Trauma
A 32 year old man presents to the Emergency Department following a low speed rear end collision in a car park. He was mobile at the scene but is complaining of neck pain. He has no past medical history. He has walked into the Emergency Department unaided. You are asked to assess him in the triage room by the triage nurse. You find he is unable to rotate his head left or right without experiencing pain. What is the next test or investigation in this patient's management?
Answer:
NICE Guidelines for spinal injury state that for suspected cervical spine injury:- Assess the person with suspected cervical spine injury using the Canadian C‑spine rule
- Carry out or maintain full in‑line spinal immobilisation and request imaging if:
- a high-risk factor for cervical spine injury is identified and indicated by the Canadian C‑spine rule or
- a low-risk factor for cervical spine injury is identified and indicated by the Canadian C‑spine rule and the person is unable to actively rotate their neck 45 degrees left and right
- Perform CT in adults (16 or over) if imaging for cervical spine injury is indicated by the Canadian C‑spine rule
Spinal Trauma: Assessment
Trauma
Last Updated: 13th February 2021
Spine injury, with or without neurological deficits, must always be considered in patients with multiple injuries. Approximately 55% of spinal injuries occur in the cervical region, 15% in the thoracic region, 15% at the thoracolumbar junction, and 15% in the lumbosacral area. Up to 10% of patients with a cervical spine fracture have a second, non-contiguous vertebral column fracture.
In patients with potential spine injuries, excessive manipulation and inadequate restriction of spinal motion can cause additional neurological damage and worsen the patient’s outcome. If the patient’s spine is protected, evaluation of the spine and exclusion of spinal injury can be safely deferred, especially in the presence of systemic instability, such as hypotension and respiratory inadequacy.
Pain management
- Assess pain regularly in people with spinal injury using a pain assessment scale suitable for the patient's age, developmental stage and cognitive function.
- Offer medications to control pain in the acute phase after spinal injury.
- For people with spinal injury use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
- If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamine.
- Consider ketamine in analgesic doses as a second-line agent.
When to maintain or carry out in-line spinal immobilisation
During initial assessment, protect the person's cervical spine manually, particularly during any airway intervention and avoid moving the remainder of the spine.
Prior to spinal assessment, carry out or maintain full in-line spinal immobilisation if any of the following factors are present OR if spinal assessment cannot be done:
- has any significant distracting injuries
- is under the influence of drugs or alcohol
- is confused or uncooperative
- has a reduced level of consciousness
- has any spinal pain
- has any hand or foot weakness (motor assessment)
- has altered or absent sensation in the hands or feet (sensory assessment)
- has priapism (unconscious or exposed male)
- has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.
After spinal assessment, carry out or maintain full in-line spinal immobilisation if:
- a high-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule
- a low-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule and the person is unable to actively rotate their neck 45 degrees left and right
- indicated by one or more of the factors suggesting thoracic or lumbosacral spine injury
After spinal assessment, do not carry out or maintain full in-line spinal immobilisation in people if:
- they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C-spine rule, are pain free and are able to actively rotate their neck 45 degrees left and right
- they do not have any of the factors suggesting thoracic or lumbosacral spine injury
Assessment for cervical spine injury
The person with suspected spine injury should be assessed as having high, low or no risk of cervical spine injury using the following Canadian C-spine rule:
- the person is at high risk if they have at least one of the following high-risk factors:
- age 65 years or older
- dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
- paraesthesia in the upper or lower limbs
- the person is at low risk if they have no high-risk features and at least one of the following low-risk factors:
- involved in a minor rear-end motor vehicle collision
- comfortable in a sitting position
- ambulatory at any time since the injury
- no midline cervical spine tenderness
- delayed onset of neck pain
- the person remains at low risk if they are:
- unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high-risk factors).
- the person has no risk if they:
- have one of the above low-risk factors and
- are able to actively rotate their neck 45 degrees to the left and right.
Be aware that applying the Canadian C‑spine rule to children is difficult and the child's developmental stage should be taken into account.
Assessment for thoracic or lumbosacral spine injury
Assess the person with suspected thoracic or lumbosacral spine injury using these factors:
- age 65 years or older and reported pain in the thoracic or lumbosacral spine
- dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
- pre-existing spinal pathology, or known or at risk of osteoporosis – for example steroid use
- suspected spinal fracture in another region of the spine
- abnormal neurological symptoms (paraesthesia or weakness or numbness)
- on examination
- abnormal neurological signs (motor or sensory deficit)
- new deformity or bony midline tenderness (on palpation)
- bony midline tenderness (on percussion)
- midline or spinal pain (on coughing)
- on mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).
Be aware that assessing children with suspected thoracic or lumbosacral spine injury is difficult and the child's developmental stage should be taken into account.
Diagnostic imaging
Imaging for spinal injury should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area.
Suspected spinal cord or cervical column injury in children:
- Perform MRI for children (under 16s) if there is a strong suspicion of:
- cervical spinal cord injury as indicated by the Canadian C‑spine rule and by clinical assessment or
- cervical spinal column injury as indicated by clinical assessment or abnormal neurological signs or symptoms, or both.
- Consider plain X‑rays in children (under 16s) who do not fulfil the criteria for MRI but clinical suspicion remains after repeated clinical assessment. Discuss the findings of the plain X‑rays with a consultant radiologist and perform further imaging if needed.
Suspected spinal cord or cervical column injury in adults:
- Perform CT in adults (16 or over) if:
- imaging for cervical spine injury is indicated by the Canadian C-spine rule
- there is a strong suspicion of thoracic or lumbosacral spine injury associated with abnormal neurological signs or symptoms
- If, after CT, there is a neurological abnormality which could be attributable to spinal cord injury, perform MRI.
Suspected thoracic or lumbosacral column injury only (children and adults):
- Perform an X-ray as the first-line investigation for people with suspected spinal column injury without abnormal neurological signs or symptoms in the thoracic or lumbosacral regions (T1–L3).
- Perform CT if the X-ray is abnormal or there are clinical signs or symptoms of a spinal column injury.
- If a new spinal column fracture is confirmed, image the rest of the spinal column.
Whole-body CT:
- Use whole-body CT (consisting of a vertex-to-toes scanogram followed by CT from vertex to mid-thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole-body CT.
- Use clinical findings and the scanogram to direct CT of the limbs in adults (16 or over) with limb trauma.
- If a person with suspected spinal column injury has whole‑body CT carry out multiplanar reformatting to show all of the thoracic and lumbosacral regions with sagittal and coronal reformats.
- Do not routinely use whole‑body CT to image children (under 16s). Use clinical judgement to limit CT to the body areas where assessment is needed.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
