Cervical Spine Clearance

Cervical spine clearance can be challenging in trauma patients. I will review simple algorithms for clearing the c-spine in the emergency department, and for clearing it in an inpatient.

Clearing the c-spine requires two things: evaluation of the bones and evaluation of the ligaments. There is some new literature that suggests that it may be possible to clear based on a high quality cervical CT scan only. However, there is not yet enought data to adopt this as a standard of care.

A copy of a clearance algorithm for use in the ED will be available shortly.
Click here to download a copy of our clearance algorithm for inpatients with normal mental status.

A complete evaluation of both bones and ligaments can be performed in a few patients by a clinical exam alone. However, this requires several things:

1. Awake and alert
2. Not intoxicated
3. No "distracting injuries." These are painful injuries that may preclude the patient being aware of discomfort in their neck.

If these conditions are met, then a careful exam of the neck can allow spine clearance. The exam consists of:

• Palpation of the cervical spine in neutral position
• Gentle flexion and extension to the limits of comfort
• Left and right rotation to the limits of comfort
• Gentle compression by pressing on top of the head

If at any point the patient experiences pain or tenderness in the posterior midline, then the clearance process is terminated and the collar replaced. Pain or tenderness in the paraspinous muscles is common and is not a contraindication to clearance. If all maneuvers are successfully completed, then the collar can be removed and clearance documented in the medical record.

For patients who are not eligible for clinical clearance, the vertebrae must be evaluated radiographically. Although standard cervical views can be obtained with conventional radiography, helical CT has become the standard. Once radiographic clearance is complete, clinical clearance can be performed using the guidelines listed above.