Advanced Emergency Nursing Journal:
Introduction to Reading and Clearing Cervical Spines for Advanced Practice Nurses, Part I
Flarity, Kathleen ARNP, PhD, CFRN, FAEN; Ramirez, Elda PhD, RN, FNP-BC, FAANP
Section Editor(s): Ramirez, Elda PhD, RN, FNP-BC, FAANP
Wenatchee Valley Medical Center, Wenatchee, Washington (Dr Flarity); and University of Texas Health Science Center at Houston, Texas (Dr Ramirez).
Corresponding Author: Kathleen Flarity, ARNP, PhD, CFRN, FAEN, Wenatchee Valley Medical Center, Wenatchee, WA (kflarityR@aol.com).
The authors have no conflict of interest.
This article is Part I of a two-part series and will focus on the key concepts of radiographic interpretation, functional cervical anatomy, and the interpretation and clearance of cervical spines in emergency care. In the subsequent issue, Part II will cover the additional epidemiology of cervical-spine injuries, specific injuries, case studies, and advanced diagnostic imaging.
FOR the novice advanced practice nurse, reading and clearing cervical spines (C-spines) can be one of the most intimidating aspects of the advanced practice role. However, a systematic, thorough approach with meticulous attention to detail can assist in the prevention of errors in diagnosis. The goal of this article is to provide a tool to the advanced practice nurse to increase competency with reading and clearing C-spines. This article is Part I of a two-part series and will focus on the key concepts of X-ray interpretation, functional cervical anatomy, and the interpretation and clearance of C-spines in emergency care. In the subsequent issue, Part II will cover additional epidemiology of C-spine injuries, specific injuries, case studies, and advanced diagnostic imaging.
More than 1 million patients with blunt trauma and potential C-spine injuries are treated each year in the United States (Stiell et al., 2001). The incidence of spinal injuries in the United States has been reported at approximately 10,000 cases annually, with nearly 200,000 people having a history of spinal injuries (Hertner & Stewart, 2008). The most common mechanism for spinal injury is motor vehicle crashes (MVCs), followed by sports-related activities and falls. Approximately 5%–10% of unconscious patients who present to the emergency department (ED) as a result of an MVC or fall have a major injury to the C-spine (Grossman, Reilly, Gillett, & Gillett, 1999; Sinclair, Schwartz, Gruss, & McLellan, 1988). Although C-spine injuries occur in only 3%–6% of all trauma patients, these injuries can be devastating to the patient, family, and the provider if an injury is missed (Ghafoor, Martin, Gopalakrishnan, & Viswamitra, 2005).
Plain cervical radiographs are a common initial screening diagnostic in the evaluation of C-spine structural changes for patients with blunt trauma. Initially, providers need to determine which patients are at risk of C-spine injury, and of those who are at risk, who will need imaging to determine whether or not the patient has sustained a traumatic injury. Providers also need to determine which type of imaging is of the highest priority and should be ordered first. Are there other adjunctive studies that may be helpful in this process? Who needs referral? It is important to recognize that providers in emergency care will not “clear” every patient; some patients will require consultation beyond the ED. Therefore, it is helpful to categorize patients into those who can be cleared clinically, those providers can clear with imaging, and those who will need clearance in the acute care setting.
KEY CONCEPTS—RADIOGRAPHIC INTERPRETATION
A good-quality film is essential in ED care to aid in the diagnosis of a patient with a potential C-spine injury. The specific approach to reading C-spines will be discussed later; however, the following holds true for all radiological imaging:
Obtain previous films, if possible, for comparison. This allows the practitioner to determine whether the abnormality identified is acute or chronic.
Next, check the technical quality. A film should not be too dark (overexposed) or too white (underexposed). There are five radiographic densities that can be seen, and in order of increasing brightness they are air, fat, fluid, bone, and metal (Fig. 1A). A film with a longer exposure time results in a much darker film. In an overexposed film, the border between the air and the fat is lost (Fig. 1B). The short exposure time results in a much brighter film. The border between the key and the fluid is lost (Fig. 1C).
