Selective Spinal Selective Spinal ImmobilizationImmobilization

Matt Dunn, DOMatt Dunn, DO

Dept. of Emergency MedicineDept. of Emergency Medicine

Albany Medical CenterAlbany Medical Center

ObjectivesObjectives

Understand the background of spinal Understand the background of spinal immobilization.immobilization.

Understand the rationale for Understand the rationale for developing a selective spinal developing a selective spinal immobilization protocol.immobilization protocol.

Review the data on the selective Review the data on the selective spinal immobilization.spinal immobilization.

Cases and application of protocolCases and application of protocol

The ProblemThe Problem

Between 2-4% of Between 2-4% of bluntblunt trauma trauma patients sustain cervical spine injurypatients sustain cervical spine injury

Early trauma education suggested Early trauma education suggested mechanism of injury as a sole reason mechanism of injury as a sole reason for treatment of presumed spinal for treatment of presumed spinal injuryinjury

EMS education resulted in increased EMS education resulted in increased practice of cervical immobilizationpractice of cervical immobilization

Immobilization - The ConceptImmobilization - The Concept

Prevent Prevent neurologically neurologically intact, unstable intact, unstable injuries from injuries from deterioratingdeteriorating

Prevent progression Prevent progression of neurologic of neurologic deficits as a result deficits as a result of unstable injury of unstable injury movementmovement

Why not immobilize everybody?Why not immobilize everybody?

99.5-96% of EMS trauma patients 99.5-96% of EMS trauma patients do not have a spine injurydo not have a spine injury

EMS provider confusion/educationEMS provider confusion/education Immobilization causes patient Immobilization causes patient

pain and anxiety…possibly injurypain and anxiety…possibly injury Patient refusal for immobilizationPatient refusal for immobilization

Why not board and collar Why not board and collar everybody?everybody?

Time consuming for EMS/EDTime consuming for EMS/ED Unnecessary transportsUnnecessary transports Immobilization is uncomfortableImmobilization is uncomfortable Time immobilized =Time immobilized =

Increased painIncreased painPotential traumaPotential traumaRisk of aspirationRisk of aspirationVulnerable positionVulnerable position

Cervical Spine EvaluationCervical Spine EvaluationEMS vs. ED PerspectivesEMS vs. ED Perspectives

EMSEMS– Who is at risk for cervical injury such Who is at risk for cervical injury such

that injury might be exacerbated with that injury might be exacerbated with EMS movement / transport?EMS movement / transport?

EDED– Who is at risk for cervical injury such Who is at risk for cervical injury such

that radiographic studies need to be that radiographic studies need to be done to elucidate question of injury?done to elucidate question of injury?

What’s all the fussWhat’s all the fuss

Why is this such a big deal?Why is this such a big deal?– TimeTime– MoneyMoney– Health issuesHealth issues

Why not film/immobilize Why not film/immobilize everybody?everybody?

>1,000,000 U.S. Patients receive >1,000,000 U.S. Patients receive cervical radiography each yearcervical radiography each year

>>97%97% of exams are negative of exams are negative Cost exceeds Cost exceeds $175,000,000$175,000,000 each each

yearyear Patient exposure to radiation Patient exposure to radiation

– ~3000 cases of thyroid cancer/yr~3000 cases of thyroid cancer/yr Immobilization causes pain and Immobilization causes pain and

anxietyanxiety Slows time to dispositionSlows time to disposition

Cervical Spine EvaluationCervical Spine EvaluationEMS vs. ED PerspectivesEMS vs. ED Perspectives

EMSEMS– Who is at risk for cervical injury such Who is at risk for cervical injury such

that injury might be exacerbated with that injury might be exacerbated with EMS movement / transport?EMS movement / transport?

EDED– Who is at risk for cervical injury such Who is at risk for cervical injury such

that radiographic studies need to be that radiographic studies need to be done to elucidate question of injury?done to elucidate question of injury?

Can we recognize who may Can we recognize who may have injuries? Yes!have injuries? Yes!

National Emergency X-National Emergency X-Radiography Utilization StudyRadiography Utilization Study

NEXUS!NEXUS!

