Clearing the cervical spine is the process by which medical professionals determine whether

cervical spine In tetrapods, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In sau ...

injuries exist, mainly regarding

cervical fracture A cervical fracture, commonly called a broken neck, is a fracture of any of the seven cervical vertebrae in the neck. Examples of common causes in humans are traffic collisions and diving into shallow water. Abnormal movement of neck bones or pie ...

. It is generally performed in cases of

major trauma Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Dependin ...

. This process can take place in the

emergency department An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pati ...

or in the field by appropriately trained EMS personnel. If the patient is obtunded, i.e. has a head injury with altered

sensorium A sensorium (/sɛnˈsɔːrɪəm/) (plural: sensoria) is the apparatus of an organism's perception considered as a whole, the "seat of sensation" where it experiences, perceives and interprets the environments within which it lives. The term origi ...

, is intoxicated, or has been given potent analgesics, the cervical spine must remain immobilized until a clinical examination becomes possible.

Neurosurgeon Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peri ...

s or

orthopaedic surgeon Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...

s manage any detected injury. Today, most large centers have spine surgery specialists, that have trained in this field after their orthopedic or neurosurgical residency.

History and examination

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...

and

physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...

can be sufficient in clearing the cervical spine. Notable

clinical prediction rule A clinical prediction rule or clinical probability assessment specifies how to use medical signs, symptoms, and other findings to estimate the probability of a specific disease or clinical outcome. Physicians have difficulty in estimated risks of ...

s to determine which patients need

medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...

are the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS). The following is based on the NEXUS (National Emergency X-Radiography Utilization Study) criteria. Excluding a cervical spinal injury requires clinical judgement and training. Under the NEXUS guidelines, when an acute blunt force injury is present, a cervical spine is deemed to not need radiological imaging if all the following criteria are met: * There is no posterior midline

cervical In anatomy, cervical is an adjective that has two meanings: # of or pertaining to any neck. # of or pertaining to the female cervix: i.e., the ''neck'' of the uterus. *Commonly used medical phrases involving the neck are **cervical collar **cerv ...

tenderness * There is no evidence of intoxication * The patient is alert and oriented to person, place, time, and event * There is no focal neurological deficit (see

focal neurological signs Focal neurologic signs also known as focal neurological deficits or focal CNS signs are impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg, paresis, or pl ...

) * There are no painful distracting injuries (e.g., long bone fracture)

Medical imaging

Choice of method

*In ''children'', a CT scan of the neck is indicated in more severe cases such as neurologic deficits, whereas

X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

is preferable in milder cases, by both US and UK Updated in June 2017 guidelines. Swedish guidelines recommend CT rather than X-ray in all children over the age of 5. *In ''adults'', UK guidelines are largely similar as in children. US guidelines, on the other hand, recommend CT in all cases where medical imaging is indicated, and that X-ray is only acceptable where CT is not readily available.

Magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...

may be useful if it is necessary to exclude a ligament injury. The indication for MR spine is a focal neurological deficit. Another indication for MR of the cervical spine is persistent mid-line neck pain or tenderness despite a normal CT in the awake patient.

Imaging settings

X-ray consists of a three view cervical x-ray series, adding a swimmer's view if the lateral doesn't include the C7/T1 interface. CT scan should be thin slices, ideally 1.5 mm or less. It should include first thoracic vertebra. Updated: 4/24/2019

Evaluation

CT scan or

images are evaluated for the presence or absence of directly visible fractures. In addition, indirect signs of injury by the vertebral column are incongruities of the

vertebral lines In tetrapods, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In ...

, and/or increased thickness of the

prevertebral space The prevertebral space is a space in the neck. On one side it is bounded by the prevertebral fascia. On the other side, some sources define it as bounded by the vertebral bodies, and others define it as bounded by the longus colli. It includes ...

: File:X-ray of vertebral lines.jpg,

of normal congruous

File:Vertebral lines.png, CT scan of normal congruous vertebral lines. File:CT of prevertebral space.jpg, CT scan with upper limits of the thickness of the prevertebral space at different levels.

After imaging

If the patient is not expected to be clinically evaluable within 48–72 hours because of severe head or multiple injuries, they should remain immobilized until a time when such an examination is possible. A 64-slice CT with reconstructions does not entirely rule out ligamentous injury leading to instability, but is a practical means of identifying the majority of C-spine injuries in obtunded patients. MR C-spine has frequent false-positives, limiting its usefulness. In these cases, a consultation with a Spine Surgery specialist is prudent.

References

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External links

Wilderness Medicine Protocols

NEXUS Criteria for C-Spine Imaging

Canadian C-Spine Rule
Emergency medicine Injuries of neck