Cervical Immobilization Research Articles

Evaluation and Initial Management of Cervical Injuries

The goals for evaluation and initial management of cervical injuries are prompt recognition of the problem and prevention of secondary neurological damage. Missed diagnoses are common because of the difficulty in identification of cervical spine trauma, particularly in polytrauma patients with altered level of consciousness. Close adherence to a well-reasoned spine clearance protocol may decrease the incidence of missed injury in polytrauma patients. It is estimated that 2 to 3% of all trauma patients, and 10% of patients with serious head injuries, sustaincervicalspineinjuries, 1 andofthose,between3and25% suffer extension of those injuries from delay in diagnosis or unwarrantedmanipulationintheemergencydepartment. 2 In this article, the protocols for evaluation and initial managementofcervicalspineinjuries“Onthescene,”“Playingfield,” and “In the trauma bay” have been reviewed. On the Scene Management of any obvious or potential cervical spine injury should be a part of the overall patient stabilization and preparation at the scene of the injury, before transfer to the hospital. The circumstances of the accident or injury should be assessed quickly. The basic life support measures should be initiated according to the Advanced Trauma Life Support (ATLS) 3 protocol with A (airway protection), B (breathing andventilation),andC(maintaineffectivecirculation)inthat order. The spine (especially, but not exclusively, the cervical spine) should also be protected while the ABC measures are instituted. The patient’s neck should not be hyperextended, hyperflexed, or rotated, which is especially difficult to avoid while trying to maintain the airway. Ideally, preventing such neck movements can be facilitated with appropriate cervical immobilization devices (eg, hard collar and tape). If these are not immediately available, sandbags or rolled-up pieces of clothing can be used as temporary support until a paramedic crew arrives. Use of spinal boards offers a very effective and easy-to-use means of transferring trauma patients. Asking patients simple questions, such as their name and areas of pain, and providing plenty of reassurance will help calm them and will also help in the assessment of their neurological status. If appropriate responses are received, then simple commands to move arms and legs should provide an immediate overview of the gross neurological status. Presence of peripheral injuries (eg, fractures) may make movement extremely painful and may interfere with neurological assessment. A careful record of the neurological status in the initial stage is extremely important in further management of thepatient.Neurologicalexaminationbecomesdifficultifthe patient loses consciousness or needs to be sedated at a later stage. The baseline neurological status serves as a guide to any deterioration during the subsequent course of treatment and also helps to classify any spinal cord injury as complete versus incomplete, which has important implications in prioritizing surgical stabilization of the spine. Effective pain relief is important in the initial treatment of a trauma patient. Caution should be exercised when administering high doses of opiates or other sedatives, which may depress the level of consciousness. If the patient becomes drowsy or comatose or has significant facial injuries, intubation/ventilation should be considered for airway protection and safe transfer. Patients with a score lower than 8 on the Glasgow Coma Scale (GCS) should definitely be intubated before transfer. Pupillary asymmetry and reaction to light should be assessed because they can indicate significant intracranial pathology.

Effect of hair and clothing on neck immobilization using a cervical collar

An important step during spine immobilization is application of a cervical collar. Clothing or hair covering the neck may impinge on this process. The purpose of this study was to evaluate the effect of clothing and hair covering the neck on immobilization using a cervical collar. Study participants were 18 female volunteers with long hair aged 20 to 28 years. Cervical range of motion (ROM) was tested in 6 directions (flexion, extension, right and left lateral bending, right and left axial rotation) using a cervical ROM (CROM) device. After measuring unrestricted ROM (no cervical collar), a 1-piece rigid cervical collar was placed the neck (1) covered by hair and clothing; (2) covered by clothing; (3) covered by hair; or (4) uncovered. Range of motion was retested under all 4 conditions. Data were compared using crossover-design analysis of variance ( P < .05 statistically significant). Range of motion in all directions was significantly restricted by cervical collar placement under all conditions. Unrestricted ROM in all directions ranged from 41.50° (7.25°) to 70.76° (15.4°). In contrast, ROM with a cervical collar under the 4 conditions in all directions ranged from 10.80° (5.10°) to 18.81° (7.37°). We were unable to detect any significant differences in ROM between the 4 conditions. Our data suggest that long hair and clothing, which cover the neck, do not alter the effectiveness of cervical collar immobilization as measured by the cervical ROM device.

