CERVICAL SPINE CLEARING
1. The awake, alert patient, with no other
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.
2. The mentally obtunded patient.
Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.
This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.
2. The mentally obtunded patient.
Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.
This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.