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C-Spine Evaluation: Who do you image?

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30 yo helmeted motorcyclist presents to the ED fully ... Spine Radiographs (CSR) ... spine injury: plain radiograph or computed tomography scan? ... – PowerPoint PPT presentation

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Title: C-Spine Evaluation: Who do you image?


1
C-Spine Evaluation Who do you image?
  • Steven A. Godwin MD, FACEP
  • Assistant Professor
  • and Program Director
  • Department of Emergency Medicine
  • University of Florida HSC/Jacksonville

2
Flexion Teardrop Fracture
3
Case Presentation
  • 30 yo helmeted motorcyclist presents to the ED
    fully immobilized with c-spine precautions
    following an accident. He states he was ejected
    approximately 25-30 feet from the vehicle. He
    recalls most of the accident but believes he may
    have lost consciousness briefly.
  • Physical exam is normal with a non-tender
    c-spine. GSC 15

4
Case Questions
  • Does he need neuroimaging of the c-spine prior to
    clearing the c-collar?
  • What if he were intoxicated or he had an altered
    mental status?
  • What if he had a distracting injury?

5
Background
  • Prevalence of Disease
  • Findings of NEXUS
  • 818 patients identified (2.4) of 34,069 patients
    with blunt trauma
  • 1,496 distinct cervical spine injuries to 1,285
    different spine structures
  • 27 (.08) identified via MRI with SCIWORA2

1 Goldberg W, Mueller C, Panacek E, Tigges S et
al. for the NEXUS Group. Distribution and
patterns of blunt traumatic cervical spine
injury. Ann Emerg Med. 20013817-21. 2 Hendley
G, Wolfson A, William R et al. for the NEXUS
Group. Spinal cord injury without radiographic
abnormality Results of the national emergency
x-radiography utilization study in blunt cervical
trauma. J Trauma. 2002531-4.
6
Distribution and patterns of injury
  • Most common level of injury-
  • C2 vertebra- 286 (24) fractures including
    92 odontoid fractures
  • C6 and C7 vertebra- 235 (39.3) fractures
  • Most common site of fracture-
  • Vertebral body

1 Goldberg W, Mueller C, Panacek E, Tigges S et
al. for the NEXUS Group. Distribution and
patterns of blunt traumatic cervical spine
injury. Ann Emerg Med. 20013817-21 (I)
7
Lowery et al. (NEXUS)
  • Demographics of c-spine trauma
  • 818/33,922 patients
  • Age gt 65 yo- RR 2.09 95 CI 1.77-2.59
  • Other ethnicity- RR 1.79, 95 CI 1.46-2.19
  • Male sex -RR 1.72, 95 CI 1.48-2.00
  • White ethnicity- RR 1.50, 95 CI 1.32-1.52

3 Lowery D, Wald M, Browne B et al.,for the NEXUS
Group. Epidemiology of cervical spine injury
victims, Ann Emer Med. 20013812-16 (I)
8
Truth grows and evolves over time. Harvey
and His Discovery, In An Alabama
Student, 296.
9
Previous Recommendations
  • Who should we image?
  • ATLS 1997
  • Indications
  • Every patient with multiple trauma
  • All patients with trauma above the clavicle

4 American College of Surgeons. Advanced Trauma
Life Support for Doctors Provider Manual. 6th
ed. Chicago, IL American College of Surgeons
1997
10
Previous Recommendations
  • Frohna 1999 an evidence based review
  • Neuroimaging-
  • Neurologic deficits c/w cord lesion
  • Altered mental status from head injury or
    intoxication
  • Patients complaining of neck pain or tenderness
  • Low threshold for imaging in trauma pts with
    painful, distracting injuries

5 Frohna WJ. Emergency department evaluation and
treatment of the neck and cervical spine
injuries. Em Med Clin North Am,
199917(4)739-91(Review)
11
Most Recent Recommendations
  • Clinical Decision Rules
  • NEXUS (N Engl J Med, 2000)6
  • Canadian C-Spine Rule (JAMA, 2001)7