Assessing Cervical Spine Stability in Obtunded Blunt Trauma Patients: Review of Medical Literature

To review the current medical literature on dynamic fluoroscopic and magnetic resonance (MR) imaging assessment of cervical spine stability in obtunded patients who sustained blunt trauma. The English-language literature within the Swetswise and Medline databases was searched for articles describing dynamic fluoroscopic or MR imaging assessment of cervical spine stability in patients who sustained blunt trauma. Patients with fractures or radiographic signs of injury were excluded. The frequencies of purely ligamentous injuries, injuries requiring immobilization, and other clinically important nonligamentous abnormalities were determined. The frequency of isolated cervical ligamentous injuries diagnosed with dynamic fluoroscopy, as reported in the literature, was 0.9% (11 of 1166 patients), whereas the reported frequency of these injuries diagnosed with MR imaging was 22.7% (125 of 550 patients). All injuries diagnosed with dynamic fluoroscopy and 101 (80.8%) of those diagnosed with MR imaging required continued cervical immobilization. Six (60%) of 10 injuries diagnosed with dynamic fluoroscopy and seven (5.6%) of 125 injuries diagnosed with MR imaging required surgical or halo stabilization. Five (2.5%) of the 200 obtunded patients assessed with MR imaging and six (0.5%) of the 1166 obtunded patients evaluated with dynamic fluoroscopy required surgery. Review of the current medical literature provided no clear evidence of the superiority of either MR imaging or dynamic fluoroscopy in the diagnosis of unstable ligamentous injury, although other relative advantages of MR imaging indicate that it is preferred for assessing cervical spine stability in obtunded blunt trauma patients.

Tête tombante fixée : efficacité d'une rééducation intensive

Objectives. – To point out the diagnostic and etiologic context of neck extensor weakness and to consider orthopedic and rehabilitation treatment of dropped head syndrome. Methods. – We report a case of a 68-year-old hospitalized woman with atypical and serious idiopathic neck extensor weakness who was treated by orthopedic measurements and intensive rehabilitation. Results. – Our patient had progressive neck extensor weakness and total inflection of the cervico-cephalic axis over two years. Fixed and permanent contact of the chin and the sternum severely affected her ability to eat, and mandibular and sternal pressure ulcers developed. Cervical spine radiography revealed degenerative lesions. Other clinical and biological parameters were normal. Atypical idiopathic head drop was diagnosed because of painful and fixed head position. Rehabilitation consisted of cervical traction with a halo apparatus during eight weeks and an exercise programme based on cervical proprioception and muscular work. Orthopedic management consisted of cervical collar immobilization after cutaneous cicatrization. After ten weeks of treatment, the patient was able to raise her head and maintain it horizontally. Two years later, clinical results were stable. Discussion. – Neck extensor weakness may be the presenting feature of several neuromuscular disorders. Generally, idiopathic dropped head syndrome appears to be the most likely diagnosis in patients with isolated neck extensor involvement. For our patient, clinical findings and cervical computed tomography showed important muscular weakness. However, painful passive extension and progressive stiffness of the neck do not represent the typical clinical course of idiopathic head drop. Neither degenerative lesions of the cervical spine nor other joint diseases can cause head drop. This case may result from the combined effects of idiopathic dropped head syndrome and cervical arthrosis. Orthopedic treatment and intensive rehabilitation had spectacular effects. Clinical management of head drop syndrome should always consist of orthopedic and rehabilitation treatment.

