Spinal Injury Management of the Adult



Canberra Hospital and Health ServicesClinical Procedure Spinal Injury Management of the Adult Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc508013833 \h 1Purpose PAGEREF _Toc508013834 \h 3Scope PAGEREF _Toc508013835 \h 3Section 1 - Spinal Immobilisation PAGEREF _Toc508013836 \h 41.1 Logrolling PAGEREF _Toc508013837 \h 41.2 Head Immobilisation PAGEREF _Toc508013838 \h 51.3 Trauma Soft Collars PAGEREF _Toc508013839 \h 81.4 Cervical Spine Clearance in the Trauma Patient PAGEREF _Toc508013840 \h 81.5 Spinal Orthosis PAGEREF _Toc508013841 \h 101.6 Bedrest Management PAGEREF _Toc508013842 \h 131.7 Spinal Traction PAGEREF _Toc508013843 \h 14Section 2 – Spinal Surgery PAGEREF _Toc508013844 \h 192.1 Pre-operative PAGEREF _Toc508013845 \h 192.2 Post-operative PAGEREF _Toc508013846 \h 202.3 Anterior Cervical Discectomy and Fusion (ACDF) PAGEREF _Toc508013847 \h 21Section 3 - Spinal Observations and Assessment PAGEREF _Toc508013848 \h 213.1 Spinal Injury Management and Treatment Plan PAGEREF _Toc508013849 \h 213.2 Traumatic Spinal Injury and Spinal Surgery Observations PAGEREF _Toc508013850 \h 22Implementation PAGEREF _Toc508013851 \h 24Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc508013852 \h 24References PAGEREF _Toc508013853 \h 25Definition of Terms PAGEREF _Toc508013854 \h 27Search Terms PAGEREF _Toc508013855 \h 27Attachments PAGEREF _Toc508013856 \h 28Attachment 1 Level of precaution required - assessed using the definitions for the 3 Protocol Groups PAGEREF _Toc508013857 \h 29Attachment 2: The Canadian C-Spine Rule PAGEREF _Toc508013858 \h 31Attachment 3: Spinal precaution for the unconscious trauma patient PAGEREF _Toc508013859 \h 32Attachment 4: Spinal precautions for the alert (GCS> 15) trauma patient PAGEREF _Toc508013860 \h 33Attachment 5: Indications for the use MRI in the management of patients with a potential spinal injury PAGEREF _Toc508013861 \h 34Attachment 6: Spinal injury management and treatment pla PAGEREF _Toc508013862 \h 35Attachment 7: Traumatic spinal injury and spinal surgery observation chart PAGEREF _Toc508013863 \h 36Attachment 8: Motor Grading Scale PAGEREF _Toc508013864 \h 38PurposeThe purpose of the Spinal Management Clinical Procedure is to outline the process for optimal care and management of spinal injuries and disorders in adult patients of Canberra Hospital and Health Services This procedure provides information for any clinicians who care for patients with a spinal injury or requiring spinal surgery in the acute hospital setting.Standardisation of practice means delivery of best practice, continuity of care and optimal clinical outcomes for the patients of the Canberra Hospital and Health Services.Back to Table of ContentsScopeThis clinical procedure is applicable to all Canberra Hospital and Health Services (CHHS) patients who have presented with a suspected spinal injury, those who have had radiological confirmation of a spinal injury and patients admitted for surgical management of a spinal disorder.The document applies to staff working within their scope of practice including:Medical staffRegistered and Enrolled NursesTertiary students under supervisionAllied Health Professionals all Consultants responsible for clearance of the cervical spine following review and reporting of the appropriate cervical spine imaging by a consultant radiologist or senior radiology registrar:Neurosurgeon (or senior neurosurgical registrar/fellow)General/Trauma surgeonIntensive Care PhysicianEmergency PhysicianOrthopaedic spine surgeon A registrar from the above specialties after discussion with their senior consultant.ALERT: In the consideration of spinal precautions and logrolling, head immobilisation should only be performed by Medical Officers or Registered Nurses, on completion of the appropriate training. Student nurses, medical students and wardsman to assist under strict guidance and supervision.Back to Table of ContentsSection 1 - Spinal ImmobilisationSpinal immobilisation in trauma is practiced in the management of potential and actual spinal injuries. It is usually initiated in the pre hospital setting before being maintained up to the point of medical clearance within the hospital setting. Immobilisation procedures include surgical fixation, orthosis application, spinal logrolls and traction including Gardner Well Tongs and Halo and Vest. Evidence suggests that over 5% of patients admitted presenting with a spinal injury experience the onset or worsening of neurological symptoms once they reach hospital. This is not only attributed to worsening ischaemia or spinal cord oedema but also to inadequate immobilisation of the spine. In addition to protecting the patient from worsening injury, immobilisation also plays a role in controlling pain associated with column fractures and soft tissue injuries (Attachment 1).The main aims of care for patients with a potential or confirmed spinal injury are to prevent further spinal injury, prevent complications from immobilisation and timely clearance of the spine. The level of precaution required can be assessed using the definitions for the 3 Protocol Groups outlined in Attachment 1.1.1 Logrolling Logrolling is performed to provide pressure area care, examine skin integrity, assess for further injury, during thoracolumbar spinal clearance and to protect the airway in the instance of vomiting etc. The main aim of this technique is to support and maintain the natural anatomical alignment of the spine.The number of staff required and the technique itself is dependent on the level of injury. This should be identified from medical documentation in the patient’s clinical record or in the instance of potential spinal injury; guided by the trauma team leader.The patient should be supine and anatomically aligned prior to commencement of the logrolling procedureExplain the procedure to the patient, asking them to lie still, cross their arms across their chest to prevent twisting motion and refrain from assistingEnsure any lines or medical devices i.e. indwelling catheters, intercostal catheters, are clear and reposition them where necessary to avoid dislodgementIf the patient is intubated or has a tracheostomy tube, airway suctioning prior to log rolling is recommended to prevent coughing and anatomical misalignmentPosition the bed at a suitable height for staff, if cervical precautions required the height should be suitable for the ‘head holder’Assistant 1, the assistant supporting the upper body, place one hand over the patient’s shoulder to support the posterior chest area, and the other hand around the patient’s hipsAssistant 2, the assistant supporting the patient’s abdomen and lower limbs, overlaps with assistant 1 to place one hand under the patient’s back, and the other hand over the patient’s thighThe ‘head holder’, the clinician who leads the roll, directs assistants 1 and 2 when the roll will be initiated (ON the count of three)Again, on direction from the ‘head holder’, the patient is turned in anatomical alignment