Clinical & Radiographic Evaluation

CLINICAL & RADIOGRAPHIC EVALUATION

KEY RECOMMENDATIONS

1. Document the patient’s neurologic status via the American Spinal Injury Association (ASIA) Examination. Alternatively, the Combat Neuro Exam can be used. (Level III)
2. Computerized tomography (CT) is the recommended means to radiographically assess for bony spinal injuries. (Level I)
3. Plain films can be used to radiographically assess the bony spine if CT is not reasonably available, but caution should be used in removing cervical stabilization without CT imaging. (Level III)
4. CT Angiography (CTA) is recommended for any patient with a suspected craniocervical vascular injury. (Level II)
5. Given the limited availability of MRI at echelons lower than Role 4, CT myelography may assist in the evaluation and workup of patients with spinal cord injuries in theater if the required resources are available. (Level III)
6. Cervical collars should be placed on all patients with symptoms correlating to a cervical spine injury or in accordance with the Canadian C-spine Rule. (Level III)
7. Clearance of a C-spine can be done via a clinical exam, radiographic studies, or a combination of the two depending on the neurological status of the patient. Document the clearance of the C-spine (Level II)

NEUROLOGIC EXAM

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:

- Motor exam of the 10 ASIA key motor groups (Appendix A).
- Sensory examination (pin prick and light touch) using ASIA dermatomal standards.
- Digital rectal exam that assesses voluntary anal sphincter contraction strength, pinprick sensation, resting tone and bulbocavernosus reflex (BCR).
- Normal and pathological reflex testing such as biceps, triceps, brachioradialis, knee, and ankle jerk responses as well as presence/absence of Babinski reflex and Hoffman’s signs, or evidence of spinal cord injury patterns, including Central Cord Syndrome, Brown-Sequard Syndrome, etc.

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.

RADIOGRAPHIC ASSESSMENT

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.