Limited oblique corpectomy for treatment of ossified posterior longitudinal ligament

We present our experience with treating four cases with ossified posterior longitudinal ligaments (OPLL) causing cervical cord compression by limited oblique and strategic corpectomy. Four patients with cervical OPLL were treated by the discussed technique during the period of October 2000 to January 2005. The ages of the patients ranged from 46 to 72 years. All patients presented with symptoms of progressively increasing myelopathy. Two patients had four level OPLL and two patients had two level OPLL. Surgery involved anterior cervical exposure and partial oblique corpectomy, which was essentially an extended midline and lateral undercutting of the body. The procedure provided a wide exposure for resection of the OPLL. No metal instrumentation or any other kind of fixation procedure was simultaneously carried out and there was no need for postoperative cervical immobilization. During the period of follow up that ranged from 6 month to 5 years (mean: 33 months) all the four patients have shown sustained clinical improvement. Neuroimaging studies confirmed satisfactory anatomical cervical cord decompression in all patients. The technique of oblique and strategic corpectomy provided a wide exposure for resection of the OPLL and preserved the stability of the region.

TrapEase Inferior Vena Cava Filter Placement: Use of the Subclavian Vein

The purpose of this paper was to evaluate the safety and technical success of TrapEase inferior vena cava filter placement via the subclavian vein. As of yet, no reports in the literature have specifically investigated the use of the subclavian vein as a route for deploying TrapEase vena cava filters. Retrospective chart review was conducted of 135 patients with attempted TrapEase inferior vena cava filter placement over a 2-year period. In a majority of cases, the choice of subclavian vein approach was based primarily on surgeon preference. Other circumstances for subclavian vein deployment included cervical immobilization secondary to trauma, desire for concomitant placement of a subclavian long-term central venous access catheter, and patient body habitus limiting exposure to the internal jugular vein. One hundred and thirty-five filters were placed over this 2-year period. The internal jugular vein approach was used in 56 patients, the femoral vein approach in 39 patients, and the subclavian vein approach in 40 patients. Thirty-nine of the 40 TrapEase filter placements using the subclavian vein were successful. Twenty-six were deployed through the right subclavian vein and 14 through the left subclavian vein. The single failed subclavian deployment was due to the inability to pass the guidewire adequately into the inferior vena cava after successful cannulation of the right subclavian vein. The average deployment time for subclavian vein placement was 26 minutes when TrapEase filter placement was the only procedure performed. No insertional complications were encountered, specifically no pneumothoraces confirmed by chest radiography or fluoroscopy. The subclavian vein provides an alternative site of access for the TrapEase inferior vena cava filter. This route is comparable to other alternative methods evaluated both in average deployment time and complication occurrence. Furthermore, the subclavian vein route is valuable in patients with limited central access and where combined long-term central venous catheter placement using the subclavian vein is desirable.

Outcome of halo immobilisation of 104 cases of cervical spine injury.

Retrospective review. To present and discuss the outcome of halo jacket immobilisation of cervical spine injuries. National Spinal Injuries Unit in a Scottish University teaching Hospital. Retrospective review of case-notes and radiographs of all patients treated with halo jacket both as primary means of immobilisation or as adjunct to surgical stabilisation between 1992-1999 and followed up at a weekly halo clinic. Out of a total one hundred and four patients with cervical spine injury, eighty-six were treated with Halo jacket as primary means of cervical immobilisation. Halo was used as adjunct to surgical stabilisation for the rest. There were nine cases of true failure. This is a failure rate of 10% for primary halo immobilisation. Of the nine patients who had failure of bony healing, four had fibrous healing, three had surgery to stabilise spine, two were subsequently lost to follow-up. The highest incidence of recurrence of subluxation occurred in patients with fracture/subluxation with a healing rate of 85%. Patients with ankylosing spondylitis did well. Odontoid fractures had 18% failure rate. The commonest complication was loss of reduction, followed by pin-site infection. Halo is an effective non-surgical treatment for the injured cervical spine at both upper and lower levels.

