The Journal of Emergency Mednne. Vol. 8, pp 207-208. 1990 Pnnted in the USA. CopyrIght ci, 1990 Pergamon Press plc

THE WORLD IN CERVICAL SPINE PRECAUTIONS

Does it ever appear to anyone else that there are times when the entire world is in cervical spine precautions? Through the ambulance entrance, escorted by burly attendants adorned with epaulets and scissor holsters roll elderly ladies “found on floor,” alcoholic street deni- zens who have had (or may have had) a seizure, automobile passengers who left (or didn’t leave) their facial imprints on a windshield, drivers who availed themselves of seatbelts, and those who eschewed them. A reasonably diverse group, therefore, or so one would think. Yet all make their appearance similarly taped, boarded, collared, sandbagged, sandwiched, mum- mified.

All await their release from this confinement. All await the physician to take a deep breath and to “clear the cervical spine” either clinically or radiographically. (Some actually do not wait, instead releasing themselves unilaterally, but these individuals are not the subjects of our focus.) Nonetheless, limitations of clinical assess- ment of cervical spine fracture are recognized (1) and as our experience with progressively more sophisticated diagnostic techniques broadens, the limitations of plain radiography become comparably manifest.

In this issue, Kirshenbaum et al. (2) describe the application of computed tomography of the upper cervi- cal spine to patients undergoing head CT for significant head trauma. They describe seven cases in which frac- ture was not suspected on the basis of standard radio- graphic trauma series (AP, lateral, odontoid) evaluation of the cervical spine. Indeed, these fractures would have been missed without the utilization of the additional CT views.

Readers familiar with the Medical Classics section of this journal may be cognizant of a phenomenon common to several articles in the series. This involves the reassessment required of a “classic” physical finding as more advanced diagnostic techniques are developed and come to be applied to a clinical problem. John Homans, writing of his sign for calf vein thrombosis considered it as being present “‘more frequently than either tenderness

or swelling.” However, Homans’ sign subsequently has been found to be absent in numerous series of angio- graphically demonstrated thrombosis (3). Similarly, de- spite Claude Beck’s assurance that cardiac tamponade “produces clear and distinctive earmarks for recogni- tion” in the form of a diagnostic triad, this has fre- quently not been demonstrable in large series (4). As more sophisticated diagnostic advances came to be applied to physical findings, the limitations of examina- tion were revealed. A wallpapered layer of certainty was removed from basic forms of evaluation. revealing the bare wall of fallibility.

This in no way diminished the achievements of the great medical pioneers, nor do these comments intend to denigrate their observations in the least. They made great strides with the diagnostic tools available to them (their senses, for the most part). We, in turn, must utilize those available to us. As applied to this discussion, this implies that an informed and open-minded approach should be used to evaluate the patient with potential spinal injury.

Kirshenbaum et al. have done this with respect to the place of upper spinal CT in trauma evaluation. Drawing from the cases they describe, they conclude that upper cervical spine CT is indicated as the initial diagnostic examination in patients demonstrating intracerebral hem- orrhage. Putting their policies where their findings are, they report having modified their head scan protocol to conform to this philosophy. They have, in addition, taken into account considerations of time and expense.

Whether their conclusions can be applied more widely remains to be seen. Seven cases cannot form the basis for recommendations to evaluate the world in cervical spine precautions. What is clear, though, is that the inadequa- cies of another diagnostic layer are being peeled away. As limitations are exposed, we must alter our diagnostic regimen to conform to the approach likely to yield the most informative results.

George Sternbach Associate Editor

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208 The Journal of Emergency Medicine

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REFERENCES

Bresler MJ, Rich GH. Occult cervical spine fracture in an ambu- latory patient. Ann Emerg Med. 1982;11:440-2. Kirshenbaum KJ, Nadimpalli SR, Fantus R, et al. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT. J Emerg Med. 1990;8:183-98.

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Sternbach G. John Homans. The dorsiflexion sign. J Emerg Med. 1989;7:287-90. Stembach G, Claude Beck: Cardiac compression triads. J Emerg Med. 1988;6:417-20.