1. Spinal Imaging and Clearance
Trauma Guidelines December 2008
University Hospital of North Staffordshire
Dr PA Oakley

2. Spinal Imaging and Clearance in Major Trauma
Precautions
Initial Clinical Assessment
(without movement)
Further Clinical Assessment
(with movement)
Initial Spinal
Imaging
Further Spinal
Spine Cleared
and Precautions Abandoned
Referral to On-Call
Spinal Surgeon
IF neurological features or disproportionate pain/tenderness with or without moving spine, or inadequate movement on moving spine,
then refer
IF imaging uncertain or abnormal, then refer
IF any NEXUS criteria fail then imaging
is required
IF further imaging normal and patient is assessable
IF severe pain
or any neurological
symptoms or signs
on movement
IF initial imaging
is normal
and patient is
assessable
IF all NEXUS criteria apply then imaging
is not required
IF all NEXUS criteria apply, no restriction on active neck rotation 45° to both sides (Canadian C-Spine Rule)
and able to lift head up against gravity,
then the spine is declared clear
IF adequate active movement with no neurological features, no disproportionate midline pain/tenderness
and able to lift head up against gravity
in an assessable patient with normal imaging,
IF MRI scan of the spine is normal
(and reported so by a senior radiologist or spinal surgeon)
IF C-spine CT scan and appropriate TL-spine imaging are normal
in an obtunded patient who is predicted to be
un-assessable clinically during the next 24 h,
then the spine is declared clear on risk-benefit grounds
Spinal Imaging and Clearance in Major Trauma
An expert may judge the spine to be clear
(e.g. if an injury is considered to be insignificant or old)
UHNS PAO
Suspected or Potential Spinal Injury
SEE further imaging choices
and criteria
SEE initial
imaging choices and criteria

3. Spinal Imaging and Clearance in Major Trauma
SPINAL PRECAUTIONS
Hard collar, head blocks and firm surface
Log-rolling to change position
Manual in-line immobilisation of head and neck when collar or blocks removed
(e.g. for airway procedures)
Spinal Imaging and Clearance
in Major Trauma
UHNS PAO
ASSESSABILITY WITHOUT IMAGING – *NEXUS CRITERIA
No posterior midline spinal tenderness
No focal neurological deficit
No evidence of intoxication (including presence of significant alcohol or sedative drugs)
No painful distracting injury
Normal mental status
* modified to apply to thoraco-lumbar, as well as cervical spine
ASSESSABILITY AFTER NORMAL IMAGING
Careful judgement by senior clinician on case-by-case basis if any of the NEXUS criteria still do not apply.
The patient must be at least:
Alert when roused (E  3)
Appropriate (V  4)
Able to obey commands (M = 6)
IMAGING MODALITIES
CT scan: C-spine 2-3 mm slices and chest/abdomen/pelvis 5 mm slices, all reformatted to 1 mm for sagittal and coronal spine reconstructions
Plain views: C-spine antero-posterior (AP), lateral and open-mouth odontoid peg ± 45° obliques of cervico-thoracic junction; TL-spine AP and lateral
MRI: Sagittal STIR to screen for soft tissue and bony injury; high resolution (sagittal/axial T1/T2) to assess areas of concern on CT or STIR
INITIAL IMAGING CHOICES AND CRITERIA
IF high risk mechanism with suspected serious trunk injury or any cardio-respiratory instability, then CT from occiput to pelvis, irrespective of conscious level
IF cord or nerve root symptoms or signs, or evidence of posterior circulation syndrome, then MRI entire spine (± CT of appropriate areas for bone detail)
IF GCS < 13, then CT entire C-spine from occiput (C0) and extend down to T4
IF GCS 13-14, then AP and lateral plain C-spine views (omitting peg and oblique views) and CT upper C-spine from C0 to C3 (sparing thyroid from radiation). If age  65 or clinical evidence of cord/nerve root injury/posterior circulation syndrome, or if plain views (done first) are inadequate/abnormal/uncertain, then CT entire C-spine instead
IF GCS = 15 and no cord, nerve root or vascular features, then plain C-spine films
IF mechanism puts TL-spine at risk, then plain TL-spine films, but if CT of chest or abdomen is indicated separately, then replace corresponding plain views with CT scan
IF pregnant, consider MRI TL-spine (± C-spine) instead of plain views or CT scan. Note that plain views or C-spine CT (extended down to T4) are not contraindicated. MRI of the entire spine may cause significant heating that may affect the fetus. Senior judgement is required to tailor the imaging protocol.
FURTHER IMAGING CHOICES AND CRITERIA
IF C-spine plain films normal, but severe localised posterior midline tenderness or disproportionate neck pain with or without movement, then consider CT scan ± MRI scan
IF plain films show fracture, mal-alignment or soft tissue swelling or findings uncertain, then CT scan
IF CT shows:
Fracture involving more than 1 column, or
Significant soft tissue abnormality, or
High risk factors for disco-ligamentous/vascular injury:
– Subluxation or dislocation
– Fracture through foramen transversarium
then MRI scan
IF neurological features on moving neck on further clinical assessment, then MRI scan
IF MRI scan shows unsuspected bony injury, consider CT scan of this area to reveal bone detail (if not already done)