in one smooth actionAssistant 3 completes the planned activity (pressure area care etc.)The head holder will direct the assistants to either return the patient to the supine position (ON the count of three) or to support the patient in a lateral position with wedge pillows. The patient should be left in correct anatomical alignmentConsider whether the intubated patient or patient with a tracheostomy requires further suctioning post roll.1.2 Head ImmobilisationPrior to cervical spine clearance or when a cervical injury has been diagnosed, a patient’s head should be immobilised during a log-roll, position change or when a cervical collar is removed.The main aim is to maintain the patient’s head in anatomical alignment and prevent flexion, extension and lateral tilting. The patients head is always held from the top of the bed however there are other techniques such as head and trapezius holds depending on clinician preference and environmental constraints.If a collar is insitu, ensure that it is well fitted prior to commencement of rollHead Hold: The thumb and forefingers of both hands are extended allowing the rest of the fingers to shrug the occiput. The forefingers are folded along the line of the sternocleidomastoid muscle and the thumbs provide support along the angle of the jaw.If the patient is intubated the hand which is supporting the opposite side to which is being rolled on, can support the endotracheal tubeTrapezius Hold: With the forearms in a supinated position and with the thumbs extended, slide the fingers under the trapezius muscles bilaterally with thumbs resting over the clavicles (and alongside the collar if insitu). In this hold, the forearms are used to immobilise/support the patient’s head during the log-roll.The ‘head holder’ is the team leader throughout the process of logrolling. They must ensure that all assistants are in correct position and ready to commenceOnce assured that all assistants are ready, call ‘on my count of three: one, two, three, and roll should occur ON threeThis process repeats on return to resting position – ‘back on my count of three; one, two, three’The ‘head holder’ must continue to support the head until completion of the procedure or for as long as the patient is being repositioned, i.e. slide sheet up the bedALERT.Clinicians should always be aware of the risk of neurogenic shock in severe acute spinal injury with possible cord involvement. Neurogenic Shock, is defined as vascular hypotension with associated bradycardia usually resulting from traumatic disruption of the sympathetic outflow between (T) 1 and Lumbar (L) 2 and the subsequent unopposed vagal tone. The degree of risk is related to the severity of neurological injury but clinicians should be vigilant as neurogenic shock can progress to cardiac arrest.1.3 Trauma Soft CollarsMajor trauma patients are considered to have sustained spinal trauma until proven otherwise and are immobilised as a precaution. Injuries to the cervical spine occur in2-6.6% of major trauma patients, and of the patients with missed or delayed diagnosis of cervical spine injury, 70% had altered levels of consciousness. The potential spinal patient must be immobilised and a temporary soft collar is applied at the trauma scene to physically and consciously acknowledge the possibility of a spinal injury but also dramatically reduce the risks associated with a rigid hard collar such as pressure injury, raised intracranial pressure, ventilation impairment and patient discomfort/anxiety. The only contraindication for the application of soft collars would be if the patient with a potential spinal injury was uncooperative with spinal precautions due to confusion, in which case they should have it changed to a Miami J for greater control of the neck and to optimise patient safety. On arrival to The Canberra Hospital patients with this collar insitu must be managed with full spinal precautions as outlined in Section 1.1 and 1.2. Until their cervical spine has either been cleared of injury, at which time they should have their collar removed and precautions lifted; or an injury has been diagnosed and they should be changed to a Miami J collar or to other longer term immobilisation (Section 1.5, 1.7). 1.4 Cervical Spine Clearance in the Trauma PatientAll unconscious trauma patients and conscious trauma patients where cervical injury is highly suspected, must have spinal precautions instituted upon arrival to the Emergency Department (ED) (Attachment 1).Full spinal precaution for the unconscious patient until cervical Computer Tomography (CT) performed, cleared and documented (logrolling continues without head hold until thoracolumbar X-Ray also performed, cleared and documented). (Attachment 3)In alert (Glasgow Coma Scale (GCS) 15) trauma patients with a suspected cervical spine injury Clinical exam should follow Canadian C-Spine rule. (Attachment 2)Canadian C-Spine Rule (Attachment 2)Patients considered of being at high risk of cervical spine (c-spine) injury - radiography is recommended:Age >65 yearsDangerous Mechanism orFall from elevated height (>2m/5 stairs)Axial load to the headHigh speed Motor Vehicle Accident (MVA) (>100km/hr), rollover or ejectionMotorised recreational vehicle collisionPush bike accidentParaesthesia in extremitiesIf the following criteria are met the patient is at low risk but still mandates radiography.Rear ending MVA which was either:Pushed into oncoming trafficHit by a bus or large vehicleHit at high speedCaused rolloverCannot sit up in ED comfortablyCannot ambulate comfortablyHad immediate onset of neck pain at time of accident Has midline c-spine tendernessIf answering NO to the above criteria, the patient may be safe for range of motion assessment. Assess the patient’s ability to actively rotate the neck 45° left and right; if unable, the patient requires radiography, if able, the c-spine is cleared.There should be a high index of suspicion and a low threshold for imaging when examining patients with pre-existing conditions such as ankylosing spondylitis, previous c-spine surgery or fractures.Where clinical exam is unreliable or where radiographic assessment is required, a CT scan from occiput to T4 should be performedMagnetic Resonance Imaging (MRI) may be required if CT images are abnormal, if midline tenderness is present or if neurological signs are presentClinically insignificant injury, as deemed by Shock Trauma or Neurosurgery, may result in c-spine clearanceOnly once c-spine clearance is clearly documented in patient’s clinical record by one of the following may the position restrictions be lifted and collar removed:Neurosurgeon (or senior neurosurgical registrar/fellow)General/Trauma surgeonIntensive Care PhysicianEmergency PhysicianOrthopaedic spinal surgeonA registrar from the above specialties only after discussion with their senior consultant* If imaging is abnormal, clinically significant or an unstable injury exists; the patient will be referred for consultation by NeurosurgeryIf it is expected that a patient will