Spine Clearance Guidelines
VBMC TRAUMA CARE SERVICES GUIDELINE
TITLE: Spine Clearance guidelines for the adult Trauma Patient
Spine Imaging and Clearance
SPINE CLEARANCE
Basic Principles
1. Entire spine is immobilized during primary survey.
2. Radiographic clearance of the spine is not required before emergent surgical procedures. Presence of a spinal column injury is simply assumed until excluded.
3. Secondary
and tertiary exams include examination of the spine for tenderness as well as
testing all motor roots, sensation and reflexes.
4. Tertiary
exams are performed only on alert and unimpaired patients without distracting
injuries.
5. If
any spine fractures are found, entire spine must be radiographed.
6. For
patients with radiographic injury, spine consultation should be obtained WHEN
FEASIBLE for focused pre-operative evaluation regarding relative instability
and severity of injury prior to intubation.
7. Patients
remain on thoracolumbar spine precautions until T-L spine is radiographically
and/or clinically cleared.
8. C-spine
precautions are maintained until C-spine is radiographically and/or clinically
cleared.
Cervical
1. Collars are not indicated in penetrating
trauma to the BRAIN, unless the trajectory suggests traverse of the cervical
spine (EAST).
2. In
awake, alert patients without deficit or distracting injury who have no neck
pain or tenderness with full ROM of the cervical spine, imaging is not necessary,
and collar may be removed (EAST).
3. All
other patients in whom injury is suspected (‘at-risk’) must have radiographic
evaluation, including patients with pain or tenderness, deficit, altered MS or
distracting injury (EAST).
4. C-spines
are not cleared in the at-risk population until after the tertiary exam is
completed or until it is determined that clinical examination will not be
possible within a reasonable amount of time due to obtundation.
5. Cervical
CT scan is the preferred radiographic modality when physical exam is not
adequate.
6. With
impaired or unconscious patient, rigid collars are taken off within 2 hours and
replaced with semi-rigid pressure reducing collar (Miami, Philadelphia,
etc).
7. Enter
patients in cervical algorithm for C-Spine clearance.
Thoraco-Lumbar
1. CT scan of thoracic and lumbar spines if
there are clinical findings on secondary or tertiary exams or an unreliable
exam. Multi-detector CT-scan with reformatted axial collimation is superior to
plain films (EAST Level 1).
2. Patients
with back pain, TLS tenderness on exam, neuro deficits referable to the TLS,
altered MS, intoxication, distracting injuries or known or suspected high
energy mechanisms should be screened for TLS injury with MDCT scan (EAST Level
2).
3. Clinical
exam alone may be considered in select patients but is unreliable in
patients ≥ age 60 and/or those subjected to high energy mechanism (ejection,
rollover, pedestrian, fall from height, torso crush, jump from moving vehicle,
crash of a non-enclosed vehicle) (Inaba AAST 2014).
4. In blunt trauma patients with a known or suspected injury to any region of the spine, thorough evaluation of the entire spine by MDCT should be strongly considered owing to a high incidence of spinal injury at multiple levels within this population (EAST Level 2).