Clearing the C Spine in the Emergency Department
Peter Cameron
Outline
Clearing the Cervical Spine in the Emergency Department
Spinal Clearance Protocol: Aims
To detect injury to the spine
Gross injury
Occult injury
To prevent extension of injury to para/quadriplegia
To prevent complications of immobilisation
Most protocols don’t exclude possibility of long term disability
Cervical Injury
Trauma patients are suspected of having spinal injury until proven otherwise
Most spinal trauma results from 4 main mechanisms:
Hyperflexion
Hyperextension
Axial loading (vertical compression)
Lateral rotation
Unstable cervical spine injury:
Definition --3 spinal columns (Denis, Clin Orthop Relat Res, 1983)
Anterior
ALL, anterior annulus fibrosis and anterior vertebral body
Middle
Posterior vertebral body, posterior annulus fibrosis & PLL
Posterior
All structures from ligamentum flavum to posterior bony and ligamentous complexes
2 or more columns affected = INSTABILITY
Conscious patient
Aim: to detect serious injury
Immobilised at scene
Cervical collar
Clinical Assessment
Neurological assessment
Physical assessment
NEXUS criteria & Canadian C-spine Rule
Radiology
Neurological Assessment
Sensation
Motor function
Reflexes
Rectal examination/perianal sensation
If abnormality present, do not clinically assess. Imaging required
Physical Assessment
Inspection & palpation from occiput to coccyx
Pain with movement
Tenderness
Gap or step
Oedema and bruising
Spasm of associated muscles
NEXUS Group
Hoffman et al, NEJM, 2000
Panacek et al, Ann Emerg Med, 2001
Hendey et al, J Trauma, 2002
National X Radiography Utilisation Study
Purpose of study
To whether a simple algorithm could determine need for plain cervical XR
Outcome of NEXUS Group
21 centers participated in the National
X Radiography Utilisation Study
34,069 blunt trauma patients enrolled
Radiographic studies included plain x-ray, CT, MRI
Standard three XRs were obtained on all patients supplemented by other views and CT/MRI
Results of NEXUS Group
Incidence of cervical spine injury > 2.4%
818 patients had one or more cervical spine injuries
570 (69.6%) of these had complete and adequate set of radiographs
Clinical Assessment:
NEXUS criteria
Midline cervical tenderness on palpation?
Focal neurologic deficit?
Evidence of intoxication?
Painful distracting injury?
Altered mental status?
If no to all, imaging not required
If yes to any, imaging required
Painful distracting injury
NEXUS definition (Panacek et al, Ann Emerg Med, 2001)
Any condition thought by the clinician to be causing enough pain to distract from neck injury eg. long bone #, large laceration, degloving, crush injury, burns etc
Non-specific definition
More recent view (Heffernan et al, J Trauma, 2005)
NEXUS definition may be narrowed to upper torso injuries
Canadian C-Spine Rule
Stiell et al, JAMA, 2001
Stiell et al, NEJM, 2004
High risk factors which mandate radiography?
Age ≥ 65 years?
Dangerous mechanism?
Fall > 1 metre
Axial load eg diving
High speed MCA, rollover, ejection
Motorised recreational vehicles
Bicycle collision
Canadian C-Spine Rule
Low risk factor allowing for safe assessment of range of motion?
Simple rear end MCA?
Sitting upright in ED or ambulatory?
Delayed onset of neck pain?
No midline tenderness?
Then assess ability to rotate neck 45° to left & right
Alfred Hospital Protocol
Conscious patients
NEXUS criteria
Movement assessment component of Canadian C-spine Rule
Caution
Degenerative cervical spine change
Detected on CT
History of previous neck injury
Conscious patient
Alert, sober, neurologically intact patient under 65 years with low risk mechanism
If no midline tenderness to palpation, remove collar
If pt able to rotate head 45° to left & right, clear cervical spine – no radiology required
Otherwise, imaging required
Radiology
Plain XR
CT
MRI
Plain X-rays –
skeletal fractures, cervical alignment
12-16% fractures missed on plain film
-Widder et al, J Trauma, 2004
-Ajani et al, Anaesth Intensive Care, 1998
CT-
skeletal fractures,
subluxation/dislocation injuries
disc spaces, alignment
No view of ligaments and cord
MRI-
ligamentous, disc and cord injuries
Poor view of fractures
Conscious patient
Failed NEXUS or C-Spine Criteria, then
→ CT
If CT NAD & symptoms resolved, clear spine
If CT NAD & significant ongoing symptoms incl midline tenderness or neurologic deficit
→ MRI
If MRI NAD, clear spine
Case Studies:
Conscious patient
No acute injury on CT Continuing neck pain
MRI
Pt 1: 54 year old male, truck vs tree, GCS 15, CT brain NAD, C spine degenerative changes only
Prevertebral haematoma C2-5, C5-6 disc protrusion with severe canal stenosis. Treatment: collar 4/52
Pt 2: 67 year old male, pt vs forklift, GCS 15, CT brain NAD, C spine non-acute loss of C6-7 disc height
C5-6 disc extrusion, with partial tear of ALL & high signal in PLL. Treatment: ACDF
If the pt undergoes MRI, how do we interpret the results?
Clinical significance of stable, single column injury?
Unconscious patient
Aim: to detect unstable injury & prevent progression of potential injury to permanent neurologic deficit
Neurological assessment not possible
Clinical assessment not possible – patient unable to complain of neck pain
Priority: imaging required
If CT NAD, clear spine
If abnormality on CT, MRI may be required to assess non-vertebral structures
Case Study:
Occult disc/ligamentous injury
Motorcyclist vs stationary vehicle at 100kph
GCS 3 at scene
Fixed, dilated R) pupil
CT no # (regional centre)
Strong suspicion of hyperextension injury → MRI
Case Study:
Cord Injury
27 year old male
MBA vs car
(car failed to give way from side street)
Value of MRI: Questions
No consensus on approach
Should unconscious trauma patients have routine cervical MRI? (Ackland et al, Spine, 2007)
Should conscious neck pain patients have MRI following normal CT?
Should abnormal neurology be the only indication for cervical MRI in conscious patients with normal CT? (Labattaglia, Cameron et al, Emerg Med Aust 2007)
MRI vs long term outcomes
Very few studies comparing acute cervical MRI with long term outcomes
Kaale et al (J Neurotrauma, 2005) compared functional outcome with late MRI (2-9 years post injury), inconclusive
Davis et al (Radiology, 1991), 14 pts, late MRI, found multi-level disc injury
Borchgrevinck et al (Injury, 1997), 40 pts, MRI within 48 hrs, no injuries
Further research required
Alfred Hospital/Monash University Study
(Ackland, Cameron, Cooper et al)
Commenced in December, 2006
250 patients
Funded by TAC
Emergency trauma patients with neck pain
No cervical fracture on CT
MRI within 72 hours of injury
Follow-up at time points to 12 months post injury
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Ministry of Health
