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Alex McKenzie wrote 03-11-2012 11:51:44 pm
The incidence of unstable ligamentous injury without any CT abnormality is very very small. In our unit we CT them (64 slice helical scan with recons, read by a radiologist) and if reported normal we remove the collar.

I'm not sure what the value of MRI is - subtle oedema of ligaments may have no significance. It would have to be pretty rare for a totally unstable neck to have no signs of misalignment on CT.

Ronan Oleary wrote 05-11-2012 12:56:17 am
Hi

We've recently developed some guidelines for the West Yorkshire Critical Care Network in the UK.

Essentially the protocol allows spinal protection to be removed from patients with normal CT scans of the full spine and the absence of significant brain injury (those patients should go to the regional trauma centres which have their own protocols).

This protocol is supported by the evidence available at the moment and was agreed by the intensivists, orthopaedic surgeons and radiologists.

Happy to forward a copy with the supporting literature if anyone is interested.

Cheers

Zafer Smith wrote 03-25-2012 07:34:27 pm
G'day, I'm an ED trainee doing a Paeds ICU rotation. Trying to find some good papers on C-Spine clearance in children for journal club in a couple weeks. Any good references that you know of (before I do hours of database searches)??

Todd Fraser wrote 03-31-2012 08:18:28 pm
Hi Zafer,

I'm not sure of much specific to kids, though the NEXUS trial did include kids. I remember reading an analysis of kids in that group once.

SCIWORA is well described in kids so I know there is certainly far more caution in kids than in adults.

Ian Seppelt wrote 05-21-2012 04:15:13 pm
Can we all please drop the word 'cervical'. The SPINE goes from cranium to coxxyx and we need to clear the whole spine (including thoracic and lumbar bits) after any major trauma.

For my own unit, if all imaging is complete and reported normal [by anyone willing to write that on a piece of paper which includes some but not all intensivists] the collar comes off.

Chris Poynter wrote 04-18-2012 08:08:01 pm
We tend to do the same as Alex has described with the same rationale. If CT normal and not clinically able to clear in a timely fashion (ie. 24hrs), then we remove the collar. Anyone who is able to be clnically assessed, we will involve the spinal surgeons and clear them that way. Our view is that the utility of MRI does not justify the risk (and cost and hassle) for multitrauma patients with head injuries. I am very happy with this strategy. At a previous institution, we tried to rely on the orthopods to clear them, which resulted in interminable waits with a collar on unnecessarily and the associated complications.

James Doyle wrote 03-03-2012 09:32:09 pm
This is a really interesting area at the moment. I am currently in a large PICU where we have been tring to put together c-spine clearance guidelines since before I arrived. However a clear consensus agreed to by intensivist, radiologist and spinal surgeons seems to be difficult to reach. My current understanding in children is that there is no place for plain films or flexion/extension films. Whilst CT are still commonly performed any doubt or calrification requirement results in an early MRI. With reference to your original question (or any patient that cant be clinically cleared) in our institution a CT C-spine will be perfomed. If no abnormalities are deteced the hard collar will be replaced with a philladelphia collar with continuation of full precautions. Then a MRI C-spine performed within 72 hours. Final clearance requires a formal report and intensivist/spinal surgeon documentation. Anyone have a different approach in kids or adults?

Matthew Bailey wrote 04-28-2012 08:24:53 am
Gotta agree with Chris' comment! We have had a few instances where our orthopod colleagues have suggest Philadelphia collar until able to clear the spine clinically in severe TBI patients. This just seemed silly.. they would have been more helpful if they'd asked for a collar for 2 months! We also remove the collar if the CT C-Spine is clear. Of interest - how do folks manage the intubated/sedated patient who DOES have a CT detected C-spine fracture, but which should be stable? We take collar off - and either keep it off, or put it one when desedating.

Matthew Bailey wrote 04-28-2012 08:24:53 am
Gotta agree with Chris' comment! We have had a few instances where our orthopod colleagues have suggest Philadelphia collar until able to clear the spine clinically in severe TBI patients. This just seemed silly.. they would have been more helpful if they'd asked for a collar for 2 months! We also remove the collar if the CT C-Spine is clear. Of interest - how do folks manage the intubated/sedated patient who DOES have a CT detected C-spine fracture, but which should be stable? We take collar off - and either keep it off, or put it one when desedating.