Cervical spine injury in low-impact blunt trauma

Evaluating the cervical spine in confused or unconscious adults after blunt trauma

Potential injury to the cervical spine should be considered in all patients who have suffered blunt trauma. Early spinal immobilization is required to minimize the risk of secondary spinal cord injury. However, prolonged immobilization is associated with its own morbidity. Clinical evaluation of the cervical spine in confused or unconscious adult trauma patients is challenging, and imaging is required to safely 'clear' the cervical spine. Despite the existence of national guidelines, significant variations in practice exist. This article summarizes the evidence for the initial stabilization of the cervical spine in adult trauma patients. It reviews the imaging modalities available and the criteria for discontinuation of cervical spine immobilization.

Distracting injury defined: does an isolated hip fracture constitute a distracting injury for clearance of the cervical spine?

OBJECTIVES

As the population within the USA ages, the number of hip fractures seen yearly in the emergency department is expected to rise. According to the NEXUS criteria, many of these patients receive computerized tomographic scan (CT) evaluation of the cervical spine because a hip fracture may constitute a distracting injury. The objective of this study is to determine if an isolated hip fracture constitutes a distracting injury which requires imaging of the cervical spine.

METHODS

Data were prospectively collected on 158 trauma patients with isolated hip fractures between April 1, 2015 and March 9, 2016. Patient demographics were analyzed and compared to the National Emergency X-Radiography Utilization Study (NEXUS).

RESULTS

Patients with isolated hip fractures were predominantly elderly, on average 78.6 +/- 15.9 years old, and 94.3% of these injuries occurred after a fall from standing. Only one patient also had a cervical spine fracture which was not clinically significant. When compared to the established rate of cervical spine injury of 2.4%, the absolute risk reduction (ARR) was 0.35% (95% CI, - 1.06 to 1.75%) and the number needed to treat (NNT) was 290.

CONCLUSION

In the case of an elderly patient with an isolated hip fracture and no cervical midline tenderness, cervical spine imaging may be reserved for those who have other NEXUS criteria for further workup.

Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients

AIM

Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals.

PATIENTS AND METHODS

All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%).

RESULTS

Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries.

TAKE HOME MESSAGE

There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.

The role of magnetic resonance imaging in acute cervical spine fractures

BACKGROUND CONTEXT

The role of magnetic resonance imaging (MRI) in neurologically intact cervical spine fractures is not well defined. To our knowledge, there are no studies that clearly identify the indications for MRI in this particular scenario. Controversy remains regarding the use of MRI in at-risk patients, primarily the obtunded and elderly patients.

PURPOSE

The purpose of the present study was to examine the predisposing conditions where an MRI would provide additional findings that would affect management in acute cervical spine fractures.

STUDY DESIGN

Retrospective cohort involving radiographic and clinical review.

PATIENT SAMPLE

Consecutive patients with acute cervical injuries at a single institution.

OUTCOME MEASURES

Neurologic recovery.

METHODS

A review of 830 patients with cervical spinal injuries between 2006 and 2010 was performed. Clinical information was obtained for all the patients: Glasgow Coma Scale, mechanism of injury, major medical comorbidities, associated injuries, neurologic examination, neurologic symptoms, sex, age, and alertness. Two experienced fellowship-trained spine surgeons determined if the MRI study changed the management in the individual cases based on the Sub-axial Cervical Spine Injury classification system.

RESULTS

Ninety-nine patients with a cervical fracture were included in the final analysis: median age 54 years (interquartile range, 42 years), mean Glasgow Coma Scale 13 (standard deviation ± 3.0), 68% males, 32% females, 42% older patients (age>60 years), 30% spondylosis, 27% polytrauma, 67% alert, 28% neurologic deficit. Major medical comorbidities, prior to injury level of activity, atlantoaxial versus subaxial, and gender were not associated with changes in diagnosis and management (p>.05). Age >60 years, neurologic deficit, polytrauma status, alertness, and spondylosis were associated with having additional clinically relevant findings seen on MRI and changes in management (p<.05). The majority of the changes in management were related to MRI's illustration of the spinal cord injury and not due to an occult instability. Eighty-one percent of the changes in management were related to the depiction of the spinal cord compression seen on MRI, whereas 19% of the changes in management were related to occult instability seen on MRI.

CONCLUSIONS

Older age (>60 years), obtunded or temporary non-assessable status, cervical spondylosis, polytrauma, and neurologic deficit are predisposing factors for further injury found on MRI but missed on computed tomographic scan alone. These additional findings can affect the management in acute cervical spine fractures. The rational of the on-call spine surgeon to order an MRI for a cervical spine fracture is well founded and often that MRI will affect the fracture management. Magnetic resonance imaging particularly helps with better defining the type of spinal cord compression. Picking up occult instability missed on computed tomographic scan was possible with MRI but not as common.

