C-spine injury ranges from the obvious fracture-dislocation to the less obvious ligamentous injury, affecting about 2.5% of blunt trauma patients. However, ALL of them are serious and can lead to life changing injuries, that we obviously don’t want to miss. Unfortunately reported miss rates range from 4-30%. [IJO 2007]

In our practice the patients that appear to be at highest risk of missed C-Spine injury, are elderly patients with relatively minor head injuries, and have been missed by ED, Wards, GP’s and Ambulance crews. (So always look for that C-Spine injury)

Suspecting C-Spine injury

At triage assess patients with suspected cervical spine injury using the factors below

Check if the patient:

Has any Significant distracting injuries
Is under the influence of drugs or alcohol
Has reduced GCS– Is confused, uncooperative or unconscious
Has any spinal pain
Has any hand or foot weakness (motor assessment)
Has altered or absent sensation in the hands or feet (sensory assessment)
Has priapism (unconscious or exposed male)
Has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.

If ANY of these factors OR assessment cannot be performed:

Immediate In-Line Immobilisation, & Senior Review.

Formal Assessment

We (& NICE) recommend the use of the Canadian C-Spine rules to formally assess the patient’s need for imaging. As this has been shown tone the most sensitive and reliable method Sensitivity 0.9-1.0 [CMAJ 2012]. However, remember children can be hard to assess and no test is ever perfect especially if it is not applied properly, make sure you follow the algorithm.

If you can’t apply the Canadian C-Spine rule due to Reduced GCS or Intoxication:

IMAGING IS REQUIRED

Imaging – NICE

Adults:

Perform CT C-Spine if ANY of:

imaging for cervical spine injury is indicated by the Canadian C‑Spine Rule
there is a strong suspicion of thoracic or lumbosacral spine injury associated with abnormal neurological signs or symptoms
if imaging for head injury and suspected cervical spine injury

Perform MRI if:

there is a neurological abnormality which could be attributable to spinal cord injury (regardless of whether or not the abnormality is evident on CT)

Children:

MRI is recommended if imaging for cervical spine injury is indicated by the Canadian C‑Spine Rule
- (However, MRI avaliblity is limited so it is important to discuss with Radiologist as CT is likely more practical)

Post Imaging

No Injury found – Don’t Forget SCIWORA

After the images have been reviewed (X-Ray) or reported (CT), you must assess the patients and they fulfill the following criteria.

Normal GCS
No Neurology
Able to rotate 45 degrees to left and right

SCIWORA – Spinal Cord Injury With Out Radiological Abnormality (e.g. ligamentous injuries or central cord syndrome)

Injury Found

Ensure that spinal immobilisation continues
Look for Other injuries (If you have 1 fracture there is a 10% chance you will have a second)
Online referral to Neurosurgery: for admission or adequate plan.

SOP – C-Spine

C-Spine Injury