Cervical spine issues

M PerryConsultant craniofacial surgeon

Londonwww.facialsurgery.centre

Cervical spine issues

• Up to 20% “severe” facial injuries

ATLS - “Trauma above the clavicles”

• When should we worry?

• What can / should we do?

Cervical spine issues

• When should we worry?

Cervical spine issues

Mechanism of Injury

• Blunt

• Penetrating

Mechanism of Injury

• Blunt 1. Deceleration 2. High energy

impacts

• RTAs / Falls • Interpersonal violence • Sports

High risk activities

• Diving • Equestrian activities • Football / rugby • Gymnastics • Skiing / Hang gliding

High risk groups

• Elderly • Children

Cervical spine issues

Issue 1

• We will encounter them

• Can be easily overlooked

• “Diffuse responsibility”

• Actively consider

• Anaesthetic refusal

• Walking wounded

• Multiply injured / unconscious

Recognition - 2 groups

• Walking wounded Ask this about the neck- • When injury occurred• Mechanism of injury• Where are they sore • Any loss of consciousness or signs of head injury • Any peripheral neurological symptoms• Progression of symptoms since time of injury• Any other injuries (remember the entire spine)

Look for • Peripheral neurological deficit• Bony tenderness • ROM

Recognition-Group 1

• Walking wounded Low risk factors • Simple rear end collision where the car wasn’t forced into the car in front • Ambulatory at any point after the injury • Sitting in the emergency department • Absence of midline spinal tenderness • Delayed onset of neck pain

NEXUS / Canadian C Spine rule Low risk patients - can they rotate their head >45 degree’s bilaterally ? If low risk symptoms and low risk factors then their collar can be removed and the neck carefully assessed. If cannot reach 45 degree / severe pain >7/10 or neurological symptoms, imaging is required.

Recognition-Group 1

• Assess the neurological state of the limbs. (Tone, Power, Sensation, Reflexes, Proprioception and Coordination)

• Examine relevant imaging • Are there any other distracting injuries? • Has analgesia (opiates) been given? • Is there any spinal pain? • Is the patient mentally alert? (Head injury / Alcohol / Drugs etc)

If all ok, take the front of the collar off. Assistant to support the head. • Assess for spinal tenderness. • Feel for any swelling, steps or crepitus. • Assess active movement - Lateral flexion first, then rotation, then lift head. • If complains of any neurological symptoms or pain, the neck is not cleared. • Cleared if can move the neck freely without pain or neurological symptoms

How to “clear” the neck

• GCS 15, alert and orientated • No drugs / alcohol • No “distracting” injuries • No neurological deficit • No midline tenderness and • Normal examination

= C Spine cleared

How to “clear” the neck

Do I really need to know all this?

You may have to do this

Ward

Clinic

Issue 2

Deceptive injuries

Beware hyperextension injuries in the elderly

Often mobile, so not suspected

? NS in hands

ATLS

Know how to protect

Know how to immobilise

Recognition-Group 2

ATLS

Know how to protect

Know how to immobilise

Interventions difficult (unfasten collar)

Recognition-Group 2

Issue 3Know your role in trauma team

Know your limitations

Protect neck during any interventions

KEEP SUPINE SIT UP

Issue 4“Can I sit up ?”

“Can I sit up ?”

Thoracolumbar trauma (10%)

Delayed diagnosis in 25%

Prolonged immobilisation

KEEP SUPINE

Risk aspiration Combative patient

SIT UP

Axial loading

Issue 4

Mechanism of injury

Never restrain

Make no assumptions

When will neck be cleared ?

What to do if not

The unconscious ICU patient

Mayfield clampMake no assumptions

When will neck be cleared

What to do if not

Summary

• Identifying those at risk (esp. occult) • Screening in the clinic or on the ward • How to ‘clear' a neck • How to protect a neck • Limitations in intervention • ICU patients • When to sit up