Written by Bo Stubblefield
Cervical spine (c-spine) injuries are uncommon but potentially devastating among trauma patients presenting to the ED. The Western Trauma Association (WTA) has recently published an algorithm to be used as a general framework in the approach to adult patients with potential c-spine injury.
Why does this matter?
We have come to know and love the NEXUS and Canadian C-Spine criteria. But beyond the eternal question of “to image or not to image”, the WTA has provided us with an expanded algorithm for c-spine management. This is aimed to minimize unnecessary imaging without increasing the risk of missing a clinically significant injury and to discontinue use of spine motion restriction (SMR) and avoid prolonged use of rigid collars where appropriate.
“Doc, can you please get this thing off my neck?”
This is an evaluation and management algorithm from the WTA for adult trauma patients with potential c-spine injury. The recommendations are based on published prospective and retrospective cohort data as well as expert opinion from WTA members. Each part of the algorithm, A-I annotations, are summarized below the figure. The WTA authors recognize that this algorithm is a general framework and that no algorithm can completely replace expert bedside clinical judgment.
A – This is governed by local protocols
B – This means: normal mental status, not intoxicated, no language barrier, no ‘distracting injury’. Distracting defined as preventing participation in a thorough and reliable physical exam.
C – This means: normal active range of motion, absence of midline cervical pain/tenderness, focal neurologic deficit, or spine deformity. Examinable, asymptomatic patients do not need imaging to discontinue c-collar immobilization. Consider CT in asymptomatic patients with higher energy transfer mechanisms, concurrent medical conditions, or patients at the extremes of age. Patients with persistent neurological deficit with normal diagnostic neck CT should prompt a diagnostic neck MRI.
D – High-resolution (64-slice, <3mm thickness) CT with multiplanar reconstructions has replaced plain x-ray as the standard radiographic evaluation of the c-spine.
E – Fractures should be referred for spine consultation. Some c-spine fractures are associated with increased risk of blunt CV injury and should be investigated with a neck CT angiogram.
F – Abnormal CT with significant findings other than bony fractures should be further investigated with a diagnostic MRI.
G –EAST guidelines recommend the discontinuation of SMR in obtunded patients with a normal screening neck CT. The NPV of a high-quality screening neck CT in excluding unstable injuries approaches 100%. C-collars may also be discontinued in intoxicated patients with a normal screening neck CT. Check out our FOAMed links for a second helping of this literature.
H – Discontinue SMR. There is an option for a comfort collar for neck strain/sprain.
I – Maintain SMR and obtain spine consult.
University of Cincinnati EM’s blog ‘taming of the SRU’ does a nice podcast and lit review.
Cervical spine clearance in the intoxicated patient:
Cervical Spine Clearance with distracting injury:
Western Trauma Association critical decisions in trauma: Cervical spine clearance in trauma patients. J Trauma Acute Care Surg. 2020 Feb;88(2):352-354. doi: 10.1097/TA.0000000000002520.
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Reviewed by Clay Smith