6 Hoffman JR, Mower WR, Wolfson AB, et al., for
the NEXUS Group. Validity of a set of clinical
criteria to rule out injury to the cervical spine
in patients with blunt trauma. N Engl J Med
200034394-99. 7 Stiell IG, Wells GA, Vandemheen
KL, et al. The Canadian C-spine rule for
Radiography in alert and stable trauma patients.
JAMA 20012861841-1848.
12
NEXUS
  • Prospective observational study at 21 centers
    across the US (n 34,069)
  • Validation of a clinical criteria for indications
    for c-spine imaging
  • A decision instrument
  • The instrument identified all but 8/818
    patients with cervical spine injury

13
NEXUS
  • So what does 8/818 patients mean?
  • Sensitivity 99 (95 CI, 98-99.6)
  • NPV 99.8 (95 CI, 99.6-100)
  • Specificity 12.9

14
NEXUS
  • Were any of the 8 missed injuries clinically
    significant?
  • 2 patients met preset definitions of clinically
    significant injuries (n576)
  • An asymptomatic 54 yo s/p motorcycle accident
  • Fracture of anteroinferior C2 w/no soft tissue
    swelling
  • ? Extensor tear drop fracture
  • 57 yo s/p head on MVC w/ transient LOC pain in R
    shoulder w/ tenderness at paraspinous muscles, R
    clavicle and scapula
  • Fracture of R lamina of C6 developed R arm
    parasthesias and required laminectomy/fusion

15
NEXUS Decision Instrument- 5 criteria
  • Absence of posterior midline cervical tenderness
  • Absence of focal neurologic deficit
  • A normal level of alertness
  • No evidence of intoxication
  • Absence of clinically apparent distracting injury

16
NEXUS Conclusions
  • Application of the decision instrument would have
    decreased overall imaging by 12.6
  • A simple decision rule can reliably predict
    patients who need neuroimaging following blunt
    trauma with very high sensitivity
  • There may still be compelling reasons to order
    c-spine images outside of the criteria in
    individual cases

17
Anterior Occipitoaltlantal Subluxation
18
Canadian C-Spine Rule7
  • Prospective cohort study at 10 community and
    university hospitals
  • Convenience sample of 8924 adults
  • Objective- To derive a clinical decision rule to
    detect C-spine injury and allow more selective
    use of radiography in alert and stable blunt
    trauma patients

19
Canadian C-Spine Rule
  • 151/8924 (1.7) patients identified with
    clinically significant injury
  • Decision rule results
  • Sensitivity- 100 (95 CI, 98-100)
  • Specificity- 42 (95 CI, 40-44)
  • Ordering rate utilizing criteria- 58

20
Canadian C-Spine Rule7
  • Decision rule results
  • Clinically insignificant injury
  • 28/8924 patients (0.3)
  • 1/28 missed
  • 63 yo with unidentified C3 osteophyte avulsion fx

21
Canadian C-Spine Rule
  • Decision Rule- 3 questions
  • Is there a high risk factor present mandating
    radiography ?
  • Defined as
  • age gt 65y,
  • dangerous mechanism, or
  • parasthesias in extremities

22
Canadian C-Spine Rule
  • Decision Rule-
  • Is there low-risk factor present that allows for
    safe assessment of ROM?
  • Defined as
  • simple rear-end MVC,
  • sitting position in ED,
  • ambulatory at any time since injury,
  • delayed onset of neck pain, or
  • absence of midline C-spine tenderness

23
Canadian C-Spine Rule
  • Decision Rule-
  • Is the patient able to actively rotate neck 45o
    to R and L

24
Canadian C-Spine Rule
  • Dangerous Mechanisms
  • Fall gt 1 meter/ 5 stairs
  • Axial load
  • MVC high speed (gt100 km/hr), rollover, ejection
  • Motorized recreational vehicles
  • Bicycle collision

25
Canadian C-Spine Rule
  • Conclusions
  • Potential sensitive rule for identifying patients
    requiring c-spine radiography following blunt
    trauma
  • Potential c-spine radiography rate of 58.2
  • Relative reduction of 15.5 from 68.9

26
Recommendations
  • Both the Canadian and Nexus clinical decision
    rules provide sensitive and reliable indicators
    for identification of patients at risk for
    cervical injury following blunt trauma
  • Use of clinical decision rules may reduce the
    number of imaging test performed

27
Summary
  • Which study to use?
  • Does it really matter?
  • Dont get caught up in the hype!
  • Might be as simple as finding the one you can
    best remember and follow it!

