Clinical Practice Guidelines

Cervical Spine Assessment

  • This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

    See also:
    Radiology guideline - Acute indications

    This document provides a framework for assessment of a child with a possible cervical spine injury in Victorian hospitals.

    All children under 16 years of age with major trauma (including confirmed or highly suspected spinal cord injury) should have ongoing management at Royal Children's Hospital.

    Background

    Traumatic injuries of the cervical spine are uncommon in children. However in many circumstances it is prudent to assume there is a cervical spine injury until examination and radiological investigation prove otherwise.
    It is often challenging to assess and immobilise children when a cervical spine injury is suspected.

    • Constant reassurance is required to help keep the child still and reduce their anxiety levels.
    • If the child is anxious or uncooperative and a thorough examination is not possible, try and maintain in line C-spine immobilisation with or without a collar.

    On Arrival at hospital

    1. Spinal boards:

    All children should be taken off the spinal board as soon as possible, ideally at time of transfer from ambulance trolley.

    2. Patient position, head immobilisation,

    If children are less than 8 years they should be placed on a mattress with a cut away head space or on an airway pad.

    Airway Pad

    BDP_9127.JPG

    "A suitable folded airway pad allows for a child's large occiput and keeps spine in a neutral position."

    Immobilisation

    Patients with suspected or possible cervical spine injury must have their cervical spine properly immobilised until formal assessment occurs.

    Sand bags and tape are NO longer recommended in the hospital setting

    Who to immobilise:

    • Any patients with a history of trauma if the patient is
      • Unconscious
      • Complaining of neck pain or tenderness or limitation of movement
      • Using hands to support neck
      • Has any neurological deficit
      • Significant head /facial injuries
    • Any patient with a mechanism which may indicate spinal injuries
      • Pedestrian / cyclist hit > 30km/hr.
      • Passenger – MVA collision > 60km/hr.
      • Fall - more than 3 metres.
      • Kicked by, or fall from a horse.
      • Backed over by a car.
      • Thrown from vehicle.
      • Thrown over handlebars of bike.
      • Severe electric shock.

    How to immobilise the cervical spine:

    • Apply manual in line immobilisation 
    • Apply a one piece hard collar: ensure appropriate sizing or check sizing of collar in situ
    • If unable to apply a hard collar, manual in line immobilisation should be maintained

    eg

        • Uncooperative patient
        • Infant or baby too small for a hard collar
        • Child with traumatic torticollis
    • Ensure adequate analgesia is provided.

    Sizing a one piece hard collar:

    • Measure the distance from the top of the patient's shoulder to the angle of the jaw with your hand (image 1)
    • On the collar, measure from the bottom of the rigid plastic to the "measuring post". This should correspond to the above measurement (image 2)
    • Check that the collar fits correctly
      • The neck should not be overextended
      • The mouth should not be able to be fully opened (image 3)

    1 Measuring collar size on neck.jpg

    Image 1: Measuring collar size on neck

    Image 2 Checking collar size.jpg

    Image 2: Checking collar size

    Image 3 Appropriately fitting collar.jpg

    Image 3: Appropriately fitting collar

    Assessment and clearance of the c-spine of injury

    Spinal assessment and management plan MUST be clearly documented.
    IF ABNORMAL NEUROLOGY – CONTACT RCH NEUROSURGERY IMMEDIATELY (03 9345 5522)

    To be able to adequately assess the patient, he/she must:

    • Be conscious
    • Be cooperative
    • Not have distracting injuries (eg limb fracture)
    • Not be affected by alcohol or drugs
    • Be developmentally able to engage in the assessment process.

    If patient is unable to be assessed, immobilisation should be maintained in a hard collar. 

    Flowchart: Assessment of the Cervical Spine

    Assessment of the Cervical Spine

    Download PDF

     

    Patients with possible cervical spine injury must have their cervical spine properly immobilised throughout assessment.  

     

    Two piece collars refers to – Aspen / Philadelphia two piece soft collars

    Radiology

    It is imperative that the person making the clinical decision regarding clearing the      c-spine has both examined the patient and viewed the films.