Follow a systematic approach for viewing the film and scan the entire film thoroughly. For example, consistently view from top to bottom, and address everything within the film borders. Verify anatomic alignment and positioning (Mettler, Guiberteau, Voss, & Urbina, 2000; Ouellettte & Tetreault, 2007). Refer to Table 1 for a succinct systematic approach to reading cervical radiographs. Seek the radiologist's opinion if there are any concerns; it can often expedite the diagnosis. Finally, document findings and interpretations per institution protocols.
FUNCTIONAL ANATOMY OF THE C-SPINE
The normal anatomy of the C-spine consists of seven cervical vertebrae separated by intervertebral disks and joined by a complex network of ligaments. The spine provides structural support and bony protection of the spinal cord. The intricate network of ligaments keeps individual bony elements moving as a single unit.
The spinal or vertebral column can be divided into three distinct columns based on function and injury patterns: anterior, middle, and posterior. The anterior column consists of the anterior two thirds of the vertebral bodies, intervertebral disks, and the anterior longitudinal ligaments. The middle column is composed of the posterior longitudinal ligament and the posterior one third of the vertebral bodies, the annulus, and the intervertebral disks. The posterior column contains the spinal canal and consists of the pedicles, laminae, articulating facets, and transverse and spinous processes.
These structures together form the vertebral arch, which encloses the vertebral foramen and protects the neural tissues. The arch is formed by bilateral pedicles that are oriented posteriorly and join two laminae. The spinous process arises posteriorly from the vertebral arch. The cervical transverse processes and four articular processes also arise from the arch. The cervical transverse processes are unique to the vertebral column with an oval foramen transversarium. The vertebral arteries pass through these foramina. The posterior column also includes a group of ligaments including the supraspinous, infraspinous, interspinous, and nuchal ligaments.
The first two cervical vertebrae are atypical in form and function (Fig. 2). The next five vertebrae are all similar in structure and function. The atlas, C1, is a ring-shaped bone that supports the skull. Two concave, superior articular facets articulate with the occipital condyles. The atlas does not have a body or spinous process. The atlas has an anterior and posterior arch, each with a tubercle and lateral mass. The axis, C2, is the strongest of the cervical vertebrae. The atlas rotates on two large articulating surfaces. The odontoid process (also known as the dens) projects superiorly from the C2 body and is the bony structure that the atlas rotates on. The odontoid process is held in place by the transverse ligament of the atlas (Hertner & Stewart, 2008; Novelline, 1998).
CLEARING RADIOLOGICALLY AND CLINICALLY: WHEN TO GET C-SPINE FILMS
Clearing C-spines clinically has been researched internationally for decades. The criteria for clinical clearance of the C-spine is initiated by a patient presenting with low-risk blunt trauma. The remaining criteria have been established by a series of large-scale prospective research studies.
The importance of clinically clearing C-spines stems from the ordering of plain films that are not necessary to clear a C-spine. In addition, millions of dollars were being spent annually on patients whose C-spines may have been clinically cleared using evidence-based criteria that rule out C-spine injury.
In the past decade, it has been estimated that 13 million patients presented to EDs in the United States with possible C-spine injury (Bandiera et al., 2003). Of those patients who were seen in these EDs, approximately 40,000 had a vertebral column or spinal cord injury (Bandiera et al., 2003).
When Can a C-spine Be Clinically Cleared?
The question then arises, “When can a C-spine be clinically cleared?” Providers in today's litigious society are inclined to order plain radiographs for fear of “missing” an injury. Thus, the impetus for evidence-based practice has been established for clinically clearing C-spines.
An additional question then arises, “Is there proof that under certain circumstances, a patient with blunt trauma can be clinically cleared from a cervical collar and not meet criteria for C-spine imaging? Yes, there is.
Review of the Literature
Since the 1980s, there has been a plethora of research evaluating the criteria necessary to exempt a patient from a C-spine radiographic image.
