Cervical Spine Clearancein Trauma

Duke Emergency Medicine Residency, PGY1 Lecture SeriesJoseph M Reardon, MD

with thanks to Sarah Crosby, MBBS; Hunter New England Health, New South Wales

Disclosure Statement

• I have no financial conflicts of interest to disclose.

Special Thanks• Josh Broder• Sam Francis• Steve Barmach• Steph Eucker

Case

• Jethrow Williams, farmer injured on Yates Store Road, 1943• C-spine injury• Brought to Duke Hospital (recently opened)

Original C-collar

Overview

• When to collar• How to collar• When to image• When to take it off

Overview

• When to collar• American Association of Neurological Surgeons Guidelines• Current Evidence• Clinical Practice

• How to collar• When to image• When to take it off• Other spinal trauma

Overview

• When to collar• American Association of Neurological Surgeons Guidelines• Current Evidence• Clinical Practice

• How to collar• When to image• When to take it off• Other spinal trauma

When to collar - AANS

• “all trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spinal injury should be immobilize

• “A combination of a rigid cervical collar and supportive blocks on a backboard with straps is very effective in limiting motion of the cervical spine and is recommended”

AANS, 2001

When to collar - AANS

• “As many as 20% of spinal column injuries involve multiple non-continuous vertebral levels”

• Immobilize whole spine if truly concerned

AANS, 2001

Overview

• When to collar• American Association of Neurological Surgeons Guidelines• Current Evidence• Clinical Practice

• How to collar• When to image• When to take it off• Other spinal trauma

When to collar – Current Evidence• 2001: Fresno/Kings/Madera Protocol

• 99% sensitive• 5 fractures missed: 1 adverse outcome• All patients missed by the protocol were >67yo or <1yo

• 2005: University of Michigan EMS Protocol Study• 92% sensitive• 33 fractures missed; no adverse outcomes

When to collar – Current Evidence, contd• 2010: Natl Trauma Data Bank Study

• Penetrating trauma pts with doubled risk of death if collared• Mult sources of confounding

• 2011: EMJ• Collaring on scene associated with critical scene delays

Overview

• When to collar• American Association of Neurological Surgeons Guidelines• Current Evidence• Clinical Practice

• How to collar• When to image• When to take it off

When to Collar – Clinical Practice

• Durham County EMS Protocol:• Immobilize spine by either long board, scoop board, or Kendrick extrication

device, based on paramedic’s assessment• C-collar using portable Ambu c-collar device• No need for spinal immobilization for isolated penetrating trauma

Overview

• When to collar• How to collar

• Miami J• Philadelphia• Portable EMS Collar• Lab!

• When to image• When to take it off• Other spinal trauma

Poll

• When do you use a Miami J versus Philly?• 70mph rollover, GCS 6• Penetrating injury to spine• Fall from standing, 20y healthy male• Fall from standing, 80y female with multiple myeloma and osteoporosis• Resident of Fort Lauderdale• Resident of Camden, New Jersey

How to collar – Miami J vs Philadelphia• Miami J superior to Philadelphia in flexion, extension, rotation and

lateral tilt• Philadelphia has not been rigorously studied in clinical trials although

subjectively more comfortable• Cost:

• Miami J: Approx $300• Philadelphia: Approx $150

• “But Doctor, do we really need to spend the extra money for an uncomfortable collar?”

• Yes. Askins, Eismont, Spine 1997

How to collar – Miami J

How to collar: Philadelphia, Ambu

• Ambu: EMS Standard• Philadelphia:

• Not currently evidence-supported.

• Soft collar:• Use for patients with definite muscular (aka NON-traumatic) neck pain for

whom neck support will reduce pain medication requirements

Overview

• When to collar• How to collar• When to image

• American Association of Neurological Surgeons Guidelines• Eastern Association for Surgery of Trauma Guidelines• Current Evidence• Clinical Practice

• When to take it off• Other spinal trauma

When to Image - Guidelines

• AANS:• “Radiographic assessment of the cervical spine is not recommended in

trauma patients who are awake, alert, and not intoxicated, who are without neck pain or tenderness, and who do not have significant associated injuries that detract from their general evaluation.”