    How to x-ray

    • A doctor and /or nurse MUST accompany the patient to radiology for imaging to ensure maintenance of cervical spine immobilisation and airway management.
    • All patient transfers (on/off x-ray tables, CT scan etc) must be done using a patient-slide, keeping the spine in-line and with the head being held.
    • The hard collar should remain in place during the cervical spine x-ray series.
    • Do not remove the patient from the mattress with cut away head space airway pad (if available)

    What to x-ray

    Lateral c-spine

    • Most important view.
    • Portable film can be taken (eg: in resuscitation)
    • Ensure shoulder traction is performed to help view the C7-T1 junction
    • If the cervico-thoracic C7-T1 junction has not been satisfactorily imaged, a single attempt at a swimmer’s view may be obtained.
    • Flexion and extension views should not be performed 

    AP and Odontoid (Peg) view

    • Non urgent  - may be taken after priority CT imaging of other body regions if required 
    • Odontoid view:
      • Usually for children ≥ 5 years old (requires cooperative child for appropriate quality view)
      • collar may be opened – but ensure in line neck immobilisation is maintained. 

    Further imaging of C-Spine

    • All intubated patients requiring CT brain should be discussed with neurosurgery to see if a CT cervical spine is also indicated.
    • A normal CT of the cervical spine does not exclude injury in the unconscious patient and an MRI scan may be required.
    • Patients in whom the cranio-cervical or cervico-thoracic junction remain obscured after a single extra view should not have repeated attempts at plain imaging but have a CT of the relevant area
    • Patients with abnormalities on plain c-spine x-rays should be discussed immediately with the orthopaedic team (RCH) or neurosurgical team (MMC).

    Ongoing Care

    Guidelines for timing of fitting long term hard (Aspen) collars:

    (a) For patients being discharged:

    • If imaging is normal and there is ongoing tenderness of the posterior c-spine but the patient is otherwise well enough to be discharged, a two piece Aspen (or Philadelphia) collar should be applied.
    • Collar should be kept on until Outpatient review (eg: local Fracture clinic), usually within 2 weeks.
    • Give handout to parents: click here

     (b) For admitted patients:

    • If the c-spine cannot be cleared, continue immobilisation in a two piece collar.

    Pressure area care (PAC)

    Pressure area care is important for all patients requiring immobilisation, and should be considered from initial presentation.

    • Children must be removed from spinal board as soon as possible.
    • Regular pressure area care requires log-roll and maintenance of immobilisation. Pay particular attention to pressure areas:
      • Occiput (especially younger children), sacrum and heels.

    Positioning:

    Ideal positioning:

    • Flat on back, remember pressure area care.

    Bed tilting and mattresses - (if the head is to be elevated for neurological reasons):

    • If none of the spine has been cleared the bed should be tilted maintaining body alignment – "Trendelenburg tilting"
    • If everything but the c-spine has been cleared then the bed can be tilted from the hips.
    • Air mattresses are not generally recommended until c-spine has been cleared.

    For further information, see Pressure ulcer prevention and management guideline

    Consider consultation with local paediatric team:

    • All children with suspected cervical spine injury

    When to consider transfer to tertiary centre:

    • All children with major trauma, including suspected or confirmed spinal injury should have ongoing management in a trauma centre (RCH).
    • Child requiring care beyond the comfort level of the hospital.

    For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007

     

    Information Specific for RCH

    Documentation: Use the Major Trauma management record for documentation of spinal assessment and plan

    Further imaging (including CT, MRI) must be discussed with the Emergency consultant or unit registrar and Medical Imaging fellow.
    Intubated patients requiring CT brain should be discussed with Neurosurgery.
    Patients with abnormalities on plain c-spine x-rays should be discussed with Orthopaedics.

    Admission:
    Patients with multiple injuries are admitted under General Surgery with Neurosurgical and/or Orthopaedic input.
    Patients with isolated spinal cord injury are admitted under Neurosurgery.
    Patients without neurological signs, who cannot be cleared in the Emergency Department, should be discussed with the Orthopaedic team. 
     

     

    Information Specific for Southern Health

    The neurosurgical unit at Monash Children’s provides a service for assessment of paediatric patients with brain and spinal injuries. All patients with suspected injury should be discussed with the neurosurgical unit (03 9594 6666).

     

    Last updated December 2012