Clearing the cervical spine in the blunt trauma patient

The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. The temporarily nonassessable patient may have short-term mental status changes (eg, intoxication, painful distracting injuries) and can be evaluated by two methods. When there is urgency, the evaluation is similar to that for the obtunded patient. Alternatively, the patient can be reevaluated within 24 to 48 hours, after return of mentation or following treatment of painful injuries. The patient then can be assessed as the asymptomatic patient is. The symptomatic patient requires advanced imaging. The obtunded patient should undergo, at minimum, a multidetector CT scan. Two methods are advocated. One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.

Traumatic cervical spinal cord injury with "negative" cervical spine CT scan

A 46-year-old man fell four steps, striking his neck and having associated neck pain and discomfort. He was evaluated at a local emergency department and reported no neurological deficit but focal mid cervical tenderness. Radiographs and computed tomography (CT) scan were "negative" for cervical spine fracture, dislocation or pre-vertebral soft tissue swelling. He was discharged home in a cervical collar with a scheduled outpatient follow-up. Over the proceeding hours neurologic deterioration occurred, including hand and lower limb weakness with the inability to urinate. The patient returned to the local emergency room and was transferred to a tertiary care hospital where examination revealed C5ASIAB deficits. Repeat high resolution CT scan of the cervical spine with reformatted images was unremarkable for osseous fractures except some loss of definition in the posterior cervical musculature. Emergency magnetic resonance imaging MRI revealed a subluxation of C5/6 right facet (not evident on CT) with disruption of the posterior longitudinal ligament, ligamentum flavum, and disc space with abnormal T2 weighted spinal cord hyperintense signal at C5/6. He underwent emergency C5-C6 anterior and posterior decompression and fusion. One week later an examination showed improved C5ASIAD. This case reveals the difficulty of assessing the cervical spine for instability and potential limitations of current management schemes.

A systematic review of the prognosis of acute whiplash and a new conceptual framework to synthesize the literature

STUDY DESIGN

Systematic review of prognostic studies of acute whiplash.

OBJECTIVES

To update the systematic review on the prognosis of acute whiplash published by the Quebec Task Force on Whiplash-Associated Disorders and to propose a new conceptual framework to conduct systematic reviews on prognosis.

SUMMARY OF BACKGROUND DATA

In 1995, the Quebec Task Force published a systematic review of the literature on whiplash and concluded that its prognosis is favorable. However, few prognostic factors were identified. Recent studies have added to this knowledge, and there is a need to update the review conducted by the Quebec Task Force.

METHODS

A bibliographic search of four electronic databases was performed to identify prognostic studies of acute whiplash published after 1995. The literature was appraised with standard review criteria. The consistency of evidence across studies was assessed. A conceptual framework was designed to classify the literature according to methodologic quality, target population, and phases of investigation.

RESULTS

Thirteen cohort studies were included in the review. The framework used in this study demonstrates that most of the recent prognostic studies are descriptive in nature. The prognosis of acute whiplash varies according to the population sampled and the insurance/compensation system under which individuals are allowed to claim benefits. Besides age, gender, baseline neck pain intensity, baseline headache intensity, and baseline radicular signs and symptoms, there is little consistency in the literature about the prognostic factors for the recovery of whiplash.

CONCLUSIONS

Scant knowledge about the prognosis of whiplash has been gained since the release of the Quebec Task Force report. However, it is becoming obvious that the insurance and compensation systems have a large impact on recovery from acute whiplash injuries. The conceptual framework used in this study demonstrates that large cohort studies investigating a wide range of prognostic factors are necessary to improve the understanding of this problem.

Clearing the Cervical Spine in Victims of Blunt Assault to the Head and Neck: What is Necessary?

A number of guidelines have been proposed to aid in determining the need for radiologic evaluation of the cervical spine (c-spine) in victims of blunt trauma. Mechanism of injury has not been shown to be an independent predictor of injury or the lack thereof. The current study was undertaken to determine the incidence of clinically relevant c-spine injuries in patients who sustained a blunt assault to the head and neck. The trauma registry of an urban Level 1 trauma center was used to identify patients who suffered a blunt assult to the head and neck and were admitted to the hospital over a 30-month period. One hundred two patients were identified. Only 8 patients met criteria for clinical clearance of the c-spine. Eighty patients were unable to be evaluated because of head injury or intoxicants; 14 patients had neck pain on initial examination. These 94 patients underwent plain film examination of their c-spine. Twelve required CT scanning to supplement visualization. The possibility of ligamentous injury was investigated by MRI or flexion/extension radiographs in 26 patients. No clinically significant c-spine injuries were identified. Although many victims of a blunt assault to the head and neck region may have a decreased LOC or neck pain, the likelihood of a ligamentous injury is so low that plain-film X-ray evaluation of the c-spine is all that is necessary to rule out injury in this patient population.