Cervical Spine Clearance Guideline

Authors: Adam Gutierrez, Brandon Parker, Ed Lineen – 5/15/23
Approval: Namias – 6/15/23

Purpose

To minimize unnecessary imaging studies without increasing the risk of missing a clinically significant cervical spine injury
To discontinue cervical spine motion restriction (SMR) as soon as possible

Trauma patients with significant blunt mechanism of injury will be placed in cervical spine motion restriction (SMR) with rigid cervical collar on admission.
No cervical SMR in penetrating trauma unless directed by Trauma Attending or Neurosurgery

An examinable patient should be able to participate in a reliable history and physical examination and meet all the following criteria:
- Age <65
- Normal mental status (GCS 15)
- Not intoxicated.
- No language barrier
- No significant distracting injury
If an evaluable patient has a normal physical exam, the rigid cervical collar can be removed. A normal physical exam consists of all the following:
- Normal active range of motion
- Absence of midline cervical spine tenderness
- Absence of focal neurologic deficit
- Absence of spinal deformity
CT Cervical Spine should be obtained if above criteria not met.
- If an acute cervical spine fracture is detected on CT, cervical SMR with rigid cervical collar should be continued and spine consultation should be obtained.
- If no acute cervical spine fracture is detected on CT, but the patient remains symptomatic or with an abnormal physical exam per the above criteria then the patient should have a spine consult.

A screening cervical spine CT scan should be obtained in any patient who cannot participate in a reliable physical exam.
- If a acute cervical spine pathology is detected on CT, a spine consultation should be obtained.
- If no acute cervical spine pathology is detected, the collar can be discontinued if the patient has been seen to move all extremities.

Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Hault ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018;84(5):736-744.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-99.
Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
Healy CD, Spilman SK, King BD, Sherrill JE, Pelaez CA. Asymptomatic cervical spine fractures: current guidelines can fail older patients. J Trauma Acute Care Surg. 2017;83(1):119-125.
Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78(2):430-441.
Ciesla DJ, Shatz DV, Moore EE, Sava J, Martin MJ, Brown CV, Alam HB, Vercruysse GA, Brasel KJ, Inaba K. Western Trauma Association critical decisions in trauma: cervical spine clearance in trauma patients. J Trauma Acute Care Surg. 2020;88(2):352-354.

To minimize unnecessary imaging studies without increasing the risk of missing a clinically significant cervical spine injury
To discontinue cervical spine motion restriction (SMR) as soon as possible

Trauma patients with significant blunt mechanism of injury will be placed in cervical spine motion restriction (SMR) with rigid cervical collar on admission.
No cervical SMR in penetrating trauma unless directed by Trauma Attending or Neurosurgery

An examinable patient should be able to participate in a reliable history and physical examination and meet all the following criteria:
- Age <65
- Normal mental status (GCS 15)
- Not intoxicated.
- No language barrier
- No significant distracting injury
If an evaluable patient has a normal physical exam, the rigid cervical collar can be removed. A normal physical exam consists of all the following:
- Normal active range of motion
- Absence of midline cervical spine tenderness
- Absence of focal neurologic deficit
- Absence of spinal deformity
CT Cervical Spine should be obtained if above criteria not met.
- If an acute cervical spine fracture is detected on CT, cervical SMR with rigid cervical collar should be continued and spine consultation should be obtained.
- If no acute cervical spine fracture is detected on CT, but the patient remains symptomatic or with an abnormal physical exam per the above criteria then the patient should have a spine consult.

A screening cervical spine CT scan should be obtained in any patient who cannot participate in a reliable physical exam.
- If a acute cervical spine pathology is detected on CT, a spine consultation should be obtained.
- If no acute cervical spine pathology is detected, the collar can be discontinued if the patient has been seen to move all extremities.

Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Hault ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018;84(5):736-744.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-99.
Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
Healy CD, Spilman SK, King BD, Sherrill JE, Pelaez CA. Asymptomatic cervical spine fractures: current guidelines can fail older patients. J Trauma Acute Care Surg. 2017;83(1):119-125.
Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78(2):430-441.
Ciesla DJ, Shatz DV, Moore EE, Sava J, Martin MJ, Brown CV, Alam HB, Vercruysse GA, Brasel KJ, Inaba K. Western Trauma Association critical decisions in trauma: cervical spine clearance in trauma patients. J Trauma Acute Care Surg. 2020;88(2):352-354.