CLINICAL & RADIOGRAPHIC EVALUATION
KEY RECOMMENDATIONS
Every effort must be made to document an accurate and thorough neurological examination, especially when surgery or aeromedical transport is planned. The quality of the examination can be degraded by patient’s mental status, effort and degree of cooperation, medication effect including sedatives, the presence of an airway adjunct or endotracheal tube, or the presence of other injuries. Failure to perform and document a neurological exam has been the most common source of discrepancy between serial neurological examination findings, especially between levels of care.
A thorough neurologic exam should include:
In patients with suspected spinal column injury, with or without neurologic deficit upon presentation, frequent repetition and surveillance of the neurologic examination (focusing upon motor and sensory performance) is imperative. It is recommended to use Appendix A: ASIA Worksheet and attach to the patient’s chart.
Alternatively, the Combat Neuro Exam is a simpler documentation tool than the ASIA Worksheet and may be more amenable to non-spine specialists to complete. (See Appendix B: Combat Neuro Exam.) This note addresses the minimal elements of a complete neurological exam for a patient with significant spinal column injury. Fill out and attach to the patient’s chart.
In the assessment of the patient with possible spinal injury, plain radiography has been superseded by axial CT with sagittal and coronal reconstruction where available.11 If CT is not available and evacuation to a higher level of care will not occur in a timely fashion, then plain radiographs will suffice for clinical decision.
Often, polytrauma patients will undergo a protocoled study involving a CT angiography of the neck, with follow-through of the chest, abdomen and pelvis, which adequately assesses the entire spinal axis for osseous as well as craniocervical vascular compromise. For less severely injured patients not warranting such a study, clinical suspicion should guide the decision to obtain imaging. A low threshold to obtain a CTA should be maintained, particularly in those with a documented cervical spinal fracture, or positive screening criteria for blunt cerebrovascular injury (BCVI); see Appendix C: Expanded Screening Criteria for Blunt Cerebrovascular Injury).12
In instances of spinal injury with incomplete deficits of the spinal cord, conus medullaris or cauda equina, particularly when those deficits are progressive, consideration should be given to performance of CT myelography (See Appendix D: Adaptation from OmnipaqueTM (iohexol) package insert). This would allow for the most rapid diagnosis and potential opportunity for decompression when faced with an incomplete or progressive deficit.