Cervical Spine Clearance

Original Date: 07/2025

The cervical spine can be cleared and cervical collar removed in awake and alert patients once the following criteria have been met:

  • The radiologist has dictated and signed the final report of the CT Cervical Spine.
  • The final report has no cervical spine fracture or acute abnormality.
  • Physical examination reveals no mid-line tenderness and the patient states no midline pain when turning the head from shoulder to shoulder.
    • Pain should be midline. Lateral pain can represent musculoskeletal or transverse process injury.

Midline pain on palpation or movement should warrant a MRI Cervical Spine. Place patient in a Philadelphia collar until the results of the MRI are known.

The cervical spine can be cleared and cervical collar removed in unconscious or obtunded once the following criteria have been met:

  • The radiologist has dictated and signed the final report of the CT Cervical Spine.
  • The final report has no cervical spine fracture or acute abnormality (except transverse process fractures).
  • A tertiary survey has been completed and documented.

The cervical collar should remain in place and the Neurosurgery spine service consulted if ANY of the following criteria are present:

  • Any signs of focal neurologic deficit on physical exam
  • Any acute, abnormal findings on CT Cervical Spine (except transverse process fractures)
  • Do not order a Miami J cervical collar until after Neurosurgery has seen the patient.

Any patient leaving the ED without the cervical spine cleared should be placed into a Philadelphia collar. No patient should leave the ED with a pre-hospital or hard cervical collar still in place.

If the patient is obtunded for reasons likely to be temporary (e.g. intoxication), leave Philadelphia collar in place and perform examination once alert and oriented.

Transverse process fractures: In the absence of another non-transverse process bony fracture of the spine and any suggestion of ligamentous injury on CT, any number of transverse process fractures do not require a Neurosurgery consultation, additional imaging, or bracing unless midline tenderness is present in awake and alert patients.