Session II - Pediatrics/Spine
Fluoroscopic Evaluation of the Cervical Spine in the Polytrauma Patient
Mitchel B. Harris, MD; Steven C. Kronlage, MD; Phyllis Carboni, RN; Norman B. Chutkan, MD, Louisiana State University School of Medicine, New Orleans, LA
Purpose: To evaluate the safety and efficacy of a fluoroscopic guided spine examination in the trauma victim unable to be cleared by 'standard measures'.
Methods: All trauma victims with a normal cervical spine trauma x-ray series (AP,lat, dens) that were deemed unable to be free of an unstable injury due to an incomplete clinical exam were prospectively enrolled. Reasons for an incomplete examination included the presence of an altered sensorium secondary to drugs or alcohol, significant 'distracting injuries', or those intubated and narcotized prior to their trauma unit evaluation. Utilizing real-time fluoroscopy, with the patient anesthetized, 20-25 lbs. of traction is applied in a progressive manner through a cervical halter. In-line axial distraction, i.e., the "stretch test" is performed with fluoroscopic visualization of the entire cervical spine. If the stretch test is negative ( no instability), passive flexion/extension views are performed with direct fluoroscopic visualization. A positive finding includes any of the following:
Additional positive findings include splaying of the spinous processes, or subluxation of the facet joints. If the cervical spine is unable to be adequately visualized at either junction (oc.-cervical or cervical-thoracic) during the fluoroscopic evaluation, standard measures for cervical spine clearance are utilized with a collar maintained throughout.
Results: Over a 27-month period, 113 patients were prospectively enrolled in this IRB-approved protocol. 74 males, 39 females. 92% were victims of vehicular trauma. Ave. ISS=17, ave. age 32 y/o. 109/113 have completed data. 9/113 were unable to be cleared intra-operatively due to inadequate visualization of the cervical-thoracic junction. 3 positive studies were identified and all three were subsequently operatively stabilized. Intra-operative findings confirmed that the patients had injuries to their cervical spine rendering their spines as "unstable". 83/113 patients were admitted from the trauma unit directly to the operating room. Five (5) of these patients were unable to be cleared due to non-visualization of the cervical-thoracic junction. The remainder of this subset of patients (78, trauma unit-OR), had their cervical spines 'cleared' within eight (8) hours of their time of admission to the trauma unit.
Discussion/Conclusion: This preliminary study illustrates the safety and utility of intra-operative fluoroscopic evaluation of the cervical spine in the polytrauma patient. A similar protocol has been successfully and safely utilized for isolated head-injured patients (Davis et al J of Trauma '95; Sees et al. J of Trauma '98 ). Not only does this method of evaluation of the cervical spine allow for early removal of the hard collar, it can also delineate an unstable ligamentous injury. These soft tissue injuries would otherwise be unknown and carry significant risk of neurological injury with routine patient care activities. Early removal of the rigid collar in a multitrauma patient will aid in respiratory management, avoidance of skin problems and facilitate safe patient care.