Guidelines Summary
CCR and NEXUS
The Canadian C-Spine Rules (CCR) and the National Emergency X-Radiography Utilization Group (NEXUS) criteria allow clinicians to "clear" low-risk patients of C-spine injury, obviating the need for radiography. Additionally, a model was developed specifically for injured children. [2, 40]
To be clinically cleared using CCR, a patient must be alert (GCS 15), must not be intoxicated, and must not have a distracting injury (eg, long bone fracture, large laceration). The patient can be clinically cleared provided the following apply:
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The patient is not high risk (age >65 yr or dangerous mechanism or paresthesias in extremities).
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A low risk factor exists that allows safe assessment of range of motion. This includes simple rear end motor vehicle collision, seated position in the ED, ambulation at any time post trauma, delayed onset of neck pain, and absence of midline cervical spine tenderness.
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The patient is able to actively rotate the neck 45 degrees left and right.
The NEXUS criteria state that a patient with suspected C-spine injury can be cleared provided the following are true:
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No posterior midline cervical spine tenderness
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No evidence of intoxication
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Normal level of alertness
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No focal neurologic deficit
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No painful distracting injury
Both studies have been prospectively validated as being sufficiently sensitive to rule out clinically significant C-spine pathology. The CCR were shown to be more sensitive than the NEXUS criteria (99.4% sensitive vs 90.7%), and rates of radiography were lower with the CCR (55.9% vs 66.6%). [41] Debate continues as to which criteria are more useful and are easier to apply.
ACOS
The American College of Orthopaedic Surgeons now recommends routine cervical spine screening via CT scan instead of plain radiography. Low-dose multidetector CT scanning has been found to be as sensitive and specific as standard dose multidetector CT scans. [45, 46]
ASIA
The American Spinal Injury Association defines spinal cord injury as follows [17, 54] :
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A = Complete. No sensory or motor function is preserved in sacral segments S4-5.
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B = Sensory Incomplete. Sensory but not motor function is preserved below the neurologic level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than 3 levels below the motor level on either side of the body.
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C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments [S4-S5] by LT [light touch], PP [pinprick], or DAP [deep anal pressure]) and has some sparing of motor function more than 3 levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single neurologic level of injury (NLI) have a muscle grade ≥3.
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D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥3.
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E = Normal. If sensation and motor function as tested with the INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY (ISNCSCI) are graded as normal in all segments, and if the patient had prior deficits, the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.
WFNS
According to the World Federation of Neurosurgical Societies (WFNS), angiography has been considered the gold standard for vertebral artery injury after cervical trauma, but it is difficult and time consuming to perform. CTA, using multislice machines, has been shown to identify the injury with a sensitivity of 100%. [43]
ACR
According to the American College of Radiology (ACR), CT is preferred over radiographs for initial assessment of spinal trauma; CT angiography and MR angiography are both acceptable in assessment of cervical vascular injury; MRI is preferred over CT myelography for assessing neurologic injury in the setting of spinal trauma; and MRI is usually appropriate when there is concern about ligament injury or when screening obtunded patients for cervical spine instability. [1]
The ACR has published the following specific recommendations [1] :
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Imaging is not recommended for the initial imaging of patients ≥16 yr and < 65 yr with suspected acute blunt cervical spine trauma when imaging is not indicated by NEXUS or CCR clinical criteria and the patient meets low-risk criteria.
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CT of the cervical spine without IV contrast is usually appropriate for the initial imaging of patients ≥16 yr with suspected acute blunt trauma of the cervical spine when imaging is indicated by NEXUS or CCR clinical criteria.
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MRI of the cervical spine without IV contrast is usually appropriate as the next imaging study for patients ≥16 yr with suspected acute blunt trauma of the cervical spine and confirmed or suspected cervical spinal cord or nerve root injury, with or without traumatic injury identified on cervical CT.
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CT of the cervical spine without IV contrast and MRI of the cervical spine without IV contrast are usually appropriate for patients ≥16 yr with acute cervical spine injury detected on radiographs and for treatment planning in cases of a mechanically unstable spine. These procedures are complementary in the assessment of unstable spine injuries.
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CTA of the head and neck with IV contrast or MRA of the neck without and with IV contrast is usually appropriate as the next imaging study for patients ≥16 yr with suspected acute blunt trauma of the cervical spine and clinical or imaging findings suggesting arterial injury with or without positive cervical spine CT. These procedures are equivalent alternatives.
