It is Saturday night and yet again there comes another trauma patient in a hard collar to the OR. Is the c-spine cleared? The discussion goes on but what does that phrase mean to “clear the c-spine”? The article by Harrison and Cairns provides a succinct and up to date discussion of the issues relating to “clearing the c-spine.” Key points include: 1) The incidence of c-spine injury is 5% in association with blunt polytrauma. 2) Factors that increase the risk include the presence of a focal neurologic deficit, concurrent head injury and a Glasgow coma score < 8. 3) The inability to do a neurologic exam or obtain patient self report of pain greatly complicates the diagnosis of spinal cord injury; radiologic exam is not an “easy” substitute. 4) The success rate for obtaining adequate lateral x-rays of the c-spine may be as low as 50% and with an ET tube in place the sensitivity for detecting injury may be as low as 30%. The authors do not consider plain films adequate for c-spine clearance. 5) The authors suggest that helical CT scans with 1 mm slices especially with 3D reconstruction may be the best “first step” in radiologic diagnosis. 6) Finally the authors note that communication may be the largest contributor to failures in timely c-spine clearance and suggest local development of agreed upon “best practices” with “sign off” sheets may help prevent errors leading to miss-identification, failed identification and inappropriate management. Ref: Harrison P, Cairns C: Clearing the cervical spine in the unconscious patient. Cont Edu Anaesth Crit Care & Pain. 2008;8:117-120.
David S. Smith, M.D., Ph.D.