SPINE
CLEARANCE
Basic
Principles
1. Entire spine is immobilized during primary survey.
2. Radiographic clearance of the spine is not required before
emergent surgical procedures. Presence of a spinal column injury is simply
assumed until excluded.
3. Secondary and tertiary exams include examination of the spine for
tenderness as well as testing all motor roots, sensation and reflexes.
4. Tertiary exams are performed only on alert and unimpaired patients
without distracting injuries.
5. If any spine fractures are found, entire spine must be
radiographed.
6. For patients with radiographic injury, spine consultation should
be obtained WHEN FEASIBLE for focused pre-operative evaluation regarding
relative instability and severity of injury prior to intubation.
7. Patients remain on thoracolumbar spine precautions until T-L spine
is radiographically and/or clinically cleared.
8. C-spine precautions are maintained until C-spine is radiographically
and/or clinically cleared.
Cervical
1.
Collars are not indicated in
penetrating trauma to the BRAIN, unless the trajectory suggests traverse of the
cervical spine (EAST).
2.
In awake, alert patients without
deficit or distracting injury who have no neck pain or tenderness with full ROM
of the cervical spine, imaging is not necessary and collar may be removed
(EAST).
3.
All other patients in whom injury is
suspected (‘at-risk’) must have radiographic evaluation, including patients
with pain or tenderness, deficit, altered MS or distracting injury (EAST).
4.
C-spines are not cleared in the at-risk
population until after the tertiary exam is completed or until it is determined
that clinical examination will not be possible within a reasonable amount of
time due to obtundation.
5.
Cervical CT scan is the preferred
radiographic modality when physical exam is not adequate.
6.
With impaired or unconscious patient,
rigid collars are taken off within 2 hours and replaced with semi-rigid pressure
reducing collar (Miami, Philadelphia, etc).
7. Enter patients in cervical algorithm for C-Spine clearance.
Thoraco-Lumbar
1. CT scan of thoracic and lumbar spines if there are clinical
findings on secondary or tertiary exams or an unreliable exam. Multi-detector
CT-scan with reformatted axial collimation is superior to plain films (EAST
Level 1).
2. Patients with back pain, TLS tenderness on exam, neuro deficits
referable to the TLS, altered MS, intoxication, distracting injuries or known
or suspected high energy mechanisms should be screened for TLS injury with MDCT
scan (EAST Level 2).
3. Clinical exam alone may be considered in select patients but is unreliable
in patients ≥ age 60 and/or those subjected to high energy mechanism (ejection,
rollover, pedestrian, fall from height, torso crush, jump from moving vehicle,
crash of a non-enclosed vehicle) (Inaba AAST 2014).
4. In blunt trauma patients with a known or suspected injury to any
region of the spine, thorough evaluation of the entire spine by MDCT should be
strongly considered owing to a high incidence of spinal injury at multiple
levels within this population (EAST Level 2).