In 1987, Bachulis, Long, Hynes, and Johnson performed a retrospective study of 4,941 trauma patients with suspected C-spine injuries. Through the use of their trauma registry, they determined that 1,823 patients had C-spine X-rays. The outcome was that none of the patients without neck pain or other complaints had an injury detected via plain radiographs. These authors also concluded that asymptomatic patients did not need plain C-spine films.
Another early prospective study by Neifeld et al. (1988) identified blunt trauma patients with suspected cervical injuries but without neck pain or other related complaints. These patients were found to have no cervical vertebral or spinal cord injuries. Neifeld studied 886 blunt trauma patients with suspected C-spine injuries. Of these patients, 244 were asymptomatic, and therefore, no plain films of the C-spine were performed. These patients had no pathology. The authors concluded that asymptomatic blunt trauma patients did not require plain film radiographs. There was a negative predictive value of 100% and positive predictive value of 6.2% (Neifeld et al., 1988.)
Roberge et al. (1988) studied 467 blunt trauma patients with suspected cervical injuries. Of that group, 155 of those patients were asymptomatic and none were found to have a vertebral column or spinal cord injury. Of the 312 patients that were symptomatic, 8 patients were found to have C-spine injuries such as fractures (all levels of C-spine), dislocations, or ligamental instability. Negative predictive value of the asymptomatic examination was 100% and the positive predictive value of the symptomatic examination was 2.5% (Roberge et al., 1988.) The conclusion of this study was that asymptomatic patients did not need plain film radiographs of the C-spine.
The above-mentioned studies are only a small fraction of early studies that instigated an evidence-based trail of similar studies with the same conclusions. Those studies ultimately culminated in two large prospective studies that yielded statistically significant outcomes. That research data ultimately established the criteria for the clinical clearance of blunt trauma C-spine clearance that trauma centers across the country utilize at present.
The National Emergency X-Radiography Utilization Study (NEXUS)
The first large prospective study of blunt trauma patients with suspected cervical injuries was performed by Hoffman, Schriger, Mower, Luo, and Zucker (1992). The researchers studied 974 patients and found an overall incidence of C-spine injury to be 2.8%. The study population had 353 patients that were asymptomatic; none of these patients were found to have a significant spine injury that included fracture, dislocation, or ligamentous instability. In this study, asymptomatic patients were followed for 3 months via chart reviews, quality assurance records, and risk management records. The recommendation was that radiographic imaging in asymptomatic blunt trauma patients with suspected cervical injuries was not required.
In 2000, Hoffman, Mower, Wolfson Todd, and Zucker performed another study by validating a set of clinical criteria to rule out injury to the C-spine in blunt trauma patients with no neck pain. Those criteria are now recognized as the criteria for use in EDs for clinical C-spine clearance. The NEXUS criteria were utilized, using a decision algorithm in 21 emergency centers nationally in 2000. The instrument had five criteria that patients had to meet to be considered low-risk for cervical injury. The criteria included (1) no midline cervical tenderness, (2) no focal neurological deficit, (3) normal alertness, (4) no intoxication, and (5) no painful or distracting injury (Hoffman et al., 2000).
The research team of the NEXUS study utilized the instrument on 34,069 patients who had C-spine X-rays after blunt trauma (Hoffman et al., 2000). This instrument identified 818 patients with C-spine injury. Only eight patients were missed when NEXUS criteria were employed. The sensitivity rate was 99.9% with a 95% confidence interval (98.0%–99.6%). The negative predictive value was 99.8% with a 95% confidence interval (99.6%–100%) and a specificity of 12.9% (Hoffman et al., 2000). The positive predictive value was 1.9% (Hoffman et al.). Therefore, the conclusion of the study group was to utilize the NEXUS clinical criteria.
The NEXUS study was a clinical “breakthrough” for emergency providers in the management of low-risk blunt trauma C-spine imaging both nationally and internationally.
The Canadian Cervical Spine Rules for C-Spine Clearance in Low-Risk Patients With Blunt Trauma
In Canada, Stiell et al. (1997) were paralleling the work of Hoffman et al. (1992). In 1997, Stiell and his research team performed a retrospective study of the emergency utilization of C-spine radiography for alert, stable, adult trauma patients in British Columbia. This research group utilized eight EDs and enrolled 6,855 patients in this C-spine study. Of the 3,979 patients who had C-spine X-rays done in the ED, 60 were noted to have C-spine injuries (Stiell et al., 1997). These researchers also concluded from their findings that C-spine radiography could be used more “efficiently” with the help of a clinical decision rule (Stiell et al.).
