Cervical spine clearance

Revision as of 23:34, 3 September 2015 by Neil.m.young (talk | contribs) (see also)

Background

  • US and Canada with more than 13 million trauma pts per year at risk for C-spine injury
  • Most blunt trauma patients will be placed in a cervical collar by EMS to protect the C-spine
  • C-spine can be clinically cleared by trained personnel

Clinical Features

C-spine injuries may present with

  • rarely neurogenic shock (bradycardia, hypotension)
  • posterior neck pain
  • pain on palpation of spinous processes
  • limited neck ROM with pain
  • weakness, numbness, or paresthesias

Decision Rules

NEXUS Cervical Spine Rule

Radiography is not necessary if the patient satisfies ALL of the following low risk criteria:

  • No midline cervical tenderness
  • No focal neuro deficits
  • Normal alertness
  • No intoxication
  • No painful distracting injury

C-spine imaging should be considered unless the patient meets all of the above low risk criteria[1] [2]

Canadian Cervical Spine Rule

Algorithm for evaluation of cervical spine injuries (Canadian C-spine Rule)

No High Risk Factors

  • Age >65
  • Dangerous mechanism (fall>3ft/5 stairs, high speed MVC (>60mph)/rollover/ejection, bicycle crash, RV, axial load injury)
  • Parasthesias in extremities

ANY Low Risk Factor

  • Simple rear end MVC
  • Delayed onset of pain
  • Sitting position in ED
  • Ambulatory at any time
  • Absence of midline C-spine tenderness

ROM

  • Rotates neck 45 degrees to left and right

C-spine can be cleared clinically if above criteria met[3] [4]

Canadian rule vs. Nexus

A single trial showed Canadian rule would pick up 312 or 313 clinically important cases, while NEXUS would miss 1 one in 10 cases[5]

Sensitivity

Canadian 99.4% vs Nexus 90.7%

Specificity

Canadian 45.1% vs. Nexus 36.8%

Management

  • if unable to be cleared by NEXUS or Canadian C-spine Rules then imaging is indicated
  • CT C-spine noncon or X-rays with odontoid view
    • CT better than Xray [6]
  • Xrays/CTs not adequate to assess for ligamentous instability
  • if pt continues to have midline pain after adequate pain control obtain MRI (can be done outpatient)
    • keep C-collar until MRI results or pain resolves

Disposition

  • based on imaging results

See Also

External Links

References

  1. 27. Hoffman JR, et al. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 1992;21:1454-60.
  2. Mahadevan, et al. Interrater reliability of cervical spine injury criteria inpatients with blunt trauma. Ann Emerg Med1998;31:197-201
  3. Stiell IG,et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8. EBQ:Canadian C-spine Rule Study
  4. Stiell IG, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8.
  5. Stiell IG, Clement CM, and McKnight DR, et al. The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. NEJM. 2003; 349:2510-2518.
  6. Bailitz J, Starr F, Beecroft M, et al. CT should replace three view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma. 2009;66:1605e1609.