require a cervical collar for >24hrs, a Miami J collar should be fitted by the physiotherapist, medical officer or registered nurse, on completion of the appropriate training (see section 1.5)A Spinal Management Plan (Attachment 5) should be completed by neurosurgical or shock/trauma registrar or consultant outlining appropriate management and restrictions.1.5 Spinal OrthosisSpinal Orthoses (brace, splint, or other artificial external device serving to support the spine) are prescribed to patients as an immobilisation device during the diagnostic phase (in the instance of possible cervical injury) and for stabilisation and management of a confirmed fracture. Appropriate orthosis are prescribed by Neurosurgical or Shock/Trauma registrars/consultants and should be suitably fitted by qualified Physiotherapists, Medical Officers or Registered Nurses. Miami J CollarSuspected and confirmed cervical injuries are managed with the application of a cervical collar. For a conscious and cooperative patient, a soft collar with the alert sticker “C-spine Not Cleared” will be applied in the pre hospital setting which is used to consciously and physically acknowledge a potential c-spine injury and to prompt the use of spinal precautions when repositioning, but not to immobilise. It is felt that a fully awake and alert patient will stabilise their own spine, with muscle spasm and pain providing adequate immobilisation and the risks associated with rigid trauma collars eliminated. These soft collars remain insitu until the c-spine has been cleared, in which case they can be removed, or until an injury has been confirmed.For a patient with a decreased level of consciousness or who is uncooperative, a rigid trauma collar will be fitted in the pre hospital setting. If an injury has been radiographically confirmed, or a patient has had a rigid trauma collar on within 4 hours of admission, a Miami J collar should be fitted. Extended application of rigid collars can cause pressure injuries, increase intracranial pressure, restrict venous return, increase patient discomfort and aspiration risk.Initially, a Miami J collar should be fitted by the physiotherapist, medical officer or registered nurse, on completion of the appropriate training and worn for the time prescribed by the treating/consulting Neurosurgeon.Size it up: Use your fingers to observe and determine the vertical distance between the highest point of the trapezius and the top of the chin when the head is in the desired treatment alignment.Select appropriate collar size by using the distance observed in step 1 and corresponding it to the distance from the top of the Velcro strap to the bottom edge of the collar plastic.Miami J sizes are phenotype-driven according to sizing silhouettes and come in Adult Tall, Regular, Short as well as specialty sizes Stout, Super Short and Extra Small.Two persons are needed for initial collar placement: one to maintain the patient’s head and neck in proper alignment, the second to fit the collar.Remove any pillows from behind the patient’s head. Position patient with arms to the side, shoulders down and head centrally aligned.Slide the Back Piece behind the patient’s neck and centre it. To avoid pushing/pulling on the patient, push down into the mattress during slide and avoid towels or other materials which will increase friction. Ensure the blue Sorbatex? padding extends beyond the edge of the hard plastic.To apply the front, flare the sides out, slide it up the chest wall and ‘scoop’ up to achieve a neat fit under the chin. Caution must be taken to ensure that the head is not extended during this process. Orient the sides of the collar up, away from the trapezius, and toward the ears.Place the front of collar inside the back, lining the blue Velcro straps up with the ‘buddy’ Velcro on the collarTighten straps alternately, one at a time, ensuring that they finish up equal in length (an indication that both the front and back are centred to the midline).If the patient can slip his/her chin inside the collar, it is clear indication that it is not snug enough and proper alignment is not being maintained.Miami J collars should be removed DAILY, at a minimum, to inspect skin integrity and change the blue Sorbatex padding. Each patient should have 2 sets of padding to be interchangeable, when removed they should be washed in warm soapy water, rinsed and air dried (a mechanical dryer will shrink the pads) ready to use the next day. Any removal of the collar should be in supine position and two people required, one to maintain alignment and one to provide cares (unless otherwise specified in ‘CHHS Spinal Management Plan’ by the neurosurgical registrar).Pressure injuries can easily occur underneath the Miami J collar, especially on bony prominences such as sternum, clavicles and occiput as well as trapezius. Underlying skin should be inspected for redness or signs of pressure injury when collar removed or patient reporting any irritation. Any areas of redness should have management strategies applied as soon as they are observed. Check blue Sorbatex padding is covering rigid plastic edgesEnsure Velcro straps are aligned with buddy Velcro so ensuring appropriate fitApply mepilex border dressings to reddened or irritated areas to offload pressure. Bulkier dressings such as combine will increase pressure and should be avoided.If pressure injury noted, follow normal procedure including referral to Tissue Viability Unit and completing RiskMan.Thoracic, Lumbar and Sacral OrthosisFor management of confirmed thoracic, lumbar and sacral fractures, orthoses may be prescribed. The type of orthosis will differ depending on the level of injury, as well as restrictions for donning and doffing dependant on stability of fracture (and specified in CHHS Spinal Management Plan by a neurosurgical consultant, registrar or nursing Team Leader. (Attachment 5)). These braces will be fitted by a physiotherapist who has completed the appropriate competency. Daily donning and doffing of brace in line with prescription attended by Nursing Staff, physiotherapists or medical officers who have completed the competency.1.6 Bedrest ManagementNon operative management of spinal fractures may include a period of bedrest at the prescription of the neurosurgical consultant and will be documented on the Spinal Injury Management and Treatment Plan (Attachment 5) along with associated bed mobility restrictions.Provide patient education regarding bed rest procedure and orientate to ward routines. Inform of risks associated with extended periods of bedrest and educate on deep breathing and coughing exercises, VTE and Pressure Injury prevention. Include signs and symptoms to be aware of and to report to nursing staff. (i.e. tender calf muscles, shortness of breath)Nurse patient resting in bed with head of bed height and whole bed tilt as directed by surgeon ALERT.Spinal patients are not to have alternating air mattress unless approved by neurosurgical team. Step down vital sign observations and spinal observations