Session VI - Spine
Cervical Dynamic Screening in Spinal Clearance Now Redundant?
Background: The safest and most effective method of early spine clearance in unconscious patients is the subject of intense debate.
Hypothesis: Helical CT is a sufficiently sensitive investigation to render dynamic screening of the cervical spine redundant.
Protocol: Our protocol for cervical spinal clearance in the unconscious patient since April 1994 involves the use of plain radiographs, CT scan, and dynamic screening (DS).
Method: Over a 10-year period, April 1994 to September 2004, 839 patients were admitted to intensive care under the orthopaedic surgeons. 35 patients were excluded because of incomplete records.
Results: Demographics: The mechanism of injury was a road traffic accident in 80% and the mean ISS was 24.1. There were 95 patients (11.8%) with a cervical spine fracture, 96 (11.9%) with a fracture in either/both thoracic and lumbar regions.
Spine clearance: The mean intubation period was 7.1 days with a mean time to spine clearance of 0.4 days. In 318 patients, clearance was performed with the patient conscious (284 prior to intubation, 34 after intubation of <24hrs). 42 patients (5.2%) died before spine clearance. In 10 patients, the protocol was not followed.
Inclusions: 434 patients underwent CT. 10 of the 95 cervical fractures were deemed stable and underwent DS (n = 349).
Missed Cases: CT missed 2 cases of instability; one of these (an atlanto-occipital dislocation) was also missed by DS. Critical analysis revealed that a Powers ratio calculation would have diagnosed this injury on CT. The sensitivity of CT was 97.7% and for DS, 98.8%. The specificity for both CT and DS was 100%. There were no complications from either procedure.
Conclusion: DS is a safe procedure but has no real advantage over helical CT. Powers ratio calculation is essential to reduce the chance of a missing an upper cervical injury. The cervical spine can be reliably cleared using helical CT alone.