Cervical spine management in the wilderness: can we trust our clinical exam?

Abstract

The case report by Levitan, 'Occult cervical spine fracture in a wilderness setting' which appears in this issue of the Journal of Wilderness Medicine deals with a current area of controversy. Dr Levitan's article provides another example of the growing body of literature questioning our ability to predict clinically which patients will have an unstable cervical spine injury. Nowhere is this controversy more poignant than in the wilderness, where rescue and evacuation can be arduous when there is a particular need to maintain spine immobilization. In wilderness medicine, as in urban medicine, the indications for placing a victim in cervical spine immobilization pending radiographic analysis include complaints of neck or back pain, neurologic symptoms such as paresthesias, a positive physical examination including pain on palpation of the neck or neurologic signs, or a patient who is intoxicated who also has an altered mental state with a significant mechanism of injury [1-4]. Occult cervical spine injury has been defined previously as a cervical injury in the alert, cooperative, non-intoxicated patient without associated signs or symptoms on exam [5-6]. Several retrospective published reports and anecdotal cases of occult cervical spine fractures have led to a widespread ordering of cervical spine radiographs and a reluctance by physicians to clear the spine clinically. If the presence of a painful, distracting injury away from the neck were to be added as an exclusion factor, then all of the published reports claiming to have identified an occult cervical spine fracture could be criticized for not meeting strict criteria. The "occult cervical spine fracture" described by Bresler and Rich [7] occurred in a woman who was drinking alcohol and who had a painful fracture of her radius and ulna. Her neck was also mildly tender to palpation. McKee et al. [8] described an 85-year-old male victim of a motor vehicle accident with multiple rib fractures and an associated hemopneumothorax. Liberman and Maull [9] described an occult cervical spine injury in an intoxicated trauma victim with upper extremity fractures, a renal contusion and a subdural hematoma. Ogden and Dunn [10] reported an occult cervical spine fracture in a 33-year-old woman with bilateral femur fractures and a flail chest. In two cases reported by Haines [11], both patients had either neck pain or paresthesias on presentation. Levitan's report of an occult cervical spine fracture in this issue occurred in a 33-year-old man with bilateral upper extremity fractures and multiple rib fractures. Thus, each of these cases demonstrated signs and symptoms of a cervical spine injury, an altered mental status, or major concomitant distracting injuries. A recent prospective series by Hoffman et al. [12] of 1000 patients undergoing cervical spine radiography following blunt trauma found that all 27 patients with spine fractures had at least one of the following four clinical findings: midline neck tenderness,