Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXIII: Wounds and Injuries of the Spinal Column and Cord
United States Department of Defense
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Protection of the cervical spine must continue until that area is radiographically cleared. The first X-ray to be obtained is a lateral view of the cervical spine. The entire cervical spine, C-1 to the C-7, T-1 junction, must be visualized. If the C-7 vertebra cannot be visualized, either the arms can be pulled towards the feet by an assistant standing at the foot of the stretcher, or a "swimmers view" (lateral X-ray of the cervical spine with one arm at the side and other elevated alongside the head) can be taken. If questions remain about interpretation of the cervical spine films and if the techniques to improve visualization are unsuccessful, protection of the neck must continue throughout the stabilization phase and the casualty must be transferred to a facility where either tomography or computerized tomography capabilities are available. Immobilization can be discontinued only after all seven cervical vertebrae, including the ring of C-1, the odontoid, and the soft tissues anterior to the cervical spine are visualized and cleared. After the cervical spine has been evaluated, the remainder of the spine can be examined physically and radiographically. The medical officer should palpate the spinous processes in order to disclose areas of tenderness or malalignment. The search for malalignment is particularly important in the evaluation of the unresponsive patient.
When complex wounds involving the head, thorax, abdomen, or extremities coexist with vertebral column injuries, lifesaving measures take precedence over the definitive diagnosis and management of spinal column and cord problems. During these interventions, secondary injury to the unstable spine must be prevented by appropriate protective measures.
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