Stiell et al. followed with a similar study in 2001 in which the objective was to derive a “clinical decision rule” for detecting acute C-spine injury and for decreasing imaging in alert and stable trauma patients. The population of the study included 8,924 adults who presented to 10 EDs in a Canadian community with blunt trauma to head/neck. Inclusion criteria were: stable vital signs and a Glasgow Coma Scale score of 15. The Canadian C-spine Rule (CCR) asked three questions:
Is there a high-risk factor that mandated radiography (i.e., ≥ 65 years, dangerous mechanism, paresthesias in the extremities)?
Are there low-risk factors present that allow safe assessment of range of motion (i.e., simple-rear-end motor vehicle accident, sitting position in the ED, ambulatory at the scene, no midline tenderness to the spine)?
Is the patient able to actively rotate the neck 45° to left and right (Stiell et al.)
The study yielded 151 patients with significant C-spine injury, and the rule was found to have a 100% sensitivity (95% confidence interval, 98%–100%) and a 42.5% specificity (confidence interval 95%, 40%–44%) for identifying the C-spine injuries (Stiell et al., 2001). This research group also concluded that this “CCR rule,” if used appropriately could reduce practice variation among providers and decrease C-spine radiography (Stiell et al.).
NEXUS vs. CCR
NEXUS and CCR are used to clinically clear C-spines. But which is best? In 2003, Stiell et al. conducted a prospective cohort study with 8,283 stable posttrauma patients in 9 Canadian EDs comparing the NEXUS to the CCR. There were 169 patients with significant C-spine injuries in this group. The comparison population was identified by patients that had not had range of motion assessed that were in this study, as recommended by the CCR. With this group excluded the remaining patients data were reviewed and the CCR was more sensitive than the NEXUS as evidenced by (99.4% vs. 90.7%, p < 0.001) and more specific than the NEXUS (45.1% vs. 36.8%, p < 0.001) (Stiell et al.).
Stiell et al. (1997) performed a secondary data analysis which included all patients, with the assumption that the cases that had not had range of motion evaluated, were positive, and had a specificity and sensitivity of (99.4% & 40.4%, p < 0.001 for both comparisons with the NEXUS. However, given the assumption that the CCR was negative for all the patients that did not have the range of motion of the neck without pain, the specificity and sensitivity data showed specificity of 95.3% (p = 0.09 for comparison with NEXUS) and a sensitivity 50.7% (p = 0.001). According to Stiell et al., this result indicated that the CCR would have missed 1 patient with a significant cervical injury and the NEXUS criteria would have missed 16 patients (Stiell et al.).
In summary, the CCR has been shown to be a more sensitive specific instrument than the NEXUS in the context of C-spine injury in patients with blunt trauma. It must be made clear, however, that in combing both the provider has a highly predictive instrument with the knowledge that the single variable of range of motion assessment is so valuable. Thus, the instrument for competency skills “check off” as found in Table 2 is a combination of these instruments.
HISTORY AND PHYSICAL EXAMINATION
As with all trauma patients, initial clinical evaluation begins with a primary survey. The primary survey focuses on life-threatening conditions. Assessment of airway, breathing, and circulation (ABCs) takes precedence while concurrently considering C-spine injury (refer to Table 3 for the history and physical examination; Hadley et al., 2002).
The standard radiographs obtained in a C-spine series may vary slightly by facility. Usefulness of some views in routine radiographic screening has been debated. A large patient study indicated that standard three-view imaging is reliable for screening trauma patients. The three-view series includes lateral (or crosstable lateral), anteroposterior, and open-mouth odontoid views (Duane, Dechert, Wolfe, Aboutanous, Malhotra, & Ivatury, 2007; Edwards et al., 2001; Mower, et al. & NEXUS Group, 2001). Additional radiographic views may include oblique views, odontoid tip shots, swimmer's view, and flexion/extension views.