as suitable. Any decrease to observation frequency should only be after consultation with surgical team. Measure patient for TED’s and apply, ensure these are worn every shiftEnsure regular aperients charted and commence bowel chart to ensure bowels open consistently. Notify > 2 days of bowels not open to treating team and consider enemaIf suitable for portable bedbath (as documented on the Spinal Injury Management and Treatment Plan (attachment 6)) offer this to patient as option for personal care – encourage independence where ableMonitor patient for signs of depression or inability to cope with treatment plan. Notify team if suspected and consider Psychology referral for coping strategiesEnsure physiotherapist aware of planned date to mobilise so that appropriate orthosis may be measured for and sourced if required.1.7 Spinal TractionGardner Wells Tongs Applied either in the neurosurgical acute care unit or in the operating theatre, Gardner Wells Tongs are indicated in cases of facet subluxation or dislocation, and in burst-type fractures. Gardner Wells Tongs immobilise the cervical vertebrae, reduce a fracture and/or dislocation, reduce pressure on the spinal cord in the instance of a burst fracture and provide relief from the pain associated with malalignment. EquipmentTraction bed with head bar and pulley.Gardner Wells TongsDouble cordLocal anaestheticBetadineBlue under padsClippersSyringes and needlesTap waterLeukoplast strappingWeight bag and S hookSterile gloves and gownSand bags x 2ProceduresConsent is obtained by attending Registrar or consultantAssess the patient’s level of understanding of the immobilisation process and educate the patient and significant others about the immobilisation process.Facilitate preparation of the patient by ascertaining the type of traction prescribed by the treating MO Administer premedication/analgesia as prescribedPosition the patient in the supine position in centre of the bed to ensure the line of pull will be correctly set upThe scalp may be clipped in the temporal region superior to the ear depending on preference. The scalp is prepared with Betadine and the insertion sites are infiltrated with local anaesthetic. The tongs are positioned by the MO with the sterile points contacting the skin at the predetermined sites of placement. The points are then advanced until the position of the spring-loaded points shows that the proper pressure is being exerted. An assistant may be necessary to hold the metal ring of the tong. Weights are applied via a double cord to reduce the fracture-dislocation. A cervical spine x-ray may be obtained to evaluate vertebrae alignment.Position either head bar/pulley at the head of the traction bed ensuring the line of pull will be in alignment with the cervical spineApply traction by tying a double cord (two separate cords) to the tongs and passing it straight over the pulley. Tie double cord to S-hook and attach weight. Ensure the correct weight is applied and that the weight hangs freely if the height of the bed is adjusted. Secure knots by taping the loose end to the main body of the rope as taping the actual knot will make observation and adjustments difficult.The MO may request that the bed be tilted with the foot down to maintain counter tractionMonitor neurological status including spinal observations (Attachment 7) and vital signs hourly for 4 hours and then Q4/24 for duration (or more frequently if prescribed and documented in the patient’s clinical record)Inspect pin sites each shift. Clean with normal saline, monitor for any signs of infection and report these to MOMO should document specific instructions for patient log roll. Ensure Q3/24 turns for pressure injury prevention following spinal precautions outlined in Section 1.2 (NOTE: traction is NOT to be removed when rolling patient. Attend normal c-spine precautions including head hold whilst maintaining traction)Apply anti-embolic stockings and sequential compression devices, encourage deep breathing and leg exercises. Educate patient on the signs and symptoms of VTE and pressure injuriesAdminister low dose Heparin, analgesia, aperients and antispasmodics as prescribed by the MOPatients with Gardner Wells tongs will have progressive cervical spine x-rays which can be done on the ward with a mobile x-ray. If patient is required to move anywhere within the hospital they require a registered nurse escort and traction should never be removed without specific documentation from a consultant or registrar and even then, manual traction must be applied.Refer for consult with Physiotherapist, Social Worker, Dietician, speech pathologist and Occupational TherapistIf patient has cervical surgery ensure all relevant equipment for Gardner Wells tongs is returned to the ward from the Operating Theatre.ALERTWith proper placement of the tongs and continuous traction, the patient should have only minimal pain which should be relieved by medication. Notify MO immediately if the patient experiences undue discomfort or change in neurological status. Muscle spasms are a common discomfort rather than pain – notify MO to consider diazepam.Crown Halo and VestCrown halo and vest is utilised as a non-operative stabilisation of unstable high cervical spine fractures. They provide precise positional control of the cervical spine while allowing early mobilisation and shorter hospital stay for the patient.EquipmentPre-packaged halo ring (measured for size as per below), including bolts and halo clampsPre-packaged vest with synthetic liner (measured for size as per below) including transverse bars, connectors and boltsTape measure and sizing chartPositioning spoonTitanium skull pins with locking nuts x 5 (1 pack)Hair clippersLocal anaesthetic, drawing up needle and syringesBasic dressing pack with extra gauze squaresSterile glovesTorque pin driver and wrench (kept in Neurosurgical Registrar’s office)Ossur (manufacturer) ‘Patient Information Manual’ProcedureExplain the procedure to the patient.Gain consentMeasure the greatest circumference of the skull (about ?” above the ears)Choose the appropriate size Ossur halo ring as per table belowSIZE CHART_______________________________________________________________________________SIZE HEAD CIRCUMFERENCESMALL43-51 cmSTANDARD51-59 cmLARGE 59-66cmMeasure the patient’s chest circumference at the xyphoid process. If patient has a pendulous abdomen, measure around the widest part of the costal margin and the sternal length to ensure appropriate fit.Choose applicable Ossur vest size as per table below.SIZE CHART_____________________________________________________________________________SIZEChest CircumferenceX-SMALL 50-66 cmSMALL66-84 cmSMALL/MEDIUM81-92 cmMEDIUM84-102 cmMEDIUM/Large96-107 cmLARGE102-117cmX LARGE117-132 cmAdminister analgesia/premedication as ordered and reassess/administer as required during the application processThe positioning spoon may be placed under the patient using spinal precautions.Before moving a patient on whom a crown/halo vest has been applied, 