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C-SPINE CLEARANCE

These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

During the initial evaluation of an emergency department patient by the treating physician, he/she will be placed into one of three categories regarding probability of an injury to the cervical spine. Radiographic evaluation alone is not sufficient to determine if a child has a cervical spine injury. This categorization will be determined by a careful history and physical exam rather than whether or not the patient arrives with cervical immobilization. If there is any question, it is best to err toward the more severe category. Cervical spine risk categorization and ordering of spine x-rays may only be done by a physician. Placement in Category III must be verified by PGY 3 or more senior Surgery or ED resident or by the Surgery or ED Attending.

Category I
A neck injury sufficient to cause a spinal injury may have occurred. Example: A patient with impaired consciousness or communication, involved in a motor vehicle crash or fall, with evident head trauma, multiple injuries, complaints of severe neck pain, or any neurologic deficit.

Category II
There is a history of neck injury, but with a mechanism unlikely to result in an unstable cervical spine injury. Some complaints or physical findings may be present. Example: An alert, cooperative individual with some pain on motion, spasm, and/or tenderness, but no neurologic findings.

Category III
No history, mechanism of injury or physical finding suggests a cervical spine injury. Example: The patient is alert, has no complaint of neck pain, no tenderness, no head or facial injury or other distracting injuries, and demonstrates a full, pain-free range of neck motion.

Procedure
The cervical spine must be evaluated first for all patients. If the patient falls into Category II or III, the physical exam should be continued to evaluate the thoracic and lumbar spines before x-rays are obtained. Patients placed in Category I will have initial cervical spine x-rays taken and will be evaluated before x-ray examination of the thoracic and lumbar spines. Remember: in children under 2 years of age, physical exam is unreliable. Therefore, a high index of suspicion is necessary (e.g., mechanism of injury). Also, incidence of spinal cord injury without radiographic abnormality is more common in children than in adults.

CATEGORY-BASED RADIOGRAPHIC EVALUATION
of the Cervical Spine in Emergency Patients

Category I
A supine lateral C-spine (with or without swimmer's view, as required to see the cervico-thoracic junction), AP, and open mouth view will each be taken while the patient remains immobilized for children over 5 years of age. For children 5 years of age and under, an exaggerated waters view film replaces the open-mouth view film. Trauma oblique views, flexion/extension views, and/or CT scans of areas in question may be obtained at the discretion of the radiologist or treating physician.

Category II
Patients who arrive with a cervical collar in place and who have no other injuries that prevent sitting should have an erect lateral c-spine x-ray taken with the collar on. This film must be evaluated by the PGY 3 or greater emergency or trauma resident, the ED or Surgical attending, or the Radiology resident followed by supine AP and open mouth views out of the collar. If the patient arrives without a collar, place the patient in a collar prior to sending to x-ray. Trauma oblique views, flexion/extension views, and/or CT scans of areas in question may be obtained at the discretion of the radiologist or treating physician.

Category III
No x-ray of the cervical spine is indicated.

INITIAL TREATMENT OF SPINE-INJURED PATIENTS

Patients who are categorized as I or II will have their initial x-rays evaluated by the radiologist and treating physician. The decision to discontinue immobilization will be made by the PGY 3 resident or above or the ED attending physician. It will be documented in the notes. If positive findings are noted, the Spine Service should be notified immediately.

Cervical collars on pediatric trauma patients can only be removed by a physician. This will encourage residents to perform a clinical exam at the time of collar removal and it will eliminate concerns relating to telephone and verbal orders for collar removal to the nursing staff.

CONSULTATION OF SPINE SERVICE

There are two arms to the team - a neurosurgical arm and an orthopaedic arm - involved in the management of pediatric spine injuries. The Spine Service will be consulted by either the Trauma Service or the Emergency Department if there is any suspicion of pediatric spine or spinal cord injury. Every time a consultation is requested for suspected spine injury, the Neurosurgical Service and the Orthopaedic Service will communicate directly with one another in all cases. These opinions will be given to the leader of the managing team, which in most cases will be the Trauma Service. These consultations will be rendered within 2-3 hours of request and will not be delayed beyond that time. It is our intent that all cervical spines that can be cleared will be done so within 6 hours of presentation to the Emergency Department or Trauma Service except in comatose patients. Since static plain radiographs may be negative and flexion/extension x-rays may not be possible, a soft collar may be requested by the treating physician until the spine can be cleared with flexion/extension x-rays or MRI.

If Neurosurgical and Orthopaedic opinions concur, the treatment plan will be promptly instituted. If there is a discrepancy between the two opinions, the Neurosurgical and Orthopaedics teams will resolve the difference. Both teams will follow their internal chains of command, although complex decisions will often be made at the highest level of the chain. Because many of these patients will be admitted to the PIC, the Pediatric Intensive Care Team involved must also be notified of the Spine Service's opinion. Therefore, it is the responsibility of the individual consultant teams to not only document in the chart but also to communicate directly with the trauma team, as well as the PIC staff, when patients are transferred to that unit.

Subsequent referral of the patient to the Pediatric Neurosurgical or Pediatric Orthopaedic Service will be decided by the Pediatric Spine Service, depending on the constellation of injuries and the best interest of the patient. Both services will continue to see all patients admitted with spinal injury throughout the period of admission. If spinal surgery is required on any pediatric patient, it will be performed utilizing a team approach, again with Neurosurgical or Orthopaedic leadership, depending on the needs of the patient.

This Pediatric Spine Service will be responsible for nursing education regarding the management of pediatric spine injury as well as the education of other involved surgical and medical services.

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