1. C-Spine Clearance in Trauma Patients
Thia Tzi Yu Ivan

2. There are a variety of trauma accidents that can cause cervical injury
The most common of which is of course motor vehicle accidents
Following that are falls
Especially when elderly people like the one in the middle of the slide fall, they are at much higher risk of sustaining c-spine injuries
Sporting injuries are another common cause
Last but not least, there are also all manners of penetrating injuries to the neck

3. Not only that, the number of cases of the top 2 causes of traumatic c-spine injury has been rising
As you can see from this graph I took from the AIHW, the number of cases of traffic accidents have been increasing
AIHW

4. AIHW Similarly, the number of falls injury have been on the rise
C-spine injuries have a bimodal distribution with peaks in the younger age group between and those >65 years of age
With cause of injury being precisely MVAs and falls
AIHW

5. Why is C-Spine Clearance Important?
C-spine injuries are
Not uncommon (2-5%)
Most commonly injured part of the spine
C2 (axis) and lower c-spine (C5-7)
Debilitating
Permanent neurological deficits
Spinal deformities
Narrow spinal canal
Easy to Miss
4-30% of missed injuries
C-spine injuries are the most common of spinal injuries, given how the cervical region is the most exposed
T-spine is protected by the ribs and L-spine by the pelvis
Can any of you tell me which other area is the second most commonly injured?
Anyway back to c-spine injuries
The axis and the lower cervical spine are the most commonly injured areas, and they are also the most difficult to diagnose on imaging
With higher cervical injuries requiring dedicated scans and lower c-spine difficult to clear in XR for obese patients
Secondly, c-spine injuries are the most debilitating
If the spinal cord were to be compromised, cervical cord injury carries the highest morbidity and mortality
Also, the spinal canal is narrowest along the c-spine, hence it runs the greatest risk of cord injury
Last but not least, c-spine injury is easy to miss
Up to 4-30% of missed traumatic injuries are c-spine injuries

6. Anatomy of the Neck
To understand c-spine and its related injuries knowledge of the anatomy of the neck is important as many vessels and nerves run along the neck
Major vessels include the vertebral and carotid vessels
While the nerves that we are most concerned about is of course the peripheral nerves that run between each segment of the vertebrae

7. Cervical injuries in trauma
Spinal Cord Injuries (SCI)
Degree of impairment (ASIA Classification)
Vertebral Injuries
Includes dislocations, fractures, or both
Ligamentous/Soft Tissue Injuries
Vascular injuries
E.g. carotid/vertebral artery injuries

8. Mechanism of Spinal Cord Injury
Transection
Neurological deficits evident
Compression
Haematoma
Contusion
Bony dislocation, subluxation, fracture segments
Vascular compromise
Spinal arteries

9. ASIA Impairment Scale Grade Description A
Complete injury – no motor or sensory function preserved B
Sensory incomplete – sensory but not motor function preserved below the level of injury C
Motor incomplete –more than half of muscle groups below injury have power <3 D
Motor incomplete –more than half of muscle groups below injury have power >3 E
Normal – no motor deficits

10. Vertebral Injuries Anterior Column (blue) Middle Column (green)
ALL
Anterior 2/3 of vertebral body
Anterior 2/3 of intervertebral disc
Middle Column (green)
Posterior 1/3 of vertebral body
Posterior 1/3 of intervertebral disc
PLL
Posterior Column (yellow)
Pedicles
Facet joints & articular processes
Ligamentum flavum
Neural arch and interconnecting ligaments

11. Pre-Hospital Management
Primary survey
If clinical suspicion of cervical injuries
Rigid cervical collar
If penetrating injuries present, no collar is required
Not all trauma patients require spinal immobilization
Cervical collars come with their own pitfalls!

12. Rigid Cervical Collars
Advantages
Immobilises spine – reduces secondary injuries
Useful during extrication
Disadvantages
Incorrect fitting
Causes increased ICP
Increased difficulty for airway management
Penetrating injuries
Pressure sores

13. C-Spine Clearance Clinical examination Imaging
Secondary & Tertiary survey – full head and neck examination is required, including neurological and musculoskeletal examination of head to thoracic spine
Imaging
Plain radiographs CT
MRI
USS/angiograms

14. Clinical Examination ABC Head and Neck, ENT
Posterior midline cervical palpation
Tenderness
Deformity
Full Neurological Examination
Cranial nerves
Sensation
Tone
Power
Reflexes
Coordination

16. Clinical Examination Nexus Criteria
No posterior midline cervical spine tenderness
No evidence of intoxication
A normal level of alertness
No focal neurological deficit
No painful distracting injuries

17. Clinical Examination Nexus Criteria Nexus II Criteria
Sensitivity 99.6% (95% CI ), specificity 12.9% (95% CI ), NPV 99.9% ( )
Sensitivity 93.5% with painful distracting injuries
Not appropriate tool for elderly (>65 years old)
Nexus II Criteria
Included age >65yo, significant skull fracture, scalp haematoma, abnormal behaviour, coagulopathy, recurrent vomiting
Little improvement in specificity

18. Clinical Examination Canadian C-spine Rule:
Perform imaging in patients with:
Age >65 years old
Dangerous mechanism
Paraesthesia in extremities
Assessment of low risk factors for ROM test:
Simple accidents
Sitting in ED
Ambulation post event
Delayed onset of neck pain
Absence of midline posterior c-spine tenderness

