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Clearing the Cervical Spine in the Blunt Trauma Patient

From the Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI (Dr. Anderson), the Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX (Dr. Gugala and Dr. Lindsey), and Brigham and Women’s Hospital, Department of Orthopedic Surgery, Harvard Medical School, Boston, MA (Dr. Schoenfeld and Dr. Harris).

Dr. Anderson or an immediate family member has received royalties from Pioneer Surgical and Stryker; serves as a paid consultant to or is an employee of Medtronic Sofamor Danek, Pioneer Surgical, and Expanding Orthopedics; has received research or institutional support from Medtronic Sofamor Danek and Titan; and has stock or stock options in Titan Surgical, Pioneer Surgical, Expanding Orthopedics, Crosstrees, and Titan. Dr. Schoenfeld or an immediate family member has received research or institutional support from DePuy, Stryker, and Synthes. Dr. Harris or an immediate family member has received research or institutional support from Synthes. Neither of the following authors nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Gugala and Dr. Lindsey.

The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. The temporarily nonassessable patient may have short-term mental status changes (eg, intoxication, painful distracting injuries) and can be evaluated by two methods. When there is urgency, the evaluation is similar to that for the obtunded patient. Alternatively, the patient can be reevaluated within 24 to 48 hours, after return of mentation or following treatment of painful injuries. The patient then can be assessed as the asymptomatic patient is. The symptomatic patient requires advanced imaging. The obtunded patient should undergo, at minimum, a multidetector CT scan. Two methods are advocated. One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.