National Emergency X-National Emergency X-Radiography Utilization StudyRadiography Utilization Study

Hypothesis:Hypothesis:

Blunt trauma vicitmsBlunt trauma vicitms have virtually no have virtually no risk of risk of cervical spinecervical spine injury if they injury if they meet all of the following criteria:meet all of the following criteria:

No Neurologic deficitNo Neurologic deficit No posterior midline tendernessNo posterior midline tenderness No evidence of ETOH/ToxNo evidence of ETOH/Tox No other distracting painful injuryNo other distracting painful injury

NEXUS CriteriaNEXUS Criteria

No Neurologic deficitNo Neurologic deficit No posterior midline tendernessNo posterior midline tenderness No evidence of ETOH/ToxNo evidence of ETOH/Tox No other distracting painful injuryNo other distracting painful injury

NEXUS Definition:NEXUS Definition:Altered Neurologic functionAltered Neurologic function

GCS 14 or lessGCS 14 or less– disoriented to person,place,time,eventsdisoriented to person,place,time,events

Inability to remember 3 objects at 5 Inability to remember 3 objects at 5 min.min.

Any focal deficitAny focal deficit– Numbness, tingling, weaknessNumbness, tingling, weakness

Delayed/inappropriate response to Delayed/inappropriate response to external stimuliexternal stimuli

NEXUS CriteriaNEXUS Criteria

No posterior midline tendernessNo posterior midline tenderness– Specific to midline spinal tendernessSpecific to midline spinal tenderness

Not considered positive if there is Not considered positive if there is tenderness on the sides of the necktenderness on the sides of the neck

NEXUS Definition: IntoxicationNEXUS Definition: Intoxication

Patients should be considered Patients should be considered intoxicated if they haveintoxicated if they have

1) History of recent intoxication or 1) History of recent intoxication or ingestioningestion

2) Evidence of intoxication on exam2) Evidence of intoxication on exam

What is a What is a significantsignificant distracting distracting injury?injury?

Ill-defined in the literature:Ill-defined in the literature: ““Distracting Painful Injuries associated Distracting Painful Injuries associated

with Cervical Spinal Injuries in Blunt with Cervical Spinal Injuries in Blunt Trauma”* suggests:Trauma”* suggests:

1)Any long bone fracture1)Any long bone fracture

2) Visceral injury necessitating surgical 2) Visceral injury necessitating surgical consultconsult

* Ullrich, et al. AEM 2001;8:25-29.* Ullrich, et al. AEM 2001;8:25-29.

What is a What is a significantsignificant distracting distracting injury? #2injury? #2

3) Large laceration, degloving or crush3) Large laceration, degloving or crush

4) Large burns4) Large burns

5) 5) any injury producing acute any injury producing acute functional impairmentfunctional impairment

Ultimately up to clinician.Ultimately up to clinician.– Use to increase sensitivityUse to increase sensitivity

NEXUSNEXUS

21 Centers enrolled 34,069 Blunt 21 Centers enrolled 34,069 Blunt trauma victims who underwent trauma victims who underwent cervical spine radiography.cervical spine radiography.

NEXUS -ResultsNEXUS -Results

818 patients with fracture identified818 patients with fracture identified All except 8 were identified by All except 8 were identified by

clinical decision ruleclinical decision rule Sensitivity 99% (95% CI 98-99.6%) Sensitivity 99% (95% CI 98-99.6%)

8 Patients8 PatientsNot Not IdentifiedIdentifiedBy NEXUSBy NEXUSRulesRules

NEXUSNEXUS

Performed in hospital settingPerformed in hospital setting Can this be applied to the pre-Can this be applied to the pre-

hospital setting?hospital setting? With less training, will an With less training, will an

EMT/Paramedic miss a fracture?EMT/Paramedic miss a fracture?– Protocol is straightforward.Protocol is straightforward.

Purpose a Selective Spinal Purpose a Selective Spinal Immobilization ProtocolImmobilization Protocol

Identify and immobilize 100% Identify and immobilize 100% of patients at risk for unstable of patients at risk for unstable injuriesinjuries

Identify and NOT immobilize Identify and NOT immobilize patients who have NO risk for patients who have NO risk for cervical spine injury…cervical spine injury…

Burton JH, Dunn MG, Harmon NR, Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. Hermanson TA, Bradshaw JR.

A Statewide, Prehospital Emergency A Statewide, Prehospital Emergency Medical Service Selective Patient Medical Service Selective Patient

Spine Immobilization Protocol. Journal Spine Immobilization Protocol. Journal of Trauma: Injury, Infection, and of Trauma: Injury, Infection, and Critical Care, 2006;61:161-166.Critical Care, 2006;61:161-166.

Maine EMS SpineMaine EMS Spine Assessment & Selective Assessment & Selective Immobilization Protocol 1994-2001Immobilization Protocol 1994-2001

Mechanism of Injury

Positive Uncertain Negative

Positive NegativeSpine Inj Spine Inj

Spine Pain/Tenderness

Yes No

Positive Motor/Sensory ExamSpine Inj Normal

Maine EMS Spine Assessment Protocol Maine EMS Spine Assessment Protocol 1994-20011994-2001

No Yes

Positive Exam Spine Inj Reliable?