Lateral Cervical View
The lateral view is the most important of the cervical views; 80% of all C-spine injuries are picked up in this view. Figure 3 shows a normal lateral C-spine (Ouellettte & Tetreault, 2007). When reading C-spine films, the provider must examine the X-ray methodically every time to prevent errors in omission.
The cervical vertebrae are numbered 1–7 from top to bottom. Ensure that all seven vertebral bodies and the top of T1 are seen. If the seventh vertebra is not completely visible, a swimmer's view may be obtained (one of the patient's arms raised to display C7 more clearly; Fig. 3). Look for fractures or bony abnormalities. Look for linear lucency suggestive of a fracture. Look for marked decreases in intervertebral disk space, which may be a sign of degenerative disc disease (wear and tear of aging). Comment on any abnormal findings (including bone spurs, degenerative changes, and other abnormalities) in your dictation. Figure 4 highlights both the normal and soft tissue and bony landmarks.
Assess the lateral view alignment with the use of four imaginary lines (Fig. 5). Ensure all cervical vertebrae align properly by conceptualizing four imaginary lines. When evaluating the lines, ensure they are continuous and that there is no step deformity. The most important (reliable) of the four lines is the posterior vertebral line (least often disrupted by bony spurs and directly aligned with spinal cord). Line 1 is the anterior vertebral line, line 2 is the posterior vertebral line, line 3 is the spinolaminar line, and line 4 is the spinous process line (Ouellettte & Tetreault, 2007).
The cervical vertebral bodies are connected by a series of ligaments that provide support and stability. If any of these supporting structures are injured it may result in abnormalities identified in the C-spine X-ray. Some of the major ligaments and stabilizers include anterior and posterior longitudinal ligaments that run the length of vertebral body. The ligaments prevent excessive flexion and extension. Others include the ligamenta flava, interspinous ligament, supraspinous ligament, spinous process, and transverse process. The cervical bodies also serve as attachment points for muscles and other ligaments.
Finally, from C1 to the top of T1 systematically and meticulously look at each bone; look for fractures or any bony abnormality (Fig. 5). Measure the distance between the odontoid process and the anterior portion of C1 (Fig. 5, one star). If the distance is greater than 3 mm, a fracture or dislocation is suspected (recommended to get a computed tomography, CT). Next, look at the soft tissue. Look for prevertebral soft tissue enlargement (suggestive of soft tissue swelling or hematoma). The prevertebral normal soft tissue thickness at the C2-C3 line is less than 7 mm. The normal soft tissue thickness at the C6-C7 level is less than 21 mm (Fig. 5, two stars). A focal bulge is always suggestive of soft tissue swelling or hematoma.
Open-Mouth View Odontoid
When reviewing the odontoid open-mouth view, ensure the edges of the lateral masses of the atlas are aligned with the edges of the axis. Slippage sideways suggests a fracture. Ensure no major discontinuity is present (Figs 6 and 7). Ensure no fractures are present (look for black line across odontoid; Ouellettte & Tetreault, 2007).
Anterior Posterior (Frontal) View of C-Spine
Ensure no major discontinuity is present and that the spinous processes are aligned. Meticulously look at each bone; look for fractures or any bony abnormality. Look to see that the disk spaces are preserved and that there is no soft tissue swelling or masses (Fig. 8; Ouellettte & Tetreault, 2007). If these three-view films are good quality and show no fracture or dislocation, the patient should remain in a Philadelphia or equivalent collar until patient clinically cleared (i.e., becomes cooperative and reliable in regard to the C-spine clinical examination and is found to meet criteria for being cleared clinically). If the patient's state of unreliability is protracted (e.g., closed head injury) do not remove C-spine protection.
