1. Cervical Spine Assessment
Peter Llewellin
SDMH EMC 2015

2. Epidemiology Incidence of 1-3% of all blunt trauma cases
Commonest in MVA, Falls patients (60-90%)
Minor trauma only in elderly and spondylytic patients
Of all spinal cord injuries, 60% are cervical spine injuries in origin

3. Anatomy C1 : Ring with lateral masses Occipital articulation above
Axial articulation below.

4. Anatomy
C2 vertebrae

5. Anatomy
C1 on C2

6. Standard C-spine vertebrae
Vertebral body
Pedicle,
Laminae,
Facet joints,
Spinous processes

7. Anatomy
Cervical alignment

8. Cervical ligaments

9. Clinical Features
History of blunt trauma - MVA, Fall > 1m, Diving, Sporting accident.
Neck pain - almost universally present
Limb weakness, paraesthesiae, paralysis (particularly upper limb). Frequently absent despite significant injury.
Clinical findings unreliable in multi-trauma, elderly or intoxicated patients.

10. C-Spine Decision Rules
Imaging not always indicated
Often immobilised and imaged without need
However, miss of cervical injury potentially disastrous
Major decision rules –
NEXUS
Canadian C-Spine Rule (CCSR)

11. NEXUS Midline neck tenderness Altered level of consciousness
Identified 5 features that prevent C-spine clearance
Studied pts
Plain Cervical XR
Ages 1-101
99.6% sensitive
12.6% specific
99.8% NPV
Sensitivity in elderly >65 questioned
Sensitivity may be lower in ‘real life’
Midline neck tenderness
Altered level of consciousness
Focal neurological deficit
Intoxication
Distracting injury
If present , imaging required

12. Canadian C-Spine Rule 8954 pts Excluded <16yr Plain Cervical XR
Note functional aspect of assessment
100% sensitive
42.5% specific
In practice, either rule acceptable for low risk cervical assessment
Note that elderly require special attention if using NEXUS

13. Radiology of C-spine Imaging – XR vs CT? Decision rules - plain views
CT higher sensitivity
Radiation dose? –
0.05mSv vs 3.8mSv
High risk vs Low risk patients?
CT for difficult XR pt’s

14. The C-spine Series
3 shot series
Lateral AP
Open mouth ‘peg’ view

15. C-spine films
7ABC’S
7 vertebra including C7-T1 interface need to be visible
Swimmers view may assist this

16. Assessing C-spine films
Assess Alignment of lateral film - check for the cervical spine lines, ensuring no irregularity.

17. Assessing C-spine films
Assess Bones
Assess Cartilages
Assess Soft tissues- soft tissue swelling will occur around injuries
Maximum measures -pre-dental space < 3mm; C2 < 6mm; C6 < 22mm

18. Peg view Shot as ‘open mouth’ view Needs pt. co-operation
Looks at atlanto-axial joint and dens
Dens should be intact; lateral masses of C1 should be symmetrical and aligned with C2

19. Other Imaging AP view – limited additional information
Flexion-Extension views ligamentous injury; no longer recommended (MRI)
CT scanning indicated –
a) abnormality identified
b) imaging sub-optimal.

20. Types of fracture Approximately 20 fracture patterns identified
Often more useful to assess stability rather than pattern

21. Assessing Stability 3 column theory
Instability occurs with damage to middle column and 1 other column.
i.e. spinous process fracture stable, burst fracture C6 body unstable.

22. Disposition ABC of resuscitation take priority over C-spine management
All C-spine injuries should be reviewed by spinal surgical team regarding management plan
Cord syndromes should be referred to specialist spinal units.

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