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Clinical Practice Guideline for Cervical Spine Injury

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Title: Clinical Practice Guideline for Cervical Spine Injury


1
Clinical Practice Guideline for Cervical Spine
Injury
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2
CPG for C-spine injury
  • Evidence-based informations
  • Practicality for Thai CPG
  • Participation-brain storm from audience

3
Evidence class
  • Class I Evidence from one or more well-designed,
    randomized controlled clinical trials
  • Class II Evidence from one or more well-designed
    non-randomized study
  • Class III Evidence from case series, case
    reports, expert opinion

4
Topics of Discussion
  • Pre-hospital care
  • Recognition
  • Proper transportation, immobilization
  • In-hospital care
  • Recognition, clinical assessment
  • Evidence-based clinical informations
  • Proper treatments, guidelines, specific conditions

5
Pre-hospital care
  • Immobilization before hospital
  • Transportation
  • Clinical assessment

6
C-spine immobilization
  • Evidence class III
  • All patients with spinal injury should be
    immobilized at the scene and during transport
  • Rigid collar and supportive blocks on a backboard
    with straps is effective in limiting motions of
    the C-spine and is recommended

7
Transportation
  • Evidence class III
  • Expeditious and careful transport of the victim
    by the most appropriate mode of transportation
    available to the nearest capable definitive care
    facility is recommended

8
Clinical assessment
  • General physical examinations
  • Vital signs
  • Other injuries
  • Neurological examinations
  • ASIA score
  • Functional outcome assessment
  • Modified Barthel index

9
In-hospital care
  • Clinical assessment and resuscitation
  • Investigations
  • Initial closed reduction of C-spine
  • Management of ASCI
  • Management of specific conditions

10
Radiographic investigations
  • Asymptomatic patients
  • Class I evidence
  • Not recommended in victim who is awake, alert and
    not intoxicated who is without neck pain or
    tenderness without significant other injuries
    which detract neurological assessment

11
Radiographic investigations
  • Symptomatic patients
  • Class I and II evidence
  • Three-view C-spine x-rays recommended
  • Supplement CT scan for areas not well-visualized
  • Normal Flex/extension films or normal MRI within
    48 hours discontinues immobilization

12
Initial closed reduction
  • Class III evidence
  • Early closed reduction with traction is
    recommended to restore anatomic alignment in an
    awake patient
  • Not recommended in patients with additional
    rostral injury
  • Pre-reduction MRI is not necessary except in
    patients who cannot be examined
  • MRI is recommended after failure of initial
    closed reduction

13
Management of ASCI
  • Class III evidence
  • Monitoring in ICU (or similar) for severe SCI
    patients is recommended
  • Cardiac, hemodynamic and respiratory monitoring
    devices

14
Blood pressure management in ASCI
  • Class III evidence
  • SBP lt 90 mmHg should be avoided
  • Maintenance of MAP at 85-90 mmHg for the first 7
    days after injury to improve spinal cord
    perfusion is recommended

15
Pharmacological Therapy after ASCI
  • Class III evidence
  • Methylprednisolone treatment is recommended as an
    option
  • GM-1 ganglioside is recommended as an option

16
Deep venous thrombosis and thromboembolism
  • Class I and II evidence
  • Prophylactic use of low-molecular-weight
    heparins, rotating beds, adjust dose heparin,
    pneumatic compression stockings or combination is
    recommended

17
(No Transcript)
18
After diagnosis is established
Methylprednisolone(optional if given within 8 hrs
post-injury) Care for hemodynamics and
respiratory MAP gt 85-90 mm Hg (optional ) DVT
prophylaxis
19
Guideline for specific conditions
  • Pediatric spine injury
  • Spinal cord injury without radiographic
    abnormality ( SCIWORA )
  • Atlanto-occipital dislocation
  • Occipital condyle fractures
  • Isolated Atlas fracture
  • Isolated Axis fracture
  • Combination of C1-C2 fracture
  • OS odontoideum
  • Subaxial C-spine injury
  • Vertebral artery injury

20
Management of Pediatric C-spine injury
  • Same as adult if alert, conversant, no deficit or
    tenderness and no painful distracting injury and
    not intoxicated
  • AP and lateral ( or open-mouth view if older than
    9 year-old ) C-spine x-rays in those who are not
    as above

21
Pediatric spine injury
  • Class II-III evidence
  • Thoracic elevation or occipital recess to allow
    more neutral position of the spine when strapped
    to a flat backboard is recommended if younger
    than 8 year-old
  • Immobilization by halo is recommended in C2
    synchondrosis injury if younger than 7 year-old
  • Surgery if isolated ligamentous injury with
    deformity

22
SCIWORA
  • Class III evidence
  • X-rays, CT and MRI to the suspected level of
    injury is recommended
  • Angiography or myelography not recommended
  • Immobilization ( up to 12 weeks ) until stability
    is confirmed by flex-extension films is
    recommended
  • Avoidance of high-risk activities for up to 6
    months may be considered
  • MRI may provide useful prognostic information

23
Atlanto-occipital dislocation injury
  • Class III evidence
  • BAI-BDI is useful tool for diagnosis on lateral
    C-spine film
  • Presence of prevertebral soft tissue swelling
    should prompt additional imaging
  • CT or MRI is recommended if clinical suspicion is
    high in light of normal x-ray
  • Treatment with internal fixation and arthrodesis
    is recommended
  • Traction may be used although 10 of
    neurological risk is associated

24
Occipital condyle injury
  • Class III evidence
  • Clinical suspicion in altered consciousness,
    occipital pain or tenderness, impaired cervical
    motion, lower cranial nerves paresis,
    retropharyngeal soft tissue swelling in blunt
    trauma patients with high-velocity injury
  • CT is recommended, MRI is recommended to assess
    ligamentous integrity
  • Immobilization is recommended treatment

25
Isolated fracture of Atlas
  • Class III evidence
  • Fracture with intact transverse ligament is
    treated with immobilization
  • Fracture with disruption of the ligament should
    be treated with immobilization with or with
    surgical fixation and fusion

26
Isolated fractures of Axis
  • Class III evidence
  • Type II odontoid fracture in gt 50 year-old should
    be considered for surgical fixation-fusion
  • Type I, II and III fractures may be initially
    treated with immobilization
  • Type II and III should be considered for surgery
    if dens displacement gt 5mm, comminution of the
    dens(type IIA) or inability to achieve or
    maintain alignment

27
Isolated fractures of Axis
  • Class III evidence
  • Hangmans fracture may be initially treated with
    immobilization
  • Surgical fixation should be considered in severe
    angulation ( Francis II-IV, Effendi II),
    disruption of the disc ( Francis V, Effendi III)
    or inability to maintain alignment
  • Immobilization is recommended for other types of
    Axis body fracture

28
Combination Fx of C1 and C2
  • Class III evidence
  • Treatment should be based primarily on the
    characteristic of C2 Fx
  • Immobilization for most of the Fx
  • Surgery in Type II odontoid with ADI gt 5mm,
    hangmans with C2,3 angulation gt 11 degrees is
    recommended
  • In some cases, surgical technique must be
    modified for loss of C1 ring integrity

29
Os odontoideum
  • 3-view x-rays with flex-extension is recommended
    for diagnosis with optional CT or MRI
  • Asymptomatic patient can be observed
  • Symptomatic patient can be managed with posterior
    fixation-fusion
  • Halo immobilization is recommended unless
    transarticular screws are used
  • Decompression may be necessary via
    anterior(transoral) or posterior (C1 laminectomy)

30
Subaxial injury
  • With facet dislocation
  • Closed or open reduction is recommended
  • Immobilization, fixation-fusion (anterior or
    posterior)
  • Prolong bedrest if above not available
  • Without facet dislocation
  • Same as above except third option

31
Acute central cord syndrome
  • ICU or monitored setting is recommended
  • Medical management, cardiopulmonary and
    hemodynamic care, MAP gt 85mmHg to improve
    perfusion
  • Early reduction of fracture-dislocation
  • Surgical decompression especially if focal and
    anterior

32
Vertebral artery injury
  • Angiography or MRA for diagnosis is recommended
  • Anticoagulant is recommended for evidence of
    posterior circulation stroke
  • Observation or anticoagulant for evidence of
    ischemia
  • Observation for no evidence of ischemia
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