C-spine Clearance in an Unreliable Patient (Cincinnati Children’s)
Guideline · Nov 2018 · 2 min read
In brief
In brief
Clinical algorithm for cervical spine evaluation in pediatric trauma patients with unreliable examinations (GCS≤4, intubated, or intoxicated). Provides stepwise imaging protocol from plain radiographs through CT and MRI, with criteria for neurosurgical consultation and collar removal based on clinical reliability and imaging findings.
- Unreliable patients (GCS verbal ≤4, intubated, or intoxicated) require cervical collar and imaging—clinical exam alone is insufficient
- Normal C-spine X-rays in unreliable patients warrant CT within 24 hours; if still unreliable, proceed to MRI within 72 hours
- Clinical clearance requires ALL four criteria: normal neuro exam, no tenderness, no pain with ROM, and no distracting injuries
- Escalate abnormal imaging at any stage (X-ray, CT, or MRI) to neurosurgery consultation with collar maintained
- Only remove collar after normal MRI in persistently unreliable patients or after clinical clearance once patient becomes reliable
Written by the GCMD Library team from the guideline.
2.0 DEFINITIONS
2.1. Unreliable Exam: A patient who meets any of the following criteria cannot undergo clinical clearance of the
cervical spine:
—2.1.1. Verbal GCS≤4
—2.1.2. Intubated patient
—2.1.3. ETOH/Drug intoxication
2.2. Clinical clearance of the cervical spine may be performed if ALL of the following criteria are present: 2.2.1. Normal neurologic exam; and
—2.2.2. No tenderness to palpation of the cervical spine; and
—2.2.3. No cervical spine pain with active range of motion; and
—2.2.4. No distracting injuries
3.0 GUIDELINE
3.1. Complete primary and secondary surveys per CCHMC guidelines 3.2. If patient is found to be unreliable:
3.2.1. Cervical collar should be placed
3.2.2. C-spine radiographs should be obtained in the ED (minimum: cross table/lateral) 3.3. Cervical spine radiographs are abnormal:
3.3.1. Maintain cervical collar 3.3.2. Obtain neurosurgical consult 3.3.3. Treatment as indicated
3.4. Cervical spine radiographs are normal, and: 3.4.1. Reliable exam
—a. Exit pathway; refer to reliable c-spine algorithm 3.4.2. Remains unreliable
—a. Maintain cervical collar
—b. Consider CT cervical spine (skull base through T1) within 24 hours 3.5. Cervical CT abnormal:
3.5.1. Maintain cervical collar 3.5.2. Obtain neurosurgical consult 3.5.3. Treatment as indicated
3.6. Cervical spine CT normal: 3.6.1. Patient now reliable
—a. Exit pathway
—b. Refer to reliable c-spine algorithm 3.6.2. Patient remains unreliable:
—a. Maintain cervical collar
—b. MRI cervical spine within 72 hours when stable for transport 3.7. Cervical spine MRI normal:
3.7.1. Document radiographic findings
3.7.2. Remove cervical collar 3.8. Cervical spine MRI abnormal:
3.8.1. Maintain cervical collar 3.8.2. Obtain neurosurgical consult 3.8.3. Treatment as indicated
4.0 REFERENCES
4.1. American College of Surgeons Committee on Trauma. (2012). Spine and spinal cord trauma. In Advanced trauma life support: Student course manual,(9th ed. (p. 185-189). Chicago: Il.
4.2. Como, JJ, Diaz, JJ, Dunham, CM, Chiu, WC, Duane, TM, Capella, JM, Holevar, MR, Khwaja, KA, Mayglothing, JA, Sharior, MB, & Winston, ES. (2009). EAST guideline: Identification of cervical spine injuries. Journal of Trauma, 67(3), 651-59.
4.3. Rozzelle, CJ, Arabi, B, Dhali, SS, Gelb, DE, Hurlbert, RJ, Ryken, TC, Theodore, N, Walters, BC, & Hadley, MN. (2013). Management of pediatric cervical spine and spinal cord injuries. Neurosurgery supplement, 72(3), 205- 226.
4.4. Ryken, TC, Hadley, MN, Walters, BC, Aarabi, B, Dhali, SS, Gelb, DE, Hurlbert, RJ, Rozzelle, CJ, & Theodore, N. (2013). Radiographic assessment. Neurosurgery supplement, 72(3), 54-72.
Statements in this guideline
A patient with verbal GCS ≤4 cannot undergo clinical clearance of the cervical spine.
An intubated patient cannot undergo clinical clearance of the cervical spine.
A patient with ETOH or drug intoxication cannot undergo clinical clearance of the cervical spine.
Clinical clearance of the cervical spine may be performed if all of the following are present: normal neurologic exam, no tenderness to palpation of the cervical spine, no cervical spine pain with active range of motion, and no distracting injuries.
If the patient is found to be unreliable, a cervical collar should be placed.
If the patient is unreliable, C-spine radiographs should be obtained in the ED with a minimum of cross table lateral view.
If cervical spine radiographs are abnormal, maintain the cervical collar and obtain neurosurgical consult.
If cervical spine radiographs are normal and the patient remains unreliable, maintain the cervical collar and consider CT cervical spine from skull base through T1 within 24 hours.
If cervical CT is abnormal, maintain the cervical collar and obtain neurosurgical consult.
If cervical spine CT is normal and the patient remains unreliable, maintain the cervical collar and obtain MRI cervical spine within 72 hours when stable for transport.
If cervical spine MRI is normal, document radiographic findings and remove the cervical collar.
If cervical spine MRI is abnormal, maintain the cervical collar and obtain neurosurgical consult.