Gunshot wounds of the cranium or torso: Implications for spinal immobilization and airway management

Methods to secure the airway and immobilize the spine are undertaken immediately in the evaluation of the severely injured patient. The incidence of cervical spine injury (CSI) in patients with head injury ranges from 1.7% to 11.1%. These reports predominantly include patients with blunt trauma. However, the strategy for spinal immobilization has been taught not only for blunt injuries but also for victims of penetrating trauma, such as gunshot wounds (GSWs). According to the Advanced Trauma Life Support textbook, “Any injury above the clavicle should prompt a search for a c-spine injury.” Spinal immobilization using a rigid cervical orthosis and long backboard may have certain implications with respect to airway management. Cervical and thoracolumbosacral (TLS) immobilization has been shown to interfere with respiratory mechanics. Time spent performing immobilization may delay necessary airway interventions and prolong time to definitive care at a trauma center. We undertook this examination of the medical literature to document the likelihood of cervical and TLS spine injury in patients with GSW of the cranium or torso, assess the impact of spinal immobilization on airway interventions, and provide guidance regarding the necessity for routine spinal immobilization in the prehospital setting.

C OMPARISON OF T IMES TO I NTUBATE A S IMULATED T RAUMA P ATIENT IN T WO P OSITIONS

Background. The nature of the trauma patient's injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients. Objectives. The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient. Methods. Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27°, resulting in 7° of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with χ2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position. Results. Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 ± 19.0 seconds vs 27.9 ± 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007). Conclusions. Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.

Evaluation of the performance of general emergency physicians in pediatric emergencies: Obstructive airway diseases, seizures, and trauma.

In the Lübeck region, as is usual in Germany, hospital-based emergency physicians are called for outside emergencies. They evaluate and stabilize patients and transfer them to hospital facilities of their choice (no emergency department system). These physicians are mainly anesthesiologists, surgeons, and internists-not pediatricians. Numerous quality management studies have shown an overall excellent performance of this system, but it has not been evaluated for pediatric emergencies. In a prospective, observational study conducted over a 1-year period, all pediatric emergencies (patient age < 15 y) treated by the emergency physician service were studied. A syllabus with standards of care for children with trauma, obstructive airway disease, and seizures was distributed. In accordance with this syllabus, the actions taken were documented by the emergency physicians, and the cases were documented as life threatening or not and were classified as "trauma," "obstructive airway disease," "seizures," or "other" by the admitting pediatric intensivists and surgeons. The admitting attending physician compared these data and evaluated whether the standard management required by the syllabus was followed. A total of 422 pediatric cases out of 11,605 emergencies (3.5%) were recorded (147 [34.8%] trauma patients, 41 [9.7%] patients with obstructive airway disease, and 108 [25.6%] patients with seizures). Of the pediatric patients, 20.5% had life-threatening conditions; three children died before arrival, and the others required treatment in the intensive care unit. In 25% of trauma patients, deficiencies in primary treatment were observed: no documentation of neurologic status in 10.6%, no cervical immobilization in 15% of head trauma patients, and no adequate analgesia in 7%. In 25% of seizure patients, neurologic status was not documented, although treatment was in accordance with the standard of care. The worst results were observed in infants with obstructive airway disease: no documentation of oxygen saturation in 71.4%, no oxygen therapy despite hypoxemia in seven of 12 patients, and overall therapy not in accordance with the standard of care in 50%. The high quality of the emergency physician service documented for adults is not reproduced in the pediatric population. Trauma and seizures with similarities to adult cases are handled in a fair manner. However, the most important pediatric diagnostic entity of obstructive airway disease is often not treated adequately. Intensified educational programs for emergency physicians are warranted.

The management and prevention of rigid cervical collar complications.

The rigid cervical collar has been a great addition to the successful management of cervical spine injuries. But the collar has been known to offer a false sense of security in terms of totally preventing additional and further spinal cord compromise and damage. Also, with increased length of collar wear, there is development of skin pressure points and ulcer formation, possible delay in weaning from a ventilator, potential for exposure to transmission of blood-borne diseases. Photographs are used to demonstrate examples of related skin breakdown, show proper collar fit, present the result of ineffective cervical immobilization, and show how to stabilize the head and neck during a collar change. These problem areas are addressed with the dos and don'ts for nursing management.