19. Test active range of movement
>45 degrees to both sides – no imaging

20. Clinical Examination Canadian C-Spine Rule
Sensitivity 99.4% (95% CI ), Specificity 45.1% (95% CI 44-46), NPV 100%
However, inclusion criteria included all patients in whom imaging was deemed unnecessary, thereby introducing a selection bias

21. Imaging Plain Radiographs CT MRI Sensitivity 52% (95% CI 47-56)
Lower dose radiation, suitable for less severe trauma cases CT
Sensitivity 98% (95% CI 96-99)
Not as useful for ligamentous injuries
MRI
Useful when neurological deficits present
Best for spinal cord, ligamentous and vessel injuries
Less sensitive for posterior column and craniocervical junction injuries
High false positive rate – up to 40%
CT specificity 91%, NPV 99.97%

22. However..
Perform imaging investigation in all obtunded patients, preferably CT (Henessy et al 2010)
Perform imaging in patients >65 years of age as increased risk of spinal injuries

23. New advancements Posterior ligament complex (PLC)
Supraspinous ligament
Interspinous ligament
Facet capsules
Ligamentum flavum
Moliere et al postulated that the examination of paraspinal fat pads (PFP) on CT scans can be used to determine PLC injuries without the use of MRI scans

24. Normal PFP

25. Abnormal PFP post high velocity trauma

26. Moliere et al (2016) Single Centre retrospective study
85 patients were recruited
Had both CT and MRI scans performed
3 consultant radiologists
Inter observer agreement and relationship between PFP appearance and PLC injury results were analysed

27. Moliere et al (2016)
Inter observer disagreement in 3 patients – weighted kappa of 0.76
PLC injuries (p<0.01, OR 66.9) and posterior arch fracture (p=0.06, OR14.8) were associated with abnormal PFP appearance
No relationship found with age, sex, vertebral body abnormalities, longitudinal ligament injuries or intervertebral disc injury

28. Moliere et al (2016)
PFP abnormality and PLC injury significantly associated (p<0.01, OR 46.4, 95% CI )
Sensitivity 55%, specificity 97%
PPV 92%, NPV 82%

29. Take Home Message There is no one criteria that is perfect
History and mechanism of injury is important
Brush up those clinical examinations!
Always be cautious
Never treat the investigation, treat the patient

30. Fun Time!

31. Atlanto-occipital dislocation

32. Atlanto-occipital dislocation
Very severe injury
15% of fatalities due to spinal injury
BAI/BDI and Power ratio useful to help identify the injury

35. Atlanto-axial Dislocation

36. Atlanto-axial Dislocation/C2 fracture

37. Posterior Arch Fracture

38. Posterior arch fracture

39. C2 Pedicle Fracture

40. C2 Odontoid Fracture

41. C7 Anterior Wedge Fracture

42. Tear Drop + Odontoid Fracture

43. Extension Tear Drop Fracture

44. Spinous Process Fracture

45. Burst Fracture

46. Laminar Fracture

47. Facet Dislocations

48. The End

49. References
Henessy DA, Widder S, Zygun D, Kortbeek JB. Cervical spine clearance in obtunded blunt trauma patients: a prospective study. [Internet] The Journal of Trauma. [cited 31st Aug 2016];68(3): Available from: ed_Blunt_Trauma_Patients_A_Prospective_Study
Duane T, Young A, Mayglothling J, Wilson S et al. CT for all or selective approach? Who really needs a cervical spine CT after blunt trauma. JTACS [Internet] [cited 31st Aug 2016];74(4): Available from: ly_needs.21.aspx
McCracken B, Klineberg E, Pickard B, Wisner D. Flexion and extension radiographic evaluation for the clearance of potential cervical spine injuries in trauma patients. European Spine Journal [Internet] [cited 31st Aug 2016];22(7): Available from:
Lukins TR, Ferch R, Balogh ZJ, Hanesen MA. Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm. ANZJS [Internet] Available from:
Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T et al. Accuracy of the canadian c-spine rule and NEXUS to screen for clinical important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ [Internet] [cited 31st Aug 2016];184(16): Available from:

50. References
Toretti JA, Sengupta DK. Cervical spine trauma. Indian J Orthop [Internet] [cited 31st Aug 2016];41(4): Available from:
Theodore N, Hadley MN, Aarabi B, Dhall S et al. Prehospital cervical spine immobilization after trauma. Neurosurgery [2013]. [cited 31st Aug 2016];72: Available from: mmobilization_After.6
Patel MB, Humble SS, Cullinane DC, Day MA et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg [Internet] [cited 31st Aug 2016];78(2): Available from:
AIHW: Norton L Spinal cord injury, Australia 2007–08. Injury research and statistics series no. 52. Cat. no. INJCAT 128. Canberra: AIHW.
AIHW: Pointer S Trends in hospitalised injury, Australia: 1999–00 to 2012–13. Injury research and statistics series no. 95. Cat. no. INJCAT 171. Canberra: AIHW.
Sundstrom T, Asbjorsen H, Habiba S, Sunde GA et al. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma [Internet] [cited 31st Aug 2016];31: Available from: Medline
Moliere S, Benedetti CZ, Ehlinger M, Le Minor JM et al. Evaluation of paraspinal fat pad as indicator of posterior ligamentous complex injury in cervical spine trauma. Radiology [Internet] [cited 31st Aug 2016] Available from: Medline.