15mins post application, the MO will re-torque the skull pins using the four remaining torque limiting caps and then secure the locking nuts on all four pins against the crown/halo using the wrench. A final check of all the bolts for tightness is performedThe MO will then re-torque the skull pins further using the torque pin driver at 24 and 48 hours after initial application and every 2 to 3 weeks during treatment processPatient to remain resting in bed with restrictions as documented by the MO until post procedure X-Ray has been performed to confirm correct alignment Monitor spinal observations (Attachment 7) and vital sign observations 1/24 for 4 hours then 4/24 for 24 hours if stable unless otherwise requested by MO. Ensure patient is aware of the need to report pain and sensory changes post procedure.Await documented clearance from MO before mobilising the patient. Once cleared patients should get out of bed by rolling onto their side at the edge of the bed, and dropping their legs off the edge and pushing sideways with their elbow and hand at the same time. This method puts less stress on the front pins. Spinal observations should be attended at time of mobilisation and then two hours post, if stable then may be ceased.Pin sites are cleaned daily using normal saline and gauze swabs or may be cleaned with shampoo on hair washing days (conditioner should not be used). Provide patient education on performing this daily at home once discharged. If patient unable to, refer to Community Nursing on discharge or educate family membersObserve pin sites and educate the patient on reporting any of the following:Inflammation, swelling and/or dischargeTracking (open area where the skin has pulled away from the pin)Pain or tenderness around the pin siteClicking noise reported by the patientIt is important to keep the patient’s skin and fleece liner as clean as possible because the liner should not be changed unless it is medically necessary. No soap, lotion or powder should be used under the vest because it cannot be adequately removed and may irritate the skin. To wash the skin under the vest, use a fibrella wipe that has been wrung out in warm water. Pull it back and forth in a drying motion beneath both front and back portions of the vest. The skin under the vest should be inspected daily with a torch in order to detect pressure areas. Extra fleece or foam may be inserted to relieve pressure points that may occur when the patient assumes certain positions. Try to keep the synthetic vest liner dry at all times, however if the lining gets wet, dry it with a hair dryer on a cool setting. If the vest liner should get soiled it may have to be changed by the MO.ALERTLiners should not be changed, if it can be avoided, as loosening of the superstructure (vest) carries a risk of spinal malalignment.The patient can shower rest of the body using a hand held shower hose or have a sponge bath. If the patient is mobile they can have a shallow bath, ensuring that the bottom of the vest is protected with plastic.Provide the patient with the Ossur ‘Patient Information Manual’AlertShould the patient require CPR while wearing the vest, the anterior portion of the vest must be removed. Unscrew the bottom knobs on the anterior portion of the vest to release to waist straps, place hand above the red line and bend the lower section away. Back to Table of Contents Section 2 – Spinal SurgeryPre and post-operative procedure for the management of patients who are undergoing either elective surgery for a disorder of the spine (excluding Anterior Cervical Discectomy and Fusion), or following surgical management of an acute spinal injury.2.1 Pre-operativeExplain the procedure to the patient and ensure identification label is on wristNurse patient in accordance with spinal management plan documented by registrar or consultant and assist with log rolling as requiredEnsure consent is signed – re consent will have to be completed if original was signed >24 hours previouslyIf not already collected in pre-admission clinic, ensure that the following routine bloods have been collected and that results are available prior to the patient going to theatre:Full blood count (FBC), urea, electrolytes and creatinine (UEC), blood glucose level (BGL), full coagulation profile (FCP), Group & HoldCheck bowels open recently, if not, consider aperients prior to theatreCheck and record full set of vital sign observations and baseline spinal observations (Attachment 6). Note any pre-existing neurological deficitWeigh patient and documentGive pre-operative education as well as instructions regarding deep breathing and coughing exercises, VTE and Pressure Injury preventionFast from midnight (or as per CHHS ‘Fasting Guidelines – for patients undergoing procedures requiring sedation or anaesthesia), ensure appropriate intravenous therapy is charted and IVC insituPerform pre-operative patient wash and dress in inpatient gownMeasure patient for TED’s and assist patient putting them on Ensure adequate amount of patient labels Complete Pre-operative Checklist.Back to Table of Contents2.2 Post-operativeIn addition to general post-operative care outlined in CHHS Post-operative Care and Handover GuidelineAttend spinal observations (attachment 7)? hourly x 2 hoursQ1/24 x 4 hours, then if stableQ4/24ALERT.Progressive neurological deterioration resulting from cord compression is a surgical emergency. Notify MO if any deterioration in limb movement, power or sensation.Nurse patient resting in bed with head of bed height as directed by surgeon. Post-operative spinal patients are not to have alternating air mattress unless approved by neurosurgical team.If staples insitu - replace dressing on day 2 with opsite, can be reinforced with combine and mefix if large amounts of ooze < 24 hrs postop. Monitor for potential CSF leak if postop ooze present NOTE: If dermabond insitu – do not apply any dressings.ALERT.If a dural puncture has occurred, patient may need to rest in bed, lying flat for ≥48hrs or as specified by Surgeon. Strict wound checks and monitoring for CSF leak is required.Surgical drains generally removed day 1 unless high output post operatively or specified otherwise by neurosurgical team. Remove drain when ordered in accordance with CHHS Drain Management Clinical Procedure.Encourage deep breathing, coughing and leg exercises, ensure TED stockings and sequential compression devices (SCD) insitu and source SCD pump from Central Equipment Store.If patient cannot move self in bed, ensure appropriate Pressure Injury Prevention management strategies have been implemented and regular skin checks attended.Routine post-op bloods – Day 1 – FBC, UEC.Mobilisation – as per surgeon’s orders in ‘Post-operative Instructions’. Record bowels daily and respond early to concurrent days of bowels not open.Remove staples day 7-14, as directed by neurosurgeonProvide patient education regarding avoiding heavy lifting, avoiding long car journeys, and driving restrictions for 4-6 weeksDischarge day 2-7Patient will follow