Clearance of the cervical spine requires careful clinical evaluation and, when indicated, radiological assessment.
- Patient has been cleared radiographically: Requires prior radiographic clearance.
- Normal examination: No current or recent neurological deficit can be present, and the patient must be awake without a distracting injury. There can be no history or suspicion of intoxication that could mask pain or deficit. The clinical examination demonstrates no tenderness to palpation of midline cervical spine with full active range of motion.
- Obtunded patients need neurosurgical assessment: Long-term cervical collar use may interfere with ICU care and lead to skin breakdown, particularly in patients with a tracheotomy. Consider a fine-cut CT through the cervical spine to identify any bony injury and a MRI including STIR images, preferably within the first 72 hours of injury. Consider flexion/extension x-rays under fluoroscopy with continuous SSEP monitoring later when the patient is clinically stable.
- Document impression in medical record: Examination findings should be clearly documented in the medical record
- NEXUS: The study showed that children with no midline cervical tenderness, no intoxication, normal mental alertness, a normal neurological examination, and no painful distraction injury had normal x-rays and no evidence of cervical spine injury with 100% sensitivity. Small numbers of children in the larger study prevented the authors from making a recommendation to use the criteria to identify children in need of cervical spine x-rays (51, 56).Only 1% of children in the study with one positive criterion had a cervical spine injury.
- Decision algorithm: Below is a graphical depiction of a protocol for the selection of pediatric patients who require cervical spine imaging after trauma
Decision algorithm initial management: The decision tree used at Great Ormond Street Hospital, London, to decide on need for imaging of a child when concern has been raised about an injury to the cervical spine.
- Standard 3-view x-rays: Lateral, anteroposterior, and open-mouth odontoid x-ray views are used to clear the cervical spine of traumatic injury. If lower cervical spine visualization fails to demonstrate the superior endplate of T1 on lateral x-ray, then a swimmer’s view or caudal arm traction may be attempted. If visualization is still inadequate, employ CT scanning through the region of concern. The need for the open-mouth view is controversial in young children. Some authors have concluded that it can be safely omitted in children younger than 10 years (44).
- CT or MRI if continued concern: If the patient has persistent tenderness or decreased active range of motion, consider further imaging including flexion/extension x-rays, CT, or MRI.
- MRI if positive radiographs or examination: If the patient has radiographic evidence of cervical spine injury or a neurological deficit by examination or history, then consider MRI.
- Document findings in medical record: If the above studies demonstrate no bony abnormalities or misalignment, then documentation of normal radiographic studies should be made in the medical record.