• EAST:• Same as AANS

Overview

• When to collar• How to collar• When to image

• NEXUS• Canadian C-spine Rule• Clinical Practice

• When to take it off

Poll

• When do you use Canadian C-spine rule vs NEXUS criteria?• Canadian C-spine rule all the time• NEXUS all the time• Canadian only in foreigners• None of the above, it’s simply too high risk. Scan them all.• Gestalt

When to image - Evidence

• NEXUS

Clinical Clearance of the C-Spine in the Awake Patient

NEXUS

Sensitivity 90.7%

Specificity 36.8%

Radiography Rate 66.6%

CCR

Sensitivity 99.4%

Specificity 45.1%

Radiography Rate 55.9%

Stiell IG, et al. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. NEJM 2003;349:2510-2518

When to image - Evidence

When to Image: One perspective

• Patient obtunded or you are concerned Image• Borderline, pressed for time, rolling to the scanner (trauma surgeon

breathing down your neck) NEXUS• Less concerned, patient flunks NEXUS but you really don’t think they

have an injury Canadian C-spine• You’re a hotshot with an 8 GHz processor in your head Canadian

every time

Overview

• When to collar• How to collar• When to image• When to take it off

• Evidence• Clinical Practice

• Other spinal trauma

Poll

• When do you use?• X-ray c-spine?• Flex/ex films?• CT c-spine?• MRI c-spine?• Ultrasound?• X-man vision?

C-collar Removal: Imaging

• The Primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions (Level II)

• Plain radiographs contribute no additional information and should not be obtained (Level II)

• If there is neurological deficit attributable to a c-spine injury an MRI should be obtained

C-Collar Removal: Neck Pain with negative CT in the neurologically intact patient

3 options (Level III)1. Continue collar2. Remove collar after negative MRI (<72h)3. Remove collar after negative and adequate

flexion extension films• Picks up c-spine instability in 6.75-8% of normal c-spine

films• Incidence of isolated ligamentous injury is rare (0.6% of

traumatic c-spine injuries)

C-Collar Removal: Obtunded Trauma Patient with a Negative CT C-Spine

EAST Recommendations 2009• Flexion/Extension radiographs should NOT be performed

(Level II)• The risk/benefit ratio of obtaining an MRI in addition to

CT is not clear (individualise to each institution) (Level III)• Options are:

1. Continue cervical collar immobilisation until a clinical examination can be performed

2. Remove the cervical collar on the basis of CT alone3. Obtain an MRI and if negative the collar can be safely removed

(Level II)

? MRI in addition to CT?

• Incidence of ligamentous injury with negative CT c-spine is very low (<5%)

• Incidence of clinically significant injury is even lower (<1%)• Difficult • More sensitive for identification of soft tissue injuries (Gold standard

for spinal cord injury)• Not reliable for identifying bony injury

Albrecht et al.Evaluation of cervical spine in intensive care patients following blunt trauma. World J Surg 2001

150 Patients (150 obtunded)Retrospective, blunt trauma ICU patients.25% of patients with negative x-rays or CT C-spine had extradural soft tissue or ligamentous injury on MRI(only 1 required operative stabilisation)

Ghanta et al.An analysis of Eastern Association for the Surgery of Trauma Practice guidelines for cervical spine evaluation in a series of patients with multiple imaging techniques. Am Surg. 2002

124 patients (51 obtunded)Retrospective, trauma patients.All had plain C-spine x-ray, CT and MRI.19% of patients had injuries only evident on MRI

Horn et al.Cervical magnetic resonance imaging abnormalities not predictive of cervical spine instability in traumatically injured patients J. Neurosurg Spine

314 patients (22 obtunded)Retrospective, c-spine MRI patients.42% of patients with no injury detected on CT or C-ray had abnormality detected on MRI.No cervical instability detected on MRI that wasn’t evident on CT or flexion/extension

Holmes et al.Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries. J Trauma 2002

688 patientsProspective multicenter study, blunt trauma patients.MRI superior to CT for detection of cervical spine ligamentous and cord injuries. CT was superior for skeletal and facet joint injuries.