up with consultant in 6 weeks with spinal X-Ray, appointments arranged by discharging MOBack to Table of Contents2.3 Anterior Cervical Discectomy and Fusion (ACDF)In addition to the post-operative risks and management of spinal surgery outlined in section 1.2, patients who have undergone a Cervical Discectomy and Fusion with an anterior approach are at risk of localised oedema or haematoma which may cause obstruction of swallowing and potentially obstruction of airway resulting in a medical emergency.First 12 hours postopSupervise patient during oral intake, observing for any signs of dysphagia or possible aspiration. If any concerning signs cease oral intake, report to surgical team immediately for review and consider speech pathology Closely assess airway patency and escalate any dyspnoea or stridor to surgical team immediatelyReport any new or increasing hoarseness of voice or visible swelling immediately.Monitor exudrain hourly, ensuring patency of drainage will reduce the risk of haematoma formation. Report sudden large volumes of frank drainage to surgical team and otherwise manage as per CHHS Drain Management Clinical Procedure.ALERT. Airway obstruction from haemorrhage or oedema has rapidity of onset, potential for catastrophic consequences and requires an urgent need to act to ensure positive patient outcomes. Back to Table of Contents Section 3 - Spinal Observations and Assessment3.1 Spinal Injury Management and Treatment PlanThe Spinal Injury Management and Treatment Plan form (Attachment 6) was developed to provide appropriate, safe and consistent care to patients with a spinal injury. This tool, which aids clinical handover, outlines restrictions placed on patient’s mobility, orthosis prescribed, donning and doffing orders and progress with patient education for discharge planning. This form is a clinical order and restrictions documented should be strictly adhered to. To be completed by Surgical Consultant or Registrar only. Nursing Team Leader may complete form only when restrictions have already been documented by the surgical team in the patient’s clinical recordShould be completed within 4 hours of admission to the inpatient setting.Updated as soon as patient’s condition changes and restrictions lifted OR further restrictions placed on mobility. New form to be completed and previous form voided and filed within the patient’s clinical recordTo remain within the front of the patient’s bedside clinical folder and to accompany the patient throughout the organisation, i.e. ward to ward transfer, medical imaging.3.2 Traumatic Spinal Injury and Spinal Surgery ObservationsThe Traumatic Spinal Injury and Spinal Surgery Observation chart (Attachment 7) is designed to objectively assess motor and sensory nerve function in patients with a spinal injury or who have undergone a spinal surgery. The aim is to identify any neurological compromise as a complication or deterioration in the patient’s condition, to provide documented baseline function prior to a spinal procedure and to confirm stability or improvement.Procedure To be commenced on admission to the Emergency Department, Post Anaesthetic Recovery Unit (PACU) or the ward.For traumatic spinal injury - performed hourly until surgical fixation or treatment plan documented. If for conservative management/bedrest, perform Q4/24 until stable for 72 hours then cease with clarification from neurosurgical team and nursing team leader. If for conservative management/orthosis, perform at time of first mobilised then after a further hour, continue Q4/24 until standing X-Ray reviewed and cleared by neurosurgical team postPre-operative elective spinal surgery – perform one baseline assessmentPost-operative – ? hourly for 2 hours, hourly for 4 hours then Q4/24 hourly until stable for 72 hours or ceased with clarification from neurosurgical team or nursing team leaderBegin with documenting level of injury or levels of surgery in the space provided together with the need for traction or orthosisBased on dermatome map, if level above and including T3, both upper and lower motor and sensory assessments required. If level below T3, only lower limb motor and sensory assessment required and upper limb section can be crossed out.When a region cannot be assessed for other reasons i.e. limb amputation, traction, mark the corresponding box with ‘NT’ (not testable) and document the reason in the patient’s clinical record.Motor Assessment (attachment 7)The following exercises must be performed to test motor function in the upper and lower limbs. After each exercise, a numerical score should be recorded for each muscle group using the Motor Grading Scale (0-5) (appendix 8)Upper:Gain patient consentShoulder Abduction – Place supporting hand on the patients shoulder and resisting hand on the wrist/forearm. Ask patient to lift arm out from body, as they lift arm, apply resistance downward. Assessing the Deltoid muscle and axillary nerve (nerve root C5/C6)Elbow Flexion – Place supporting hand on patients bent elbow and resisting hand on lateral wrist. Ask patient to flex arm towards the face and apply resistance downward. Assessing Biceps Brachii muscle a musculocutaneous nerve (nerve root C5/C6)Elbow Extension - Place supporting hand on patient’s bent elbow and resisting hand on medial wrist. Ask patient to straighten arm and apply resistance in opposite direction. Assessing Tricep muscle and radial nerve (nerve root C5/C6/C7)Wrist Flexion – Support patient’s forearm and ask them to make a fist and flex wrist upwards. Apply resistance downwards in attempt to straighten wrist. Assessing Flexor Capri Radialis and Flexor Capri Ulnaris and radial nerve (nerve root C7/C8)Wrist Extension – Support patients forearm and ask them to make a fist and extend wrist downwards. Apply resistance upwards in attempt to straighten wrist. Assessing Extensor Carpi Ulnaris/ Radialis and Biceps plus radial nerve (nerve root C8/T1)Finger Flexion – Curl the patient’s finger around yours (in a ‘monkey grip’) and ask the patient to resist you straightening their fingers. Pull gently in attempt to straighten fingers. Assessing Flexor Digitorum superficialis, Profundus muscles and Median and Ulnar nerve (nerve root C8)Finger Abduction – Support patient’s wrist, ask patient to place their palm down and spread the fingers. Apply resistance on index and little finger attempting to bring them together. Assessing first Dorsal Interosseous muscles and Ulnar nerve (nerve root T1)Lower:Gain patient consentHip Flexion – Ask patient to bend their knee, place supporting hand underneath the lower leg and apply resistance downwards through lower thigh/knee asking patient to bring knee up towards face. Assessing Iliopsoas muscle and lumbar sacral plexus (nerve root L1/L2)Knee Flexion – ask patient to bend their knee, place supporting hand on lower thigh/knee, asking the patient to bend their knee further (bring heel to buttocks) and apply opposing force. Assessing hamstring muscle and sciatic nerve (nerve roots L5/S1)Knee Extension – Ask