Flexion and Extension Views
Flexion and extension views are used in a number of centers to help define whether or not there is a ligamentous injury. These are dynamic studies, and the patient has to actively go through flexion and extension in an attempt to rule out unstable ligamentous injuries. These films are not routinely performed in the ED setting for a number of reasons. For instance, these films are rarely abnormal in the setting of a normal AP and lateral films. These X-rays are usually limited by the patient's spasms and pain and his or her ability or even willingness to cooperate with the study. Some providers will request these views 2–4 weeks out from the initial injury if they still have any concerns of ligamentous laxity as a result of the trauma.
COMPUTED TOMOGRAPHY SCANNING
If a fracture is seen on any of the films, a CT scan should be performed. If the patient's status does not allow immediate further study, cervical immobilization is maintained until further study is possible. Computed tomography is also useful in the evaluation of areas that are difficult to evaluate or see in plain radiographs, such as the lower C-spine in very large individuals secondary to body habitus. It is recommended in infants or very young toddlers who require head CT. If the provider is concerned about the C-spine, the provider can order a CT of C1-C2. If there is an abnormality on C-spine films or suspicion of significant focal pain with normal X-ray, consider CT (Brown, Antevil, Sise, & Sack, 2005). Computed tomography will be discussed in more detail in Part II.
MAGNETIC RESONANCE IMAGING
Magnetic resonance imagings (MRIs) are known to give much better views of the soft tissue, including the ligaments and the spinal cord. This type of imaging has also demonstrated the ability to more accurately identify patients with spinal cord edema. However, MRIs are not reliable for bony abnormality, as is the CT. MRIs are not typically used in the ED care setting. In addition, MRI often requires sedation and a time outside the ED and is not a reasonable test to use acutely. It may be useful in the case of a patient with transient neurological symptoms or in the obtunded or comatose patient in whom it is impossible to obtain an adequate neurological assessment. Since, this diagnostic is typically not obtained in the ED, it may later be obtained in the course of a patient's hospitalization. Magnetic resonance imaging will be discussed in more detail in Part II.
PEDIATRIC C-SPINE SERIES
There are some anatomical differences in the pediatric population related to C-spine injuries. The pediatric patient has a relatively large head size, which places the fulcrum at C2-C3 in terms of flexion and extension of the neck, as opposed to older children and adults, where it is C5-C6. Children have underdeveloped neck muscles that provide less protection to the neck itself and result in more mobility of the neck. The facets have a more horizontal orientation and are more likely to slip off. They also have wedge-shaped vertebrae and ligamentous laxities, all of which contribute to increased mobility of the C-spine.
However, despite these anatomical differences, the incidence of C-spine injury in children is less than what providers observe in adults (Anderson et al., 2006; Guice, Cassidy, & Oldham, 2007). In the United States, less than 10% of C-spine injuries occur in children younger than 15 years. It is important to be familiar with normal pediatric C-spine variants, however, if pediatric anomalies are seen, or if any concerns by the provider get an evaluation from the radiologist before clearing (Anderson et al., 2006).
It can be challenging for providers in emergency care to evaluate and clear C-spines in the pediatric trauma patient. Fortunately, C-spine injuries are fairly rare in the pediatric population. Mechanisms of injury that are seen frequently in the ED that do not typically cause a C-spine injury are the young child who has struck his/her head on a coffee table, tumbled down the stairs, or has a minor forehead laceration. Most of these patients are cleared clinically (Anderson et al., 2006).
The most common cause of C-spine injuries in patients younger than the age of 8 years are MVCs. As children become preteens and teens, sports take up a greater proportion of injuries, and older than the age of 8 years sports surpass MVCs. In addition, falls are also a common mechanism of injury, but these are significant falls and one third occurred from second story or above. These are not minor mechanisms of injury, but if observed, the provider should have a high index of suspicion for a C-spine injury (Anderson et al., 2006; Guice et al., 2007).
Definitively “clearing” a C-spine is more difficult in the pediatric population because most of the literature is anecdotal and based on case reports, case series, and expert opinion. Still, it is important to determine which pediatric patients are at risk for C-spine injury (Anderson et al., 2006; Guice et al., 2007). A potential difficulty in evaluating pediatric patients is the developmental level of each patient (e.g., unable to describe the location of their pain).