Cochrane Review on the Role of Surgery in Cervical Spondylotic Radiculomyelopathy

This study involved a search of MEDLINE (1966 to 2000), EMBASE (1980 to 2000), and the Cochrane Controlled Trials Register. The authors of the identified randomized controlled trials were contacted to detect any additional published or unpublished data. The trials selected for this study included all the truly unconfounded or quasi-randomized controlled investigations allocating patients with cervical radiculopathy or myelopathy to 1) "best medical management" or "decompressive surgery (with or without some form of fusion) plus best medical management," or 2) "early decompressive surgery" or "delayed decompressive surgery." Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted the data. To determine whether surgical treatment of cervical radiculopathy or myelopathy is associated with improved outcome, as compared with conservative management, and whether the timing of surgery (immediate or delayed because of persistence or progression of relevant symptoms and signs) has an impact on outcome. Cervical spondylosis causes pain and disability by compressing the spinal cord or roots. Surgery to relieve the compression may reduce the pain and disability. However, it is associated with a small but definite risk. This study sought to assess the balance of risk and benefit from surgery. Two trials involving a total of 130 patients were included. One trial with 81 patients compared surgical decompression with either physiotherapy or cervical collar immobilization in patients with cervical radiculopathy. The short-term effects of surgery, in terms of pain, weakness, or sensory loss were superior. However, at 1 year no significant differences between the groups were observed. Another trial with 49 patients compared the effects of surgery with those of conservative treatment in patients who had a mild functional deficit associated with cervical myelopathy. No significant differences were observed between the groups up to 2 years after treatment. The data from the reviewed trials were inadequate to provide reliable conclusions on the balance of risk and benefit from cervical spine surgery for spondylotic radiculopathy or myelopathy.

Evaluation of spine injury in blunt trauma.

Although prehospital trauma guidelines call for spine immobilization for many trauma victims, there is a lack of clarity in medical institutions as to how trauma or emergency medicine physicians should proceed to remove cervical immobilization devices (CIDs) and "clear" the spine. Despite wide variations in physicians' approaches to such matters, however, certain specific aspects of vertebral assessment in such circumstances are well documented. The authors describe and explore several of these issues with respect to initial approach to the immobilized patient, clinical clearance of the spine, radiographic evaluation of the vertebrae in victims of blunt trauma, management of spine tenderness or pain, removal of CIDs, and indications for subspecialty consultation. Critical care physicians should be reminded that the responsibility lies with them for removing CIDs and halting other spine precautions--underlying the importance of careful consultation with radiologists and other specialists.

Upper extremity nerve blocks for the trauma patient

Regional anesthesia can provide a number of benefits for the patient with upper extremity injury but requires careful consideration of several problems unique to the trauma victim. When planning the approach to the brachial plexus, both the site of injury as well as associated conditions, such as the presence of a cervical immobilization device, become important. The practitioner should learn several approaches to the plexus as well as supplemental blocks at the wrist. The use of a nerve stimulator or portable ultrasound device may improve success in patients with difficult landmarks. Intravenous regional anesthesia remains an effective alternative to brachial plexus block for short surgical procedures. Copyright © 2002 by W.B. Saunders Company

Atlanto-axial rotatory subluxation in children: early management.

Atlanto-axial rotatory subluxation (AARS) is an uncommon condition involving dislocation and abnormal fixation of the atlas on the axis. AARS is difficult to diagnose and if improperly treated it may lead to permanent neck deformity. We report a retrospective series of patients diagnosed with AARS seen during the last five years. The children presented with neck pain, head tilt, and reduction in neck mobility. In three of the cases the condition was secondary to cervical trauma and in the fourth it was associated with otitis (Grisel syndrome). The diagnosis was established by three-dimensional computerised tomography. In three cases, the atlanto-axial fixation was cured after cervical immobilisation and physiotherapy. A posterior cervical fusion was required in the remaining case. Early detection and intensive conservative treatment constitutes the mainstay of management of AARS. Surgery is reserved for cases with irreducible or recurrent subluxation.

Surgery for cervical radiculomyelopathy.