28
Evolving Literature
  • Prospective study of 1,757 patients to develop
    decision rule (1,449 received plain films)
  • With decision rule implementation 537 (30.6)
    studies were felt to be redundant
  • Failure of C-spine to document injury
  • 129 patients underwent CT with 33 positive
    findings
  • 9/38 (23.7) fractures were not identified with
    plain films

8 Edwards M, Frankema S, Kruit M, et al. Routine
cervical spine radiography for trauma victims
Does everybody need it. J Trauma 2001 50529-534.
29
Evolving Literature Griffen et al. 2003
  • Cervical Spine Radiographs (CSR) vs CT
  • Retrospective query of prospectively collected
    trauma database
  • CSR and CT performed on all patients with
    posterior midline neck tenderness, altered mental
    status, or neurologic deficit (3,018 patients)
  • 116 patients (9.5) identified with cervical
    spine injury (fracture or subluxation)

9 Griffen M, Frykberg E, Kerwin A, et al.
Radiographic clearance of blunt cervical spine
injury plain radiograph or computed tomography
scan? J Trauma. 2003 55(2)222-6.
30
Griffen et al. 2003
  • C-spine injury was identified on both CSR and CT
    in 75/116 (65) patients
  • Injury missed 41/116 (35) patients with CSR
  • All these injuries required some form of
    treatment
  • No identifiable factors predicted false negative
    CSR

9 Griffen M, Frykberg E, Kerwin A, et al.
Radiographic clearance of blunt cervical spine
injury plain radiograph or computed tomography
scan? J Trauma. 2003 55(2)222-6.
31
? Nexus/Canadian Rules
  • Does the new literature cloud the results of the
    previous decision rules?

32
General acceptance of truth takes time. On
The Study of Tuberculosis, Phila Med J
190061029-30
33
Questions?
34
Gracias
35
References
  • 1 Goldberg W, Mueller C, Panacek E, Tigges S et
    al. for the NEXUS Group. Distribution and
    patterns of blunt traumatic cervical spine
    injury. Ann Emerg Med. 20013817-21.(I)
  • 2 Hendley G, Wolfson A, William R et al. for the
    NEXUS Group. Spinal cord injury without
    radiographic abnormality Results of the national
    emergency x-radiography utilization study in
    blunt cervical trauma. J Trauma. 2002531-4.(I)
  • 3 Lowery D, Wald M, Browne B et al.,for the NEXUS
    Group. Epidemiology of cervical spine injury
    victims, Ann Emer Med. 20013812-16 (I)
  • 4 American College of Surgeons. Advanced Trauma
    Life Support for Doctors Provider Manual. 6th
    ed. Chicago, IL American College of Surgeons
    1997 (III)
  • 5 Frohna WJ. Emergency department evaluation and
    treatment of the neck and cervical spine
    injuries. Em Med Clin North Am,
    199917(4)739-91(Review)
  • 6 Hoffman JR, Mower WR, Wolfson AB, et al., for
    the NEXUS Group. Validity of a set of clinical
    criteria to rule out injury to the cervical spine
    in patients with blunt trauma. N Engl J Med
    200034394-99.
  • 7 Stiell IG, Wells GA, Vandemheen KL, et al. The
    Canadian C-spine rule for Radiography in alert
    and stable trauma patients. JAMA
    20012861841-1848.

36
References
  • 8 Edwards M, Frankema S, Kruit M, et al. Routine
    cervical spine radiography for trauma victims
    Does everybody need it. J Trauma 2001
    50529-534.
  • 9 Griffen M, Frykberg E, Kerwin A, et al.
    Radiographic clearance of blunt cervical spine
    injury plain radiograph or computed tomography
    scan? J Trauma. 2003 55(2)222-6.
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