Exclusion of cervical spine injury: a prospective study

Cervical spine trauma

Cervical spine injuries are a persistant problem in trauma, from detection to initial management and then definitive treatment. This is compounded by the unique anatomy of the upper cervical spine which thus responds in a different way to trauma. This article examines the anatomy, initial management, including how to clear the spine, and then discusses each level of the spine with regards to mechanism of injury, classification and treatment.

Prehospital Clinical Clearance of the Cervical Spine: A Prospective Study

Physician clinical clearance of the cervical spine after blunt trauma is practiced in many trauma centers. Prehospital clinical clearance of the cervical spine (c-spine) performed by emergency medical services (EMS) personnel can decrease cost, improve patient comfort, decrease complications, and decrease prehospital time. The purpose of this study was to assess whether EMS personnel can effectively clinically clear the c-spine of injury in the prehospital setting. All paramedics from a single urban fire department were trained in clinical clearance of the c-spine. During the 14-month period from January 2008 through March 2009, clinical examination of the c-spine was performed by paramedics on blunt trauma patients in the prehospital setting. Paramedics immobilized the c-spine and delivered the patients to the University of South Alabama Medical Center. After trauma center arrival, paramedics documented their clinical examination of the c-spine in a computerized data collection form. Paramedic clinical findings were compared with trauma surgeon clinical examination findings and computed tomographic findings of the c-spine. All patients had prehospital Glasgow Coma Score 14 or greater. Patients were not excluded for distracting injuries. One hundred ninety-three blunt trauma patients were entered. Sixty-five (34%) c-spines were clinically cleared by EMS. There were no known missed injuries in this patient group. Eight (6%) patients who were not clinically cleared by EMS were diagnosed with c-spine injury. Trauma surgeons clinically cleared 135 (70%) of the patients with no known missed injury. EMS personnel in the prehospital setting may reliably and effectively perform clinical clearance of the c-spine. Further prospective study for prehospital c-spine clinical clearance is warranted.

[Emergency trauma room management in severely and most severely injured patients. A multidisciplinary task]

The treatment of most severely injured patients represents a great challenge for the trauma room team. Besides the time factor, which is a crucial cornerstone of the treatment in general and of the appropriate treatment of life-threatening injuries in particular, minor injuries and non-life-threatening injuries must also be taken into account. For this task, multidisciplinary processes play a paramount role. Advanced Trauma Life Support®, Definitive Surgical Trauma Care and the European Trauma Course represent training concepts, which predefine structured diagnostic and treatment procedures. These concepts allocate the highest treatment priority to injuries that may be immediately fatal for the patient. Besides those life-threatening injuries that are commonly summarised under the term "deathly six", other minor traumas should also be assessed and treated in a structured manner as they may often considerably affect the quality of life after trauma.

Does the National Emergency X-ray Utilization Study make a difference?

OBJECTIVE

To assess whether the introduction of the National Emergency X-ray Utilization Study guidelines in a UK emergency department reduced the number of patients having cervical spine radiographs and altered the accuracy of diagnosis of cervical spine injury.

METHODS

This was a prospective, observational study. The number of patients with recent neck injury who had cervical spine radiographs taken was assessed for 3 months before and three months after the introduction of the National Emergency X-ray Utilization Study guidelines to an urban emergency department in the UK. The number of injuries missed by emergency department doctors during the two 3-month periods was also recorded.

RESULTS

Prior to using the guidelines, 252 of 715 patients (35%) were X-rayed and when using the guidelines, 268 of 706 patients (38%) were X-rayed. No significant difference was observed between the rates of X-ray in the two groups (P=0.288). No injuries were missed by emergency department doctors either before or after the introduction of the guidelines.

CONCLUSION

Introduction of the National Emergency X-ray Utilization Study guidelines to a UK emergency department did not reduce the number of patients having cervical spine radiographs after neck trauma and had no effect on the pick-up rate for cervical spine injuries.

