Clearing Cervical Spine Injuries: MRI, Dynamic X-rays, CT

In the past, practice guidelines based on clinical experience have led to better detection rates of injury and hence improved patient care. The development of evaluation protocols based on best evidence medicine and the increased access to advanced imaging studies (especially CT) has paralleled the improvement in patient care.1 In general, CT has become a frontline tool in the evaluation of blunt trauma and cervical spine injury, often supplanting the need for plain radiographs.11 A comprehensive review of the literature included a search of the Medline database and a review of the references of relevant review articles. The best evidence for the use of advanced radiographic imaging studies for evaluation of cervical spine injuries was chosen from the search (Table 2.1). For evaluation of MRI in clearance of the cervical spine, three level I studies were identified and one metaanalysis. Three level II studies of the use of MRI were also identified. Two level III studies comparing dynamic x-ray versus CT where identified: one relying on upright (gravity Cervical spine injury patients require careful evaluation to prevent further morbidity due to apparent and hidden injuries. Systematic evaluation including injury history, physical examination, and imaging studies helps to prevent complications from missed injuries. Awake and alert patients who have negative exam findings do not require further evaluation. When utilized appropriately, cervical spine evaluation algorithms have decreased the morbidity for injured patients.1–3 Cervical collars should be removed as soon as feasible after trauma. As soon as an injury has been excluded, the collar should be discontinued to decrease collar-associated morbidity. Some examples of morbidity associated with collar use are decubitus ulceration4–6 and increased intracranial pressure (ICP).7,8 Increased duration of mechanical ventilation, longer intensive care unit (ICU) and hospital stays, and increased incidence of delirium and pneumonia were also associated with collar use.9 Radiographic evaluation with plain x-rays, dynamic xrays, computed tomography, and magnetic resonance imaging (MRI) in a systematic manner minimizes the chance for undetected occult injury. In turn, this decreases additional patient morbidity. The end point in evaluation of these injuries is the detection or exclusion of significant injury to the cervical spine. MRI has been especially touted for the ability to detect ligament and disk injury in the face of normal radiographic and CT studies. Significant injury is that which requires ongoing treatment, either with immobilization or with surgery. Clearing the cervical spine of injury is a critical phase in the treatment of polytrauma patients to further the treatment process and prevent morbidity associated with immobilization.10 Clearance is best defined as the exclusion of significant injury, and this allows discontinuation of immobilization and precautions, better pulmonary care, and easier ancillary care. Table 2.1 Evidence of Published Studies