Once the provider has determined which children are at risk for C-spine injury, the priority is to protect the neck, concentrating on the ABCs. CCR and the NEXUS study criteria are helpful in determining which pediatric patients actually need imaging. As mentioned earlier, this study validated a set of low-risk criteria to determine which patients are at risk or can be clinically cleared without radiological imaging. The Nexus prospective multicenter study, for example, reviewed more than 30,000 patients, using five criteria. These “low-risk criteria” were 99% sensitive in ruling out a C-spine injury.
More than 3,000 pediatric patients with suspected cervical injuries were reviewed in the NEXUS study; 30 patients sustained a C-spine injury. Of those pediatric patients who were defined as low risk according to the NEXUS criteria (i.e., 600 patients), none had a C-spine injury. There were some limitations to the study related to pediatrics; only 88 patients were younger than 2 years, a smaller population on which to base the criteria. Only four patients with C-spine injury were younger than the age of 9 years, which emphasizes that C-spine injuries are rare among patients younger than the age of 9 years (Anderson et al., 2006).
Once the provider determines the need for imaging, plain radiographs should be obtained. There are a number of pitfalls in evaluating the C-spine series in the young patient. Reviewing C-spines in pediatric patients is not much different than the systematic approach described earlier, except that in the interpretation there may be some particular pediatric variants. The widths that are acceptable in the pediatric population are different from those that are acceptable in the adult. Children have a much more mobile spine, and more than 20% will normally have a predental space greater than 3 mm; in general 4–5 mm is acceptable in pediatrics. C-spine prevertebral spine also accepts slightly wider or different criteria. A C2-C3 override also may be higher and still be normal in the young child. Approximately 20% of all children will have pseudosubluxation as a normal finding (normal mobility of C2 on C3 on flexion, which may be so pronounced as to be mistaken for pathological). The anterior cortex of C2 should fall on or within 2 mm of the spinal laminal line, also known as the posterior cervical line (e.g., a line drawn through the anterior cortex of C1 and C3), to be considered normal, suggesting pseudosubluxation. When there is an actual fracture, the anterior cortex of C2 will often be displaced posteriorly >2 mm (Anderson et al., 2006).
Children may also present with spinal cord injury without radiographic abnormality (SCIWRA). Consider SCIWRA in children who have transient neurological symptoms. Those symptoms have been described as remitting and then reoccurring later on after initial evaluation. The reason is generally felt to be an injury to the spinal cord itself with no obvious fracture or ligamentous injury found on X-rays or CT. The child younger than 8 years has increased mobility of the spine and is felt to be at greater risk of SCIWRA. However, SCIWRA has been reported in adults (Anderson et al., 2006). None of the children in the NEXUS study had SCIWRA as a diagnosis (Dickinson et al., 2004).
Which patients require a neurosurgical consult? There are some patients who clearly need referral and consultants involved in their care. If neurological abnormalities are present or if a fracture is detected, immediately consult a neurosurgeon or spinal orthopedic surgeon to assume care. The consultant should make the recommendation regarding the further workup and stabilization of the fracture if needed. The unconscious patient will not be able to be cleared in the ED and will require a referral; obtain C-spines to look for major injuries, but subtle injuries cannot be ruled out. In addition, if there are concerning clinical symptoms refer the patient. If the patient has severe pain or if the provider does not feel comfortable with the combination of clinical evaluation and radiological studies it is recommended to refer the patient for further evaluation. A negative C-spine series does not rule out a significant injury or C-spine injury.
The Emergency Nurses Association's “Competencies of Nurse Practitioners in Emergency Care” lists as one of its competencies “clinically assesses and manages C-spine.” The goal in evaluating the C-spine is to recognize any unstable injury, whether it be bony or ligamentous or whether there is an actual spinal cord injury. Evaluation of the patient with suspected C-spine injury can be challenging for providers. A systematic, thorough approach with meticulous attention to detail can help prevent errors in interpretation and diagnosis. Using evidence-based practice tools such as the CCR and NEXUS criteria may allow the provider to clear C-spines clinically without radiographs. Recognize that in some cases you will not be able to clear the C-spine in the ED.
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