Clearing the cervical spine of adult victims of trauma.

The focus of this paper is on the clearance of the cervical spine in those patients who are seriously injured or have the potential to be seriously injured. Specifically excluded from this paper are children. "Whiplash" injury is covered at the end of this paper. Injuries to the cervical spine occur in 2% to 12% ofblunt trauma victims,'" 10% to 20% of patients with serious head injury,5 6 and one in 300 serious motor vehicle accidents.7 The emergency physician has a key role in the management of patients with or the potential for cervical spine and cord injuries. First, a spinal injury must be assumed to be present and the spine and cord protected from further injury by immobilisation of the whole spine. Spine and spinal cord injury must be detected and those patients with the potential for further injury from ligamentous damage identified. Cervical spine injury must be excluded in those who are alert and stable. In those who are obtunded immobilisation must continue and others must include the possibility of spine and cord injury in their subsequent investigation and management plans. The consequences of missing a cervical spinal injury are further avoidable neurological deficits that may lead to death, quadriplegia, and long term disability. The reported incidence of missed or delayed diagnosis of cervical spine injuries is 4.6% to 8.25%' 8 but may be as high as 23%.9 It is estimated that for the whole spine the incidence of a secondary neurological deficit, that is where the initial examination revealed an absence of neurological injury with subsequent development of a deficit, is 10.5% for those with delayed diagnosis compared with 1.4% for those in whom the fractures were recognised.9 However, for the cervical spine this may be as high as 30%.1 The financial cost of these patients is considerable. A lifetime cost of caring for a quadriplegic has been estimated at between $1m and $5m.1" Concern raised by the risk of missing a cervical spine injury and worsening the patient's condition was heightened by anecdotal reports of occult cervical spine fractures. The influential American College of Surgeons Committee on Trauma through the Advanced Trauma Life Support (ATLS) programme" has taught that patients sustaining an injury above the clavicle or a head injury resulting in an unconscious state should be suspected of having an associated cervical spine injury. Any injury produced by high speed vehicles should arouse suspicion of concomitant spine and spinal cord injury. This was coupled with the teaching that "a vertebral column injury should be presumed and immobilisation of the entire patient should be maintained until screening roentgenograms are obtained and fractures or fracture-dislocations are excluded". Apprehension about cervical spine injuries has led to the application of these policies intended for those who are injured or at high risk to those who have minor trauma or who are at low risk of injury. Thus Eliastam et al in 1980 found that 40% of cervical spinal films were taken for medicolegal reasons.'2 Immobilisation of the cervical spine is now widespread and liberally applied and has been associated with protocol driven ordering of cervical spine radiographs." This has led to the liberal use of radiography with, for example, more than 98% of radiographs ordered in Canadian centres being negative for fracture or dislocation (I Stiell, personal communication). Clearance of the cervical spine may be said to occur when the clinician is satisfied after appropriate history, examination, and investigation that the risk of an important injury being present is negligible. There is considerable variation in the use of radiography. Thus there is a twofold difference in the rate of use among some Canadian hospitals (I Stiell, personal communication) and there has, for example, been a twofold increase in emergency department cervical spine radiography between 1990 and 1995 at the Bristol Royal Infirmary (internal audit, 1996). This suggests that there are no clear indications as to who should and should not be have radiography. Personal communication with emergency physicians in four major departments in North America (Sunnybrook Hospital, Toronto, Vancouver General Hospital, Oregon Health Sciences University Portland, and the Shock Trauma Centre, Baltimore) confirms that not only is there considerable variation in the indications for radiography but also with regard to which views should be taken for patients who are conscious and alert (fig 1). What criteria should be met for clearance of the cervical spine? The American College of Surgeons Committee on Trauma states "usually .... when no roentgenographic Emergency Department, Southampton General Hospital, Tremona Road, Southampton S016 6YD