Cervical spine clearance: a review

Ethical concerns have hindered any randomised control blinded studies on the imaging required to assess the cervical spine in an unconscious trauma patient. The issue has been contentious for many years and has resulted in burgeoning but inconclusive guidance. MRI and multislice CT technology have made rapid advances, but the literature is slower to catch up. Never the less there appears to be an emerging consensus for the multiply injured patient. The rapid primary clinical survey should be followed by lateral cervical spine, chest and pelvic radiographs. If a patient is unconscious then CT of the brain and at least down to C3 (and in the USA down to D1) has now become routine. The cranio-cervical scans should be a maximum of 2 mm thickness, and probably less, as undisplaced type II peg fractures, can be invisible even on 1 mm slices with reconstructions. If the lateral cervical radiograph and the CT scan are negative, then MRI is the investigation of choice to exclude instability. Patients with focal neurological signs, evidence of cord or disc injury, and patients whose surgery require pre-operative cord assessment should be imaged by MRI. It is also the investigation of choice for evaluating the complications and late sequela of trauma. If the patient is to have an MRI scan, the MR unit must be able to at least do a sagittal STIR sequence of the entire vertebral column to exclude non-contiguous injuries, which, since the advent of MRI, are now known to be relatively common. Any areas of oedema or collapse then require detailed CT evaluation. It is important that cases are handled by a suitably skilled multidisciplinary team, and avoid repeat imaging due to technical inadequacies. The aim of this review is to re-examine the role of cervical spine imaging in the context of new guidelines and technical advances in imaging techniques.

Schockraummanagement bei Verletzungen der Wirbels�ule im Rahmen eines Polytraumas

Injuries to the spine are often part of life-threatening multiple trauma. In this review diagnostics and emergency room management were investigated in order to formulate effective recommendations for the emergency strategy. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The patient's history and clinical symptoms have low rates for specificity and positive predictive value, whereas their negative predictive value and sensitivity are high between 90 and 100%, respectively. CT imaging reaches higher rates for sensitivity, specificity, and positive and negative predictive values in comparison to conventional radiographic series. The patient's history should be asked and clinical investigation should be done in any case. Imaging diagnostics preferably as multislice spiral CT should be performed after stabilization of the patient's general condition and before admission to the intensive care unit.

How often should computed tomographic scans following cross-table lateral cervical films be performed?

PURPOSE

In patients with blunt trauma, a cross-table lateral cervical (CTLC) film is followed by a focused computed tomographic (CT) scan of the cervical spine to assess an area inadequately delineated by common techniques and suspected injuries, based on recent guidelines in the United States. The purpose of this study was to calculate the frequency of such supplemental CT scans and to evaluate the efficacy of the recent guidelines describing the use of CTLC films as an indicator of supplemental focused CT scanning in Japan.

METHODS

A review of CTLC films was performed. 100 initial CTLC films with injuries and another 100 films without injuries were evaluated for the lowest vertebra visualised on the CTLC film. The frequency of abnormal signs on the CTLC films was then examined.

RESULTS

Technically adequate CTLC films that showed the upper border of the T1 vertebra were not obtained from 70 patients with injuries and 63 patients without injuries. 88 patients with injuries and 28 patients without injuries had abnormal findings on CTLC films. Overall, 97 patients with injuries and 74 patients without injuries should have received supplemental CT scans.

CONCLUSION

CTLC films require frequent supplemental use of CT, even for patients without cervical spine injuries. Thus, the guidelines that consider CTLC film as an indicator of the necessity for CT scanning are not efficient and need revision.

Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

Cervical spine injury occurs in 5-10% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. In addition, many studies are limited in their application to the obtunded or unconscious trauma victim. This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme.

Radiographic assessment of the cervical spine in symptomatic trauma patients

STANDARDS

A three-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended for radiographic evaluation of the cervical spine in patients who are symptomatic after traumatic injury. This should be supplemented with computed tomography (CT) to further define areas that are suspicious or not well visualized on the plain cervical x-rays.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

It is recommended that cervical spine immobilization in awake patients with neck pain or tenderness and normal cervical spine x-rays (including supplemental CT as necessary) be discontinued after either a) normal and adequate dynamic flexion/extension radiographs, or b) a normal magnetic resonance imaging study is obtained within 48 hours of injury. Cervical spine immobilization in obtunded patients with normal cervical spine x-rays (including supplemental CT as necessary) may be discontinued a) after dynamic flexion/extension studies performed under fluoroscopic guidance, or b) after a normal magnetic resonance imaging study is obtained within 48 hours of injury, or c) at the discretion of the treating physician.

Nonoperative management of acute spinal cord injury

Advances in transport, imaging, and stabilization of the injured patient have made the topic of acute management more important than ever in patients with spinal cord injury. Optimal treatment requires prompt delivery of care for life-threatening respiratory and hemodynamic events in a manner that will not further damage the unstable spinal elements. The application of these treatment principles broadly to injured patients is necessitated by our inability to determine, on an acute basis, those patients who might eventually recover meaningful neurologic function from those who will not. Therefore, nonoperative management of acute spinal cord injury requires consideration of two goals: 1) the preservation of the patient's life and 2) optimizing the potential for recovery of neurologic function. The first consideration requires not only an understanding of the novel systemic consequences of spinal cord injury but also of treatments directed at combating them. The second includes the application of resuscitative measures without further damaging the spinal cord and, in some cases, the use of traction and immobilization. In the past these efforts were aimed primarily at increasing the survival rate of patients with spinal cord injury, whereas current care may also play an important role in the eventual recovery of neurologic function. Despite many advances in our understanding of the basic mechanisms of paralysis, clinical management of spinal cord injury remains a significant challenge and one that requires continuing efforts at improving acute and postacute therapies.