Cervical spondylosis causes pain and disability by compressing the spinal cord or roots. Surgery to relieve the compression may reduce the pain and disability, but is associated with a small but definite risk. We sought to assess the balance of risk and benefit from surgery. To determine whether: 1) surgical treatment of cervical radiculopathy or myelopathy is associated with improved outcome, compared with conservative management and 2) timing of surgery (immediate or delayed upon persistence/progression of relevant symptoms and signs) has an impact on outcome. We searched Medline (between 1966 and 1998), Embase (between 1980 and 1998) and the Cochrane Controlled Trials Register. Authors of the identified randomised controlled trials were contacted to detect any additional published or unpublished data. All unconfounded truly or quasi-randomised controlled trials allocating patients with cervical radiculopathy or myelopathy to 1) "best medical management" or "decompressive surgery (with or without some form of fusion) plus best medical management" 2) "early decompressive surgery" or "delayed decompressive surgery". Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. Two trials involving a total of 130 patients were included. One trial with 81 patients compared surgical decompression with either physiotherapy or cervical collar immobilization in patients with cervical radiculopathy. The short-term effects of surgery, in terms of pain, weakness or sensory loss were superior, however, at one year no significant differences between groups were present. One trial with 49 patients compared the effects of surgery with those of conservative treatment in patients with mild functional deficit associated with cervical myelopathy. No significant differences were observed between groups, up to two years following treatment.

Acute respiratory compromise associated with flexed cervical traction after C2 fractures.

Acute respiratory compromise is occasionally observed in a subgroup of patients with upper spinal injuries involving the C2 vertebrae. A retrospective review was performed to identify fracture types and risk factors for early respiratory deterioration following injury to the upper cervical spine. To examine the frequency of respiratory complications encountered following traction manipulation of specific upper cervical spinal injuries involving the C2 vertebrae. Major complications related to cervical skeletal traction are uncommon. Respiratory compromise with occasional mortality has been observed. Risk factors for acute respiratory failure are unknown. The medical records of 166 consecutive patients with fractures of the C2 vertebrae admitted between January 1994 and July 1998 to a regional spinal cord injury center were examined. Demographic data, injury subtype, fracture displacement, respiratory status, treatment method, and outcome at discharge were examined. Patients with comorbidities compromising respiratory function were excluded. One hundred fifty-five patients met the inclusion criteria of this study. Sixty-one patients had Type II odontoid fractures of which 53 were displaced (32 posteriorly and 21 anteriorly). In addition, there were 21 patients with Type III odontoid fractures, 33 with axis C2 body fractures, 32 with Hangman's fractures, and eight patients with an os odontoideum. Thirteen of 32 patients with posteriorly displaced odontoid fractures experienced acute respiratory compromise following reduction with cervical skeletal traction and immobilization, while only three of the remaining 123 patients had respiratory difficulties. Respiratory distress as a consequence of cervical spine fractures resulted in three deaths. Two of these patients had posteriorly displaced Type II odontoid fractures whose airway could not be emergently intubated. Frequent respiratory deterioration (40% of patients) during acute management of posteriorly displaced Type II odontoid fractures after reduction was observed. Physicians must be aware that cervical flexion in the treatment of posteriorly displaced odontoid fractures may significantly increase the risk of airway obstruction due to the presence of acute retropharyngeal swelling. This may be avoided with elective nasotracheal intubation in this upper cervical spine fracture subtype.

Cervical spine instability: clearance using dynamic fluoroscopy

Purpose Cle aring the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries. Methods We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded. Results One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury. Conclusions With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted.

Commentary

Cle aring the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries.We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded.One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury.With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted.

S PINAL I MMOBILIZATION IN THE F IELD : C LINICAL C LEARANCE C RITERIA AND I MPLEMENTATION

Awareness of the health and financial repercussions of unnecessary immobilization has made cervical spinal immobilization controversial in out-of-hospital care. Clinical criteria for clearance of the cervical spine in the hospital based on mechanism of injury have been supported by many trauma centers. However, implementation of clinical criteria for cervical spinal clearance in out-of-hospital settings is not as well validated by multicenter studies or accepted by many emergency departments. This consensus group recommends that clinical criteria to determine “low-risk” patients be available for use by emergency medical services providers in out-of-hospital settings; however, training, audits, quality management, integration into the medical community, and extent of program implementation should be decided based on individual emergency medical services systems.