C-Collar Removal: SCIWORASignificant Cord Injury without obvious radiological

abnormality• Higher incidence in pediatric population (34.8%)

• The relatively large size of the head• inherent skeletal mobility• cord vulnerable to damage

• Higher incidence above 60 yo• Posterior vertebral spurs due to spondylosis• Ligamentum flavum bulging due to loss of disc height

• Risk of central cord syndrome after hyperextension injury

SCIWORA: The debate continues…

• 2010 Meta-analysis (1550 pts): 96 pts with negative CT who underwent MRI had practice-altering findings (6.2%)

• Limitations: Retrospective, only included pts with high provider suspicion, practice-altering does not equal clinically significant

• 2011 Meta-analysis (14,327 pts): Sensitivity of CT for unstable C-spine fractures was >99.9%

• Limitations: Ignored stable fractures, heterogeneity of alternative modalities• Conclusions: Imaging for SCIWORA after negative CT, in the absence of

compelling extenuating circumstances, is unnecessary

Schoenfeld, Bono, J Trauma 2010Panczykowski, Tomcyz, J Neurosurg 2011

Overcoming SCIWORA

• Physical Exam (ATLS Secondary Survey©™®)• Check multiple dermatomes, assess progression of GCS• Strength & reflexes as proxies of upper motor neuron damage• Consider rectal exam if any suspicion for spinal cord injury (as in

ATLS, not mandatory if there is very low suspicion of neurologic injury)

Overview

• When to collar• How to collar• When to image• When to take it off

• Evidence• Clinical Practice

• Other spinal trauma

C-Collar Removal: Clinical Practice

• Persistent pain:• No study has yet validated a method of risk-stratifying patients with persistent

pain and negative CT C-spine• Seek your senior resident’s guidance.• In setting of negative CT C-spine, we assess severity of pain. For mild pain (1-

2/10) that could be attributable to positioning and discomfort of the immobilization, we generally clear the c-spine. Moderate or severe pain or consultant concern necessitates MRI

• Obtunded patient:• Do not remove collar – Defer to SICU• Consider MRI if recommended by radiologist

Overview

• When to collar• How to collar• When to image• When to take it off• Other spinal trauma

• Evidence• EAST Guidelines• Clinical Practice

Thoracolumbar Spine Trauma

• 4.4% of trauma patients have TLS fracture• 19-50% of these fractures are associated with spinal cord damage• Higher incidence of neurologic deficit when fracture identification was

delayed (10.5% vs 1.4%)

Overview

• When to collar• How to collar• When to image• When to take it off• Other spinal trauma

• Evidence• EAST Guidelines• Clinical Practice

EAST Recommendations (2007)

• Level II Guidelines• Trauma patients should be examined by a qualified attending physician

• Trauma surgeons, emergency physicians or spine surgeons (neurosurgery or orthopaedics)

• Trauma patients who are awake, without any evidence of intoxication, with normal mental status, neurologic and physical examinations may be cleared clinically

Mode of Imaging of TLS• Multidetector CT with axial reconstruction is superior to plain

films for screening of TLS for bony injury (II)• CT scout films can be used for spine assessment (II)• CT scan may be associated with less overall radiation exposure

than plain films (III)• Plain films are adequate for the examination of the TLS if the

patient does not require CT scan for any other reason (III) (Not if they have a major trauma mechanism)

• MRI is indicated for patients with neurologic deficits, abnormal CT scans or clinical suspicion despite normal radiographic evaluation suggesting an unstable injury (III)

• Early decompression of traumatic lesions improves outcome

Plain Film vs CT of TLS• Ballock et al. (1992)

• plain radiography of the thoracolumbar spine would have missed 25% of fractures

• Gestring et al. (2002)- CT protocol for examining TLS• Anterior, posterior and lateral scout films and axial images• 100% sensitivity and specificity

Plain Film vs CT of TLS, contd• Hauser et al. (2003)-prospective study 222 patients

• Plain radiography of the TL spine vs Helical CT (5mm images)• CT scan accuracy 99% vs plain radiographs 87%• CT could also differentiate acute vs old #

• Sheridan et al. (2003)• Reformatted helical T (2.5mm images) vs plain x-ray• Sensitivity for Thoracic #- CT 97% vs x-ray 62%• Sensitivity for Lumbar #- CT 95% vs x-ray 86%

Obtunded Patient

• No level I evidence• Level II

• Multidetector CT with axial reconstruction is superior to plain films for screening of the TLS for bony injury

Overview

• When to collar• How to collar• When to image• When to take it off• Other spinal trauma

• Evidence• EAST Guidelines• Clinical Practice

TLS Spinal Trauma: Clinical Practice• Concerning mechanism of injury and/or any thoracoabdominal injury

pan-scan with T/L/S reformats• Trauma Level One / Two / Three Orderset

Overview

• When to collar• How to collar• When to image• When to take it off• Other spinal trauma

• QUESTIONS