Spinal immobilization in the field: clinical clearance criteria and implementation

Awareness of the health and financial repercussions of unnecessary immobilization has made cervical spinal immobilization controversial in out-of-hospital care. Clinical criteria for clearance of the cervical spine in the hospital based on mechanism of injury have been supported by many trauma centers. However, implementation of clinical criteria for cervical spinal clearance in out-of-hospital settings is not as well validated by multicenter studies or accepted by many emergency departments. This consensus group recommends that clinical criteria to determine "low-risk" patients be available for use by emergency medical services providers in out-of-hospital settings; however, training, audits, quality management, integration into the medical community, and extent of program implementation should be decided based on individual emergency medical services systems.

Use of bullard laryngoscope in anesthesia for cervical spine surgery: Our experience in Qatar

There is great concern about the risks inflicted by intubation of patients with a potential instability of the cervical spine, as in trauma cases and in patients scheduled for elective cervical spine surgery. Some of these patients may have neurological manifestations of cord compression and limited neck movement, which can range from severe to mild. Intubation requires flexion and extension of the head and neck “Sniffing Position” to achieve optimum visualization of the vocal cords. In our institute the care given to ensure the stability of the cervical spine during intubation is either by Manual In-Line Axial Stabilization (MIAS) or by the use of Intubating-Laryngeal Mask Airway (LMA) or Bullard Laryngoscope or awke intubationin the operating theatre. All of these techniques put a minimal burden on the cervical spine and reduce the chances of neurological deficits or aggravation of an existing one. In this study we relate our experience with the Bullard Laryngoscope in these cases.

Role of clinical examination in screening for blunt cervical spine injury

BACKGROUND

The purpose of this study was to evaluate the hypothesis that awake and alert blunt trauma patients with Glasgow Coma Scores of 14 or 15 (regardless of blood ethanol level or other injuries sustained) can be effectively evaluated with clinical examination without radiographic evaluation of the cervical spine.

STUDY DESIGN

During a 32-month period at an urban Level 1 Trauma Center, 2,176 consecutive blunt trauma patients who presented with Glasgow Coma Scores of 14 or 15 were prospectively evaluated by trauma resident housestaff. Housestaff performed physical examinations of the neck and questioned the patients for the presence of neck pain. Following study form documentation of the cervical neck examination, a lateral cervical spine x-ray was performed. Further studies such as swimmer's view and CAT scan were performed if the lateral x-ray could not completely evaluate C1 to C7. These further studies were considered part of the lateral cervical spine (c-spine) x-ray screen. Attending radiologists performed final x-ray interpretations.

RESULTS

The study consisted of 2,176 patients, 33 (1.6%) of whom were diagnosed with cervical spine injury. Of the 33 patients with cervical spine injury, 3 had negative clinical examinations (sensitivity, 91%). Lateral c-spine x-ray screen was negative in 1 of these 3 patients. The 2 patients with negative c-spine clinical examination but positive lateral c-spine x-ray screens were diagnosed with C2 spinous process fracture and C6-C7 body fractures. Thirteen patients with negative lateral c-spine screens (sensitivity, 61%) were diagnosed with cervical spine injury. We evaluated 463 patients with blood ethanol levels greater than 100 mg/dL, and 6 (1.3%) were diagnosed with c-spine injury. No injuries were missed on clinical examination in this subgroup with elevated blood ethanol levels.

CONCLUSIONS

1) Clinical examination of the neck can reliably rule out significant cervical spine injury in the awake and alert blunt trauma patient. Addition of lateral c-spine x-ray does not improve the sensitivity of clinical examination in the diagnosis of significant cervical spine injury. 2) Elevated ethanol level is not a contraindication to the use of clinical examination as the screening tool for cervical spine injury. Level of consciousness, as determined by Glasgow Coma Score, is a more effective criterion to dictate a screening method for cervical spine injury.

Clearing the cervical spine of adult victims of trauma

Images

Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation

OBJECTIVE

The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head.

METHODS

A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded.

RESULTS

A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008).

