The inefficiency of plain
radiography to evaluate the cervical spine after blunt trauma. J Trauma
2005; 59: 1121– 5
9. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of
unstable cervical spine injury in obtunded patients with blunt trauma: is
120 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 4 2008
MR imaging needed when multi-detector row ct findings are normal?
Radiology 2005; 237: 106–13
10. Katzberg RW et al. Acute cervical spine injuries: prospective MR
imaging assessment at a level 1 trauma center. Radiology 1999; 213:
203– 12
11. Stassen NA, Williams VA, Gestring ML, Cheng JD, Bankey PE. Magnetic
resonance imaging in combination with helical computer tomography
provides a safe and efficient method of cervical spine clearance in the
obtunded patient. J Trauma 2006; 60: 171–7
12. Diaz JJ, Aulino JM, Collier B et al. The early work-up for isolated liga-
mentous injury of the cervical spine: does computer tomography scan
have a role? J Trauma 2005; 59: 897– 904
Downloaded from http://ceaccp.oxfordjournals.org/ by Syed Zeeshan Javaid Hashmi on November 5, 2014
13. Padayachee L, Cooper DJ, Irons S et al. Cervical spine clearance in
unconscious traumatic brain injury patients: dynamic flexion-extension
fluoroscopy versus computed tomography with three-dimensional
reconstruction. J Trauma 2006; 60: 341 –5
14. Davis JW, Kaups KL, Cunningham MA et al. Routine evaluation of the
cervical spine in head-injured patients with dynamic fluoroscopy: a
reappraisal. J Trauma 2001; 50: 1044– 7
15. Jones PS, Wadley J, Healy M. Clearing the cervical spine in unconscious
adult trauma patients: a survey of practice in specialist centres in the
UK. Anaesthesia 2004; 59: 1095–9
Please see multiple choice questions 1 –3