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MRI of the cervical spine without IV contrast is usually appropriate as the next imaging study after CT of the cervical spine without IV contrast for obtunded patients ≥16 yr with suspected acute blunt trauma of the cervical spine and no traumatic injury identified on cervical spine CT.
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MRI of the cervical spine without IV contrast is usually appropriate as the next imaging study after CT of the cervical spine without IV contrast for patients ≥16 yr with suspected acute blunt trauma of the cervical spine and clinical or imaging findings suggesting ligamentous injury.
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CT of the cervical spine without IV contrast, MRI of the cervical spine without IV contrast, or radiographs of the cervical spine may be appropriate for patients ≥16 yr with suspected acute blunt trauma of the cervical spine and as follow-up imaging for patients with no unstable injury demonstrated initially but kept in a collar for neck pain and no new neurologic symptoms, including whiplash-associated disorders.
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CT of the thoracic and lumbar spine without IV contrast is usually appropriate for the initial imaging of patients ≥16 yr with blunt trauma meeting criteria for thoracic and lumbar imaging. Thoracic and lumbar spine CT reconstructions can be performed from concurrently obtained CT imaging of the thorax or abdomen and pelvis in trauma patients who have been imaged for soft-tissue injuries, without the need for additional radiation exposure.
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MRI of the thoracic and lumbar spine without IV contrast is usually appropriate as the next imaging study for patients ≥16 yr with neurologic abnormalities and acute thoracic or lumbar spine injury detected on radiographs or noncontrast CT.
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Odontoid fractures. (A) Type I odontoid fracture represents an avulsion of the tip of the dens at the insertion site of the alar ligament. Although mechanically stable, it is associated with life-threatening atlanto-occipital dislocation. (B) Type II odontoid fracture is a fracture at the base of the dens. This is the most common type of odontoid fracture. (C) With type III odontoid fracture, the fracture line extends into the body of the axis.
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(A) Simple wedge fracture with a flexion mechanism of injury is stable. (B) Flexion teardrop fracture with a flexion mechanism is unstable.
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Anterior subluxation with a flexion mechanism is stable in extension but potentially unstable in flexion.
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Bilateral facet dislocation with a flexion mechanism is extremely unstable and can have an associated disk herniation that impinges on the spinal cord during reduction.
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Clay shoveler fracture. (A) Lateral view of this fracture caused by a flexion mechanism shows that it is stable and represents an avulsion fracture of the base of the spinous process near the supraspinous ligament. (B) Anteroposterior view shows the vertically split appearance of the spinous process.
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Unilateral facet dislocation. (A) Lateral view of this fracture caused by a flexion-rotation mechanism shows that it is stable. Anterior displacement of spine is less than one half of the diameter of a vertebral body. (B) Anteroposterior view shows disruption of a line connecting spinous processes at the level of the dislocation. (C) Oblique view shows that the expected tiling of the laminae is disrupted, and the dislocated superior articulating facet of the lower vertebra is seen projecting within the neural foramina.
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Hangman fracture caused by an extension mechanism is unstable. Fracture line is evident in the lateral projection extending through pedicles of C2, along with disruption of the spinolaminar line. Sometimes, this fracture is associated with unilateral or bilateral facet dislocation, which makes it highly unstable.
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(A) Fracture of the posterior arch of C1 fracture caused by an extension mechanism is stable. Lateral projection shows a fracture line through the posterior neural arch without widening predental space. An odontoid view must be obtained to differentiate this benign fracture from a Jefferson fracture. (B) Jefferson fracture caused by a vertical (axial) compression mechanism is unstable. This fracture of all aspects of the C1 ring is associated with possible disruption of the transverse ligament of the atlas. Lateral projection may show a widened predental space and a fracture through the posterior arch of C1. Odontoid view shows displacement of the lateral masses of C1, allowing distinction of this fracture from a simple fracture of the posterior neural arch of C1.
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Burst fracture of vertebral body caused by a vertical (axial) compression mechanism is stable mechanically and involves disruption of the anterior and middle columns, with variable degree of protrusion of the latter. This middle column posterior protrusion may extend into the spinal canal and be associated with an anterior cord syndrome.
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(A) Normal lateral projection shows the relationships of anterior, posterior, and spinolaminar lines and prevertebral spaces. (B) Normal oblique projection shows the normal appearance of the laminae as shingles on a roof forming a regular elliptical curve with equal interlaminar spaces.
