Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

Abstract

SummaryCervical spine injury occurs in 5-10% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. In addition, many studies are limited in their application to the obtunded or unconscious trauma victim. This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme. Cervical spine and associated spinal cord injury significantly affect the individual's functional capacity and quality of life, and carry significant implications for society. It was estimated in 1988 that a 27-year-old rendered tetraparetic would consume US$ 1 million for lifetime care and, with 721 tetraparetic individuals per million of the population, the total aggregate costs were an estimated US$ 5.6 billion per year [1]. In America, cervical, thoracic and lumbar vertebral fractures occur with an incidence of 50 000 per year [2], and cervical spine injury has an annual incidence of 5-10 000 cases per year [3,4]. More recent estimates suggest an incidence of 8-10 000 spinal cord injuries per year, of which 55% are cervical [5]. In the UK, there are approximately 1000 new cases of cervical cord injury each year [6]. Cervical spine injury complicates blunt polytrauma in 2-12% of cases [7][8][9]. However, several larger reviews that include 29 000 blunt trauma victims, and additional prospectively gathered data, demonstrate a generally lower incidence (2.0-5.2%) [10][11][12][13].The presence of a severe head injury increases the relative risk of a cervical spine injury, possibly by 8.5 times, and a focal neurological deficit by 58 times [14]. A Glasgow Coma Scale (GCS) score of < 8 is associated with a 50% increase in the incidence of cervical spine injury to 7.8% [15]. Similarly, Demetriades et al.[16] have shown that although the incidence of cervical spine injury in trauma victims with a GCS score of 13-15 was only 1.4%; this increased to 10.2% if GCS was < 8. 'Primary' cervical spine injury may be associated with head injury in 24-35% of cases [10,[16][17][18][19][20], and among polytrauma victims requiring cervical spine stabilization surgery, only 74% suffered an isolated injury [21]. The prognosis in patients suffering both head and cervical injury is typically poor, with approximately 25% being discharged to a dedicated nursing facility with little prospect of recovery [22]. Traumatic brain injury has a UK incidence of 100 per 100 000 population [23], typically among young, working age males, and therefore the combined consequences of brain and spine injury both ...

Distribution of Spinal and Associated Injuries in Multiple Trauma Patients

“…To that end, therapeutic algorithms need to address the outermost importance of SI in MI-patients including a standardized diagnostic work-up of the spine. The exact diagnostic procedures to achieve this result remain a matter of discussion -CT-scanning is available in most traumacenters and meanwhile considered the golden standard [26] due to lower cost [27], diagnostic accuracy [22,[28][29][30][31] and speed [32], however, others still employ plain radiographs [33] especially for screening the axial skeleton before performing CT-scans of a suspicious region [34].…”

Diagnosis, Timing and Treatment of Cervical Spine Injuries in Polytraumatized Patients

“…Often adequate monitoring cannot be provided in the MRI-unit. Additionally, the relatively large amount of time needed for data acquisition (approximately 30 min) restricts this diagnostic method to special cases, where neurologic symptoms are present without any lesions of the spine visualized by CT [7,8,10,[24][25][26].…”

“…Moreover diagnostic work up of suspected cervical spine injury varies from solely plain radiographs to whole body CTscan [4,[6][7][8][9][10][11]. Additionally, the timing of surgical intervention in acute management of spinal trauma remains controversial [12][13][14][15][16][17][18][19][20].…”

Clinical review: spinal imaging for the adult obtunded blunt trauma patient: update from 2004

“…1 the spine of the obtunded blunt trauma patient (OBTP) who is likely to remain unevaluable. Previous reviews and practice guidelines on this topic were produced in 2004, and adopted by the United Kingdom Intensive Care Society [1,2].…”