No

Motor/Sensory ExamNormal

Positive Negative Spine Inj Spine Inj

Calm, Sober, Alert

Acute Stress Rxn, Brain InjIntox, Alt MS, Distracting Inj

Yes

Stable Stable Spine Spine

InjuriesInjuries

UNUNStable Stable Spine Spine

InjuriesInjuries

NotNot Clinically Clinically SignificantSignificant

Spine Spine

InjuriesInjuries

ClinicallyClinically

SignificantSignificant

Spine Spine

InjuriesInjuries

Maine EMS 2002Maine EMS 2002Question of spine injury?

Yes No

Unreliable? Immobilize Don’t(Intox/Alt LOC) Immobilize

Distracting Inj?

Abnormal sensory motor?

Spine Pain/Tenderness?

YesNo

No

No

YesNo

Study ObjectiveStudy Objective

To evaluate the outcomes To evaluate the outcomes associated with a statewide, associated with a statewide, emergency medical services emergency medical services (EMS) protocol for selective (EMS) protocol for selective spinal immobilization in the spinal immobilization in the

trauma patient. trauma patient.

Study Design: 1 Year Maine Study Design: 1 Year Maine EMSEMS

EMS EncountersRun Reports

Spine Fractures

35 Maine Hospitals

Acute EMS Spine Fractures

Date of BirthEMS Run #Date of Run

EMS Run ReportEMS Run ReportDemographic and Clinical DataDemographic and Clinical Data

Age, gender...Age, gender... Chief complaint categorization: Medical vs Chief complaint categorization: Medical vs

TraumaTrauma Subcategorization of chief complaintSubcategorization of chief complaint Drug/Procedure interventionsDrug/Procedure interventions Immobilization interventions: cervical collar, long Immobilization interventions: cervical collar, long

board, KEDboard, KED Vital signs, GCSVital signs, GCS NarrativeNarrative

Maine Hospital DatabaseMaine Hospital DatabaseDemographic and Clinical DataDemographic and Clinical Data Age, gender...Age, gender... Injury and admission source categorizationInjury and admission source categorization

Diagnosis Coding: ICD-9Diagnosis Coding: ICD-9

Spine injury interventions: CPTSpine injury interventions: CPT “Unstable” “Unstable” DefinitionDefinition

Focused Clinical Data ReviewFocused Clinical Data Reviewfor All Spine Fracture Patientsfor All Spine Fracture Patients

DemographicsDemographics Injury categorization: Medical vs TraumaInjury categorization: Medical vs Trauma Immobilization interventions: cervical collar, long Immobilization interventions: cervical collar, long

board, KEDboard, KED Diagnosis and Procedure codingDiagnosis and Procedure coding

NarrativeNarrative

Study Design: 1 Year Maine Study Design: 1 Year Maine EMSEMS

207,545EMS Encounters(31,884 Trauma)

846 Spine Fractures

35 Maine Hospitals

158Acute

Spine Fractures

Date of BirthEMS Run #Date of Run

(0.50%)

17 unstable (11%)

Fractures by Spine LocationFractures by Spine Location

4743

68

0

10

20

30

40

50

60

70

80

Site of 158 Fractures

CervicalThoracicLumbar

Immobilization Decision in All Immobilization Decision in All Trauma PatientsTrauma Patients31,885 Trauma Evaluations

41

59

0

10

20

30

40

50

60

70

80

90

100

%ImmobNot Immob

158 EMS spine fractures

85

15

0

10

20

30

40

50

60

70

80

90

100

%ImmobNot Immob

23 Stable fxs1 Unstable

Immobilization Decision in Immobilization Decision in Spine Fracture Trauma Spine Fracture Trauma

PatientsPatients

Missed Fracture Missed Fracture Patient OutcomesPatient Outcomes

1 Unstable Injury:1 Unstable Injury:

86 yof - fall off couch one week before 86 yof - fall off couch one week before 911 call T6/7 subluxation911 call T6/7 subluxation

Treated with operative fusion Treated with operative fusion

Nonimmobilized Fractures by Nonimmobilized Fractures by Spine LocationSpine Location

410 10

0

10

20

30

40

50

60

70

80

Site of 24 Nonimmobilized Fractures

CervicalThoracicLumbar

24 Non-Immobilized Spine 24 Non-Immobilized Spine Fracture Trauma PatientsFracture Trauma Patients

0

10

20

30

40

50

60

70

80

90

100

AGE

ConclusionsConclusions

The use of this statewide, EMS The use of this statewide, EMS spine assessment protocol spine assessment protocol resulted in a decision not to resulted in a decision not to immobilize greater than half of immobilize greater than half of all trauma patients assessed.all trauma patients assessed.

