All potential major trauma patients suspected of having a cervical spine injury will arrive in the Emergency department with a rigid collar applied by ambulance crew. Assessment and imaging will occur while the patient has the rigid collar insitu. Clinical examination using the NEXUS low risk criteria should be performed, however this can only occur four hours after the last administration of narcotics.
The NEXUS low risk criteria constitute a decision tool for use in the initial assessment of conscious patients to indicate those at very low risk of cervical spine injury following blunt trauma who may not need radiographic imaging.
Patients are considered to be at extremely low risk of cervical spine injury if ALL of the following criteria are fulfilled:
If all of the above criteria are satisfied, clinical examination may then proceed. If there is no evidence of any bruising, deformity or tenderness on examination, and if a full range of active movement can be performed without pain (including 45degree rotation to left and right), the cervical spine can be cleared without radiographic imaging and the cervical collar be removed.
Should the patient exhibit any of the criteria, however, clinical examination is unreliable and radiographic assessment of the cervical spine is advised.
1. Midline cervical spine tenderness
Present if the patient indicates the existence of neck pain on palpation of the posterior midline neck region from the nuchal ridge to the third thoracic prominence, or palpation of any cervical spinous process.
2. Focal neurologic deficit
Motor or sensory examination indicates the presence of a focal neurologic deficit eg. segmental weakness, numbness or paraesthesia.
The patient is considered to be intoxicated if:
4. Painful distracting injury
Any non-spinal related condition causing sufficient pain to distract the patient from a possible cervical spine injury. Suggestions include:
5. Altered mental status
An altered state of mental alertness can be demonstrated by:
Clinical spinal clearance
If all of the NEXUS criteria are negative, there is no evidence of bruising or deformity, and if a full range of active neck movement (including 45° rotation to left and right) can be performed without pain, the cervical spine can be clinically cleared without radiographic imaging and the cervical collar can be removed. Documentation must be made on the electronic Spinal Assessment and Clearance Form.
Cervical spine imaging
Should the patient exhibit any signs of cervical spine tenderness, focal neurologic deficit, evidence of intoxication, painful distracting injury or altered mental status, however, clinical examination is unreliable and radiographic assessment of the cervical spine is advised.
MRI may be required if CT images are abnormal or if abnormal neurology is present
To ensure adequate access have another colleague maintain manual in-line stabilisation while the collar is removed for palpation and throughout the examination.
Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity. The point of maximum tenderness should be noted. Deformity may be felt in significant vertebral disruption or dislocation.
Check the soft tissues for bruising, pain and tenderness.
Complete the neck examination by observing the neck veins for distension and palpating the trachea and the carotid pulse. Note any tracheal deviation or crepitus.
The patient will need to be log rolled to complete the full examination. This should be combined with the back examination.