CONCLUSIONS

Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

Addressing the myths of cervical spine injury management

Every year in the United States about 5,000 people sustain a cervical spinal cord injury. Vastly greater numbers present to hospitals after motor vehicle crashes and falls with potential cervical spine injuries (CSI) for evaluation. This group of patients requires very careful management while undergoing evaluation for potential CSI to minimize the potential for spinal cord injury. It is, therefore, incumbent on everyone caring for these patients to distinguish between fact and fiction in regard to CSI management. This article addresses the following areas of controversy: CSI is a rare injury; patients with cranial and facial injuries are at increased risk for CSI; everyone with a significant mechanism of injury needs radiological clearance of their cervical spine; a normal cross-table lateral view radiograph excludes significant CSI; oral intubation of patients with CSI is not safe; a semi-rigid collar prevents movement of the cervical spine; and the evaluation of the cervical spine needs to begin in the resuscitation room in every patient.

'Clearing' cervical spine injuries in polytrauma patients: is it really safe to remove the collar?

Polytrauma patients are at increased risk for occult cervical spine injuries. Those unable to provide clinical clues to injury either remain in hard collars until they are able to cooperate with the physical examination or are deemed "clear of cervical injury" if the emergency room screening radiographs are without obvious bony abnormality. Cervical immobilization for a lengthy period of time is not without morbidity. Missed ligamentous injuries can lead to cervical instability, which in turn can result in permanent neurologic sequelae. This article reviews the current methodologies to "clear the cervical spine" and highlights the inadequacies.

The relevance of the occult cervical spine controversy and mechanism of injury to prehospital protocols: a review of the issues and literature

Prehospital guidelines that define the clinical indications for spine trauma also serve as the criteria for selective spinal immobilization in the field. Therefore, these criteria are important for avoiding further spinal cord damage. Because some spine injuries may occur without neurological deficits or other clinical signs, the recommended field guidelines extend beyond the signs and symptoms and include mechanisms of injury or other injuries commonly associated with a high risk of spine injury.

Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing

OBJECTIVE

To evaluate the hypothesis that alert nonintoxicated trauma patients with negative clinical examinations are at no risk of cervical spine injury and do not need any radiographic investigation.

DESIGN

Prospective study.

SETTING

A university-affiliated teaching county hospital.

PATIENTS

Five hundred and forty-nine consecutive alert, oriented, and clinically nonintoxicated blunt trauma victims with no neck symptoms.

RESULTS

All patients had negative clinical neck examinations. After radiographic assessment, no cervical spine injuries were identified. Less than half the patients could be evaluated adequately with the three standard initial views (anteroposterior, lateral, and odontoid). All the rest needed more radiographs and/or computed tomographic scans. A total of 2,27 cervical spine radiographs, 78 computed tomographic scans and magnetic resonance imagings were performed. Seventeen patients stayed one day in the hospital for no other reason but radiographic clearance of an asymptomatic neck. The total cost for x-rays and extra hospital days was $242,000. These patients stayed in the collar for an average of 3.3 hours (range, 0.5-72 hours). There was never an injury missed.

CONCLUSIONS

Clinical examination alone can reliably assess all blunt trauma patients who are alert, nonintoxicated, and report no neck symptoms. In the absence of any palpation or motion neck tenderness during examination, the patient may be released from cervical spine precautions without any radiographic investigations.

Visualization of C7-T1 on portable lateral cervical spine radiographs using a lead-lined acrylic filter

OBJECTIVE

To determine whether lead-lined acrylic cervical filters can improve the quality of portable lateral cervical spine (c-spine) radiographs for trauma patients.

METHODS

Twenty trauma patients who required portable c-spine x-rays had these taken with a lead filter attached to the collimator of the portable x-ray machine to improve penetration and visualization of lower cervical structures without overpenetrating upper cervical structures. The radiographs of these patients were compared with the first portable c-spine radiographs without filters for 20 controls matched for gender and injury severity. The comparison of radiographs was done by an experienced emergency physician and a neuroradiologist blinded to whether the filter was used.

RESULTS

The two groups were similar for demographic and clinical characteristics. There was a significant improvement in the ability to visualize the C7-T1 level for the filter group compared with the control group (65% vs 30%, p < 0.05). Agreement between the physicians was excellent (kappa = 0.79, 95% CI = 0.60-0.99).

CONCLUSIONS

Lead-lined acrylic filters improve the ability to visualize the lower c-spine in trauma patients.

Complication of hard cervical collars in multi-trauma patients

All multi-trauma patients with suspected cervical spine injury should have their cervical spine protected while other life-threatening injuries are being managed. The application of a hard cervical collar is an acceptable method of temporarily immobilizing the cervical spine. Two cases of significant occipital pressure ulceration associated with the use of hard cervical collar are presented.