The incidence of spine The incidence of spine fractures in EMS-assessed fractures in EMS-assessed trauma patients in this rural trauma patients in this rural state was 0.50% state was 0.50%

ConclusionsConclusions Approximately 15% of patients with Approximately 15% of patients with

a documented spine fracture do not a documented spine fracture do not appear to have been immobilized appear to have been immobilized with the use of this EMS spine with the use of this EMS spine assessment protocol.assessment protocol.

The use of this statewide, EMS spine The use of this statewide, EMS spine assessment protocol resulted in one assessment protocol resulted in one non-immobilized, unstable spine non-immobilized, unstable spine fracture patient in approximately fracture patient in approximately 32,000 trauma encounters. 32,000 trauma encounters.

LimitationsLimitations Large sample size is dependent on database Large sample size is dependent on database

methodology and data inherent within the methodology and data inherent within the database.database.

Database linkage methodology Database linkage methodology Decision not to immobilize does not mean the Decision not to immobilize does not mean the

decision rule/protocol was negative…EMS decision rule/protocol was negative…EMS providers may be selectively choosing not to providers may be selectively choosing not to immobilize certain patients.immobilize certain patients.

Education and practice disparities across large Education and practice disparities across large state with 6 EMS regions (one set of state state with 6 EMS regions (one set of state protocols).protocols).

Maine EMS 2002Maine EMS 2002Question of spine injury?

Yes No

Unreliable? Immobilize Don’t(Intox/Alt LOC) Immobilize

Distracting Inj?

Abnormal sensory motor?

Spine Pain/Tenderness?

YesNo

No

No

YesNo

Maine EMS 2004: QAMaine EMS 2004: QA

Sensitivity for fractures: 84.8%Negative Predictive Value: 99.9%

Sensitivity for unstable fracture: 94.1%Negative Predictive Value for unstable: 99.9%

EMS older patient spine EMS older patient spine conundrumconundrum

– Nexus: Be Nexus: Be Selective Selective on on EveryoneEveryone

– Canadian: Canadian: Don’t apply Don’t apply to pts > 65 to pts > 65 yoayoa

Maine EMS 2004: QAMaine EMS 2004: QA

-Outcomes followup study: 31,885 encounters

-QA Study: 2220 QA sheets in the state9 fractures (0.45%)

Maine EMS 2004: QAMaine EMS 2004: QA

3

1125

32

609

99

2

172

315

0

200

400

600

800

1000

1200

DiveMVCBivPedFall HtFall>5ftPenetrateBluntOther

Maine EMS 2004: QAMaine EMS 2004: QA

59

41

0

10

20

30

40

50

60

%ImmobNot Immob

Maine EMS 2004: QAMaine EMS 2004: QA

3228

6

54

0

10

20

30

40

50

60

%

UnreliableDistrct injAbn NeuroSpine Pn/Tndr

Multicenter Prospctive Validation of Multicenter Prospctive Validation of Prehsp Clin Spinal Clearance Criteria Prehsp Clin Spinal Clearance Criteria

J Trauma 2002;53:744-750 J Trauma 2002;53:744-750 280

15

0

50

100

150

200

250

300

8,975 Injuries with 295 fractures

ID'dMissed

Multicenter Prospctive Validation of Multicenter Prospctive Validation of Prehsp Clin Spinal Clearance Criteria Prehsp Clin Spinal Clearance Criteria

J Trauma 2002;53:744-750 J Trauma 2002;53:744-750

54

6

0

5

10

15

Site of 15 Missed Spine Fractures

CervicalThoracicLumbar

Multicenter Prospctv Validation of Multicenter Prospctv Validation of Prehsp Clin Spinal Clearance Criteria Prehsp Clin Spinal Clearance Criteria

J Trauma 2002;53:744-750 J Trauma 2002;53:744-750

2 unstable injuries:2 unstable injuries:71 yom fall, c1/2 odontoid fx71 yom fall, c1/2 odontoid fx

Treated with halo and Treated with halo and pain rxpain rx

47 yom head on 47 yom head on MVC, T6/7 MVC, T6/7 sublx Treated with sublx Treated with operative operative fusionfusion