patient to bend their knee, place supporting hand underneath knee and ask them to kick lower leg up straightening knee, apply opposite force. Assessing Quadricep femoris and femoral nerve (nerve root L3/L4)Ankle Dorsiflexion – Place supporting hand on lower leg, ask patient to flex foot up, toes towards face and apply opposite resistance. Assessing anterior tibialis muscle and deep peroneal nerve (nerve roots L4/L5)Ankle Plantar Flexion – place supporting hand on lower leg, ask patient point toes downwards, apply opposite resistance on ball of foot. Assessing gastrocnemius muscle and posterior tibial nerve (nerve root S1/S2)Ankle Inversion – place supporting hand on lower leg and with feet hip width apart, ask patient to bring big toes towards the midline keeping legs still, inverting the ankle. Place resistance on medial foot. Assessing tibialis posterior muscle and tibial nerve (nerve roots L4/L5)Ankle Eversion - place supporting hand on lower leg and with feet hip width apart, ask patient to bring foot away from the midline keeping legs still, everting the ankle. Place resistance on lateral foot. Assessing peroneus longus and brevis muscles and superficial peroneal nerve (nerve roots L5/S1)Sensory AssessmentGain patient consentUsing hand touch, assess both medial and lateral limb and gain patient feedback. Examiner should assess bilateral limbs simultaneously to identify subtle differences or deficits. Observations should be documented as an ‘X’ for present, tingling/pins and needles or no sensation/numb.Specifics should be then documented in patient clinical recordBack to Table of Contents Implementation This document will be added to the orientation programs of applicable clinical areas. It will be published on the CHHS Policy and Guidance register and available for viewing or download by any ACT Health CHHS employee. Its contents will be presented in area specific in-services and referred to when completing relevant clinical competencies.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentCHHS Patient Identification and Procedure Matching PolicyModified Early Warning Scores (MEWS)Patient Controlled Analgesia (PCA) ManagementProceduresCHHS Healthcare Associated Infections Clinical ProcedureCHHS Aseptic Non Touch TechniqueCHHS Venous Thromboembolism (VTE) Prevention ProcedureGuidelines CHHS Fasting Guidelines – Elective and Emergency SurgeryCHHS Post-operative Care and HandoverLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesAmerican Association of Neurological Surgeons & the Congress of Neurological Surgeons (2001) Pre-hospital cervical spine immobilisation following trauma, Disorders of the Spine and Peripheral Nerves, American Association of Neurological Surgeons & the Congress of Neurological Surgeons, Chicago Kwan I, Bunn F & Roberts I (2001) Spinal immobilisation for trauma patients (Review), The Cochrane Collaboration, 4:1-15Flynn A V & Sinclair M (2005) Exploring the relationship between nursing protocols and nursing practice in an Irish intensive care unit, International Journal of Nursing Practice, 11(4):142-149Clancy M (1999) Clearing the cervical spine of adult victims of trauma, Journal of Accident & Emergency Medicine, 16:208-214Hedger A (2002) Clearance of cervical spines in adult trauma patients, Journal of Neurosurgical Nursing, 34:331-336Morris CG, Mullan B (2004) Clearing the cervical spine after polytrauma: Implementing unified management for unconscious victims in the intensive care unit, Anaesthesia, 59:755-761Hoffman JR, Mower WR, Wolfson AB et al (2000) Validity of a set of clinical criteria to rule out injury to the cervical spine with blunt trauma, New England Journal of Medicine, 343:94-99Hoffman JR, Wolfson AB, Todd K & Mower WR (1998) Selective cervical spine radiography in blunt trauma: Methodology of the National Emergency X-Radiography Utilisation Study (NEXUS), Annuals of Emergency Medicine, 32:461-469 Marion DW, Domeier R, Dunham CM, Luchette FA, Haid R & Erwood SC (1999) Practice Parameter For Identifying Cervical Spine Instability Following Trauma: EAST Trauma Practice Guideline, Journal of Trauma, 44(6):941-956Ackland H (2006) The Alfred Spinal Clearance Management Protocol, National Trauma Research Institute, accessed online at: AE, Cooper DJ, Scheinkestrel CD, Laidlaw J, Tuxen DV. Optimal assessment of cervical spine trauma in critical ill patients: A prospective evaluation. Anaesth. Intensive Care. 1998;26:487-491.Demetriades D, Charalambides BS, Chahwan S et al. Non-skeletal cervical spine injuries: Epidemiology and diagnostic pitfalls. J.Trauma. 2000;48:724-727.Schenarts PJ, Diaz J, Kaiser C et al. Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status. J.Trauma. 2001;51:663-669.Pasquale M, Fabian TC. Practice management guidelines for trauma: EAST ad hoc committee on guideline development- identifying cervical spine instability after trauma. J. Trauma. 1998;44:941-956.Hendy GW, Wolfson AB, Mower WR et al. Spinal cord injury without radiographic abnormality: Results of the National Emergency X-Radiography Utilisation study in blunt cervical trauma. J.Trauma. 2002;53:1-4.Hills MM, Deane SA. Head injury and facial injury: Is there an increased risk of cervical spine injury? J Trauma. 1993;34:549-554.Holly LT, Kelly DF, Counelis GJ et al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors and injury characteristics. J Neurosurg. 2002;96:285-291.Surgeons, A.C.O, 2012. Advanced Trauma Life Support: Program for Doctors. 9th ed. American College of Surgeons: A.C.O.S.T. Committee, Chicago: 366. Iida H, Tachibana S, Kitahara T et al. Association of head trauma with cervical spine injury, spinal cord injury or both. J Trauma. 1999;46:450-452.Bucholz RW, Burkhead WZ, Graham W, Petty C. Occult cervical spine injuries in fatal traffic accidents. J Trauma. 1979;19:768-791.Reid DC, Henderson R, Saboe L et al. Etiology and clinical course of missed spine fractures. J. Trauma. 1987;27:980-986.Davis JW, Phreaner DL, Hoyt DB. The aetiology of missed cervical spine injuries. J. Trauma. 1993;34:342-346.Webster B, Giunti G, Young A et al. Work-related tetraplegia: Causes of injury and annual medical costs. Spinal Cord. 2004;42:240-247.Webber-Jones JE, Thomas CA, Bordeaux RE Jnr. The management and prevention of rigid cervical collar complications. Orthop.Nurs. 2002;21:19-28.Stiell IG, Clement CM, McKnight RD, Wells GA, Brison R, Schull M, Rowe B, Worthington J, Eisenhauer M, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee J, Bandiera G, Reardon M, Holroyd B, Lesiuk H. (2003) Comparative Validation of the Canadian C-Spine Rule and the NEXUS Low-Risk Criteria in Alert and Stable Trauma Patients. New Engl J Med, 349:2510-8Spivak, J et al, 1995. Thoracolumbar Spine Trauma: II Principles of Management, Journal of American Academy of Orthopeadic Surgery. 3(6): p. 353-360.Posterior Lumbar Discectomy: Mayfield Brain and Spine, Revised Bohinski, R (2016). Accessed from , J, 2014. The Clinical Practice of Neurological and Neurosurgical Nursing. (7th Ed) Lippincott, Williams and Wilkins: Philadelphia, New York and Sydney.Aidlen, JP, Caiati, J, Daniels, AH, Palumbo, MA and Thakur, NG, 2012. Airway Compromise Due to Wound Hematoma Following Anterior Cervical Spine Surgery, Open Orthopaedic Journal; 6: 108-113. HYPERLINK "" \l "!" Trivedi, JM, 2002. Spinal trauma: therapy—options and outcomes. European Journal of Radiology; 42 (2), pages 127-134. Kang, M, Vaccaro, A, & Vives, MJ (2003). The Halo Vest: Principles Of Application and Management Of Complications, The Journal of Spinal Cord Medicine, 26 (3), 186-192Clinical Quality and Patient Safety Unit, Queensland Ambulance Service (2016). Clinical Practice Procedures: Trauma/Cervical Collar. Accessed from to Table of ContentsDefinition of Terms Discectomy – A discectomy is the surgical removal of herniated disc material that is pressing on a nerve root or the spinal cordForaminotomy – the vertebral foramen or space is made larger to remove pressure on the nerve root.Laminectomy – partial or total removal of one or more vertebral lamina to expose the spinal canal for treatment of compression, fracture, dislocation, tumour or herniated disc.Rhizolysis – freeing of the nerve thereby establishing blood flow to the nerve root to relieve radiculopathy.Spinal Fusion - performed by a neurosurgeon in the operating theatre and involves the fixation of an unstable segment of the spine, using bone grafts and/or metal plates and screws. Fusion is performed to limit movement and/or stabilise the spine at a particular level in the cases of Spondylolisthesis, fractures, lesions or deformityACDF - A herniated disc in the cervical spine can be removed through an anterior approach (the front of the neck) to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. A bone graft, which is usually taken from the iliac crest, is then inserted to stabilise. Indications for this procedure are: herniated disc, degenerative disease, bone spurs, cervical stenosis and spondylosis.Dysphagia – swallowing deficitBack to Table of ContentsSearch Terms Spine, microdiscectomy, brace, orthosis, fusion, laminectomy, traction, trauma, PLIF, vertebrae, halo, cervical, disc, logroll, Gardner-wells, fracture, spinal, precaution, bedrest, clowards, discectomy, head hold, observations, rhizolysis, c-spine, ACDF, foraminotomy, collar, Miami J, spinal injuryBack to Table of ContentsAttachmentsAttachment 1 Level of precaution required - assessed using the definitions for the 3 Protocol GroupsAttachment 2: The Canadian C-Spine RuleAttachment 3: Spinal precaution for the unconscious trauma patientAttachment 4: Spinal precautions for the alert (GCS> 15) trauma patientAttachment 5: Indications for the use MRI in the management of patients with a potential spinal injuryAttachment 6: Spinal Injury Management and Treatment PlanAttachment 7: Traumatic spinal injury and spinal surgery observation chartAttachment 8: Motor Grading ScaleDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and ACT Health assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 16/03/2018Complete ReviewDaniel Wood, A/g ED SOHCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS14/053Care of Adult Patients with Potential Spinal InjuryAttachment 1 Level of precaution required - assessed using the definitions for the 3 Protocol GroupsInitial Management of Adult Patients with Potential spinal injuries* = CT is the investigation of choice for potential cervical spine and thoracic spine injuries. The use of NEXUS criteria is not an appropriate basis to proceed to CT. The patient must be evaluated using Canadian C spine rules.Arrives with prehospital soft collarArrive to ED / ICU with prehospital Hard CollarSelf presents with Neck Injury or pain after traumaTriage / Primary SurveyIf no immediate life threats then hard collar replaced with soft collar.Spinal precautions maintained:Soft collar + sandbags/ rolled towelslog rollIn line stabilisation for transfers / proceduresObtunded Patient?Spine not clearedSpinal precautions maintained:??Soft collar with sandbags or rolled towels??log roll??In line stabilisation for transfers / proceduresCT Cervical Spine +/- thoraco-lumber imaging *Follow Adult spinal injury management Protocol (see flow chart)No further spinal precautions requiredWhole Spine Cleared ClinicallySpinal Clearance Assessment using Canadian C spine Rules (see flow Chart). Thoracolumbar spine assessed clinically-1691005182816500Attachment 2: The Canadian C-Spine RuleAttachment 3: Spinal precaution for the unconscious trauma patientUNCONSCIOUS MAJOR TRAUMA PATIENTApply soft collar & spinal precautionsMSCT with reconstructions:Whole spine - E.A.M. to sacrum (sagittal, axial & coronal reformatsImaging abnormalC-spine cleared Films reviewed by appropriate Consultant AND Radiologist +/- MRIImaging normalCollar off & cease position restrictions, clearly documenting assessment and decision makingAttachment 4: Spinal precautions for the alert (GCS> 15) trauma patientCONSCIOUS MAJOR TRAUMA PATIENTSoft collar insituApply spinal precautionsCanadian C-Spine Rule*:Alert (GCS 15)Stable trauma patientAny high risk factor which mandates radiography?Age >65 orDangerous mechanism ^ orParesthaesia in extremitiesC-spine cleared Any low risk factor which allows safe assessment of range of motion?Simple rear end MVCSitting position in ED orAmbulatory at any time orDelayed onset of neck pain i.e. not immediate onset of neck pain orAbsence of midline c-spine tendernessRadiography:CT occiput to T4Collar off & cease position restrictions, clearly documenting assessment and decision makingAble to actively rotate neck?45o left and right^ Dangerous mechanism Fall from elevated height (>2 m/5 stairs)Axial load to the head (e.g. diving)MVC high speed (>100km/hr), rollover, ejectionMotorised recreational vehiclesPedal cyclist collisionParaesthesia in extremities^^ Simple rear end MVC excludes:Pushed into oncoming trafficHit by a bus or large vehicleRolloverHit by high speed vehicle^^^ Delayed:i.e. not immediate onset of neck painNo Yes YesNo*Rule NOT applicable if:Non-trauma patientGCS <15Unstable vital signsAge <16 yearsAcute paralysisKnown vertebral diseasePrevious c-spine surgeryYesAbleUnableAttachment 5: Indications for the use MRI in the management of patients with a potential spinal injuryMAJOR TRAUMA CONSCIOUSCervical CTE.A.M. to the top of T4 (saggital, axial & coronal reformats)Review by Radiologist & senior ED ConsultantClinical evidence of spinal cord injuryMRI when stableNormal imaging but symptomaticClinical examination and review MRI if indicatedMAJOR TRAUMA UNCONSCIOUSCervical CTE.A.M. toT4/5 (saggital, axial & coronal reformats)Normal imagingAbnormal imagingStop+/- MRI only if clinically indicated+/- MRI when stableMAJOR TRAUMA & SPINAL CORD INJURYCervical CTE.A.M. toT4/5 (saggital, axial & coronal reformats)MRI ASAP127025336500Attachment 6: Spinal injury management and treatment planAttachment 7: Traumatic spinal injury and spinal surgery observation chart-127011684000Attachment 8: Motor Grading Scale ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download