Spine Evaluation

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Spine Evaluation
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Anatomy of cervical spine
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Cervical Alignment

• Anterior vertebral body
• Posterior vertebral body
• Spinolaminal line
• Spinous process tips

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Transverse ligament disruption C1-C2
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Teardrop Fracture
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Compression/Burst fracture
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Hangmans Fracture
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Spinous process fracture
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Cervical Spine Injuries-The Problem

• Between 2-4 of Blunt Trauma Patients sustain
  cervical spine injury
• Improvements in EMS systems and ATLS have
  resulted in increased awareness and practice of
  cervical immobilization

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Why not board/collar and Xray everybody?

• Immobilization is uncomfortable increased time
  immobilized increased pain, risk of aspiration,
  vulnerable position, etc...
• gt800,000 U.S. Patients receive cervical
  radiography each year
• Patient exposure to radiation
• gt97 of xrays are negative
• Cost exceeds 175,000,000 each year

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Cervical Spine EvaluationEMS VS ED Perspectives

• EMS Who is at risk for cervical injury
  such that injury might be exacerbated with EMS
  movement/transport?
• ED Who is at risk for cervical injury such
  that radiographic studies need to be done to
  elucidate question of injury?

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Purpose of Maine EMS Spine Protocol

• Identify and immobilize 100 of patients at risk
  for unstable injuries
• Identify and NOT immobilize patients who have NO
  risk for cervical spine injury

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Maine Protocol Complaints

• Docs Not used correctly mechanism,
  distracting injury, intoxicated pts
• EMS Not QI consistent in regions Gap
  between training and implementation
• Data Not research compatible

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National Emergency X-Radiography Utilization
StudyNEXUS

• Hypothesis
• Blunt trauma vicitms have virtually no risk of
  cervical spine injury if they meet all of the
  following criteria
• No neuro deficit,
• Normal Level of alertness
• No evidence of ETOH/Tox
• No posterior midline tenderness
• No other distracting painful injury

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NEXUS

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

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What is a significant distracting injury?

• Ill-defined in the literature
• Distracting Painful Injuries associated with
  Cervical Spinal Injuries in Blunt Trauma
  suggests
• 1)Any long bone fracture
• 2) Visceral injury necessitating surgical consult
• Ullrich, et al. AEM 2001825-29.

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What is a significant distracting injury? 2

• 3) Large laceration, degloving or crush
• 4) Large burns
• 5) any injury producing acute functional
  impairment

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Distracting Painful InjuriesConclusions

• Very subjective evaluation
• Most cervical spine clearance studies leave it to
  clinical judgement
• Several studies show good interobserver agreement
  among clinicians regarding DPI
• Use DPI liberally to improve sensitivity

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NEXUS Definition Intoxication

• Patients should be considered intoxicated if they
  have
• 1) History of recent intoxication or ingestion
• 2) Evidence of intoxication on exam

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NEXUS DefinitionAltered neurologic function

• 1) GCS 14 or less
• 2) disoriented to person,place,time,events
• 3) inability to remember 3 objects at 5 min.
• 4) Any focal deficit
• 5) delayed/inappropriate response to external
  stimuli

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Kinematics of Blunt Spinal Injury

• Hyperextension
• Hyperflexion
• Compression
• Rotation
• Lateral Stress
• Distraction

• Axial Loading(diving)
• Blunt Trauma
• Motor Vehicle Collision
• Bicycle Fall
• Children Fall gt 3 feet
• Adult Fall from standing height

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NEXUS -Results

• 818 patients with fracture identified
• All except 8 were identified by clinical decision
  rule
• Sensitivity 99 (95 CI 98-99.6)

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8 Patients Not Identified By NEXUS Rules
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NEXUS- ER Doc Results

• Application of NEXUS criteria would reduce
  imaging by 12.6 in emergency departments.
• Average emergency physician could expect to see a
  missed fracture every 125 years of practice.

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Maine EMS 2002
Question of spine injury?
Yes No
Yes
No
Unreliable? Immobilize
Dont (Intox/Alt LOC) Immobilize
Yes
Distracting Inj?
No
Neuro Exam Abnormal?
No
Spine Pain/Tenderness?
No
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
DONT IMMOBILIZE
Unreliable? (Intox/Alt LOC/ Acute Stress Reaction
YES
NO
YES
IMMOBILIZE
Spine Pain/ Tenderness
YES
YES
NO
NO
NO
Abnormal Sensory/Motor Exam?
DISTRACTING INJURY?
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
MVC (Motor Vehicle Collision) applies to crashes
of all motorized vehicles e.g automobiles,
motorcycles, snowmobiles, ATVs, etc..
YES
NO
YES
IMMOBILIZE
YES
YES
NO
NO
NO
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
Unreliable? (Intox/Alt LOC/ Acute Stress Reaction
YES
NO
YES
IMMOBILIZE
YES
YES
NO
NO
Clearance of the spine requires the patient to
be Calm, Cooperative, Sober, and Alert.
NO
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
Unreliable? (Intox/Alt LOC/ Acute Stress Reaction
YES
NO
YES
IMMOBILIZE
YES
YES
Distracting injury includes any injury that
produces clinically apparent pain that might
distract the patient from the pain of a spine
injury - pain would include medical as well as
traumatic etiologies of pain
NO
NO
NO
DISTRACTING INJURY?
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
Unreliable? (Intox/Alt LOC/ Acute Stress Reaction
YES
NO
YES
IMMOBILIZE
YES
YES
NO
NO
NO
Abnormal Sensory/Motor Exam?
DISTRACTING INJURY?
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
Unreliable? (Intox/Alt LOC/ Acute Stress Reaction
YES
NO
YES
IMMOBILIZE
Spine Pain/ Tenderness
YES
YES
NO
NO
NO
Abnormal Sensory/Motor Exam?
DISTRACTING INJURY?
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Mechanism of Injury Axial load (diving), Blunt
Trauma, MVC or bicycle, fallgt3 ft., adult fall
from standing height
DONT IMMOBILIZE
Unreliable? (Intox/Alt LOC/ Acute Stress Reaction
YES
NO
YES
IMMOBILIZE
Spine Pain/ Tenderness
YES
YES
NO
NO
NO
Abnormal Sensory/Motor Exam?
DISTRACTING INJURY?
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Maine EMS 2002 QA

• Run Reports Check the spine box on all
  encounters where spine protocol and assessment is
  utilized - REGARDLESS OF DECISION TO IMMOBILIZE
  OR NOT.

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Maine EMS 2002 QA
Spine Assessment During Patient Encounter
Run Report - Check Box QA Form - Fax to Regional
Office
Regional Office Review State EMS Office Review
Run Report and QA Form Correlation with Spine
Injured Patients in Maine Trauma Database and
Radiography Records at Institutions