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Cervical spine assessment in PICU

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General Points

  1. There is evidence to support guidelines only, not protocols
  2. All patient should be stabilised prior to cervical spine clearance
  3. Mechanism of injury is a poor predictor of spinal cord injury
  4. One in six children with spinal injury have multiple levels of injury
  5. Ligamentous instability may be more common than thought
  6. The true incidence of C spine injury is not known, nor how many missed.

Common normal XR changes in paediatrics

  • Overriding of anterior atlas relative to odontoid on extension
  • Exaggerated atlanto-dens intervals
  • Radiolucent synchondrosis between odontoid and C2.
  • Pseudosubluxation of C2 on C3. (To differentiate between physiological and traumatic subluxation, draw a line through post arches of C1 and C3. In pseudosublux, line passes through, touches or lies up to 1 mm anterior to the anterior cortex of posterior arch of C2. If anterior cortex of C2 is 2mm or more behind line, then is true dislocation.

Technically adequate Xrays

Must see base of occiput and upper border of T1, odontoid which shows lateral masses of C1 and all of odontoid process.

Cervical Spine Guidelines

Immobilisation

Collars do not prevent forced flexion when supine on spinal boards

Collars alone do not prevent injury and may worsen respiratory function, lead to skin ulceration and thrombosis of neck veins

No collar provided acceptable immobilisation when used alone

Neutral position desirable:
- <4 years old, need elevation of torso by more than 25 mm to eliminate positional neck flexion and achieve neutral alignment.
- <8 years, need elevation of torso by 25 mm to achieve positional neck flexion and achieve neutral alignment

Recommendation
<8 years, should elevate thorax or recess the occiput. Achieve this by placing extra folded blanket to thickness of 25mm under the patient's body.

Combination of half spine board, rigid collar, sandbags and tape is best, but may affect respiratory function

Imaging

Low risk no cervical tenderness, alert, able to communicate, no neurological  deficit, no intoxication, no unexplained hypotension or absent vital
signs
Recommendation: no imaging
Medium risk with any of the above:
Recommendation:
• lateral and AP XR
• If XR normal but pain, do flexion / extension views
High risk/ Comatose (majority of PICU patients) Non verbal, due to age, head injury and pain.
Recommendation for all ages:
• AP and lateral Xray of spine. Odontoid view not required
• CT scan of upper two C vertebrae with axial CT at 3mm intervals. If possible  this can be done with the initial
  head CT.

• For children transferred in to the PICU, CT of C1 and C2 should be requested  with head CT at the referring
  hospital. If CT has already been taken at the time 
of referral call, then CT of C1 and C2 should be requested in
  Starship with the 
follow up CT head, or separately if no further cerebral imaging is planned.
• Axial CT at 3mm intervals for suspicious areas or areas not well seen on lateral  XR.
• If view are adequate and no abnormality is seen, consider the spine to be stable  and remove collar. False negative
  rate of <0.1% with Xrays and CT

• MRI indicated only for
- unstable spinal injuries who require surgical stabilisation,
- exclusion cord or nerve root compression
- evaluation of ligamentous integrity
- information re neurological deficit
Not recommended:
• Flexion/extension views: <9 years if XR normal, few injuries below C3. No  evidence for use, not more accurate
  than recommendations, high false negative 
rate and not cost effective
• Routine MRI: sensitive but not specific, difficult to perform in unstable patient


SCIWORA: Spinal Cord Injury without Radiological Abnormality

Immobilisation Recommended for:
• Severe pain/ spasm:Immobilise until flexion/ extension views confirm stability
• Transient or persisting neurological symptoms. Presenting examination relates  strongly to outcome
Radiology Recommendations:
• Plain XRs: Whole spine to exclude fractures. Fracture, subluxation or  pathological motion rules out SCIWORA
• MRI:
  - if suspected neurological injury
  - To exclude compressive cord or nerve root lesions
  - To exclude ligamentous disruption
  - To determine time for immobilisation
  - To predict outcome: hematomyelia or disruption associated with severe  permanent neurological injury, signal
    change may improve over time, normal 
do well.
Not recommended:
• spinal angiography or myelography
• CT

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Document Control

  • Date last published: 31 October 2005
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Brent McSharry
  • Editor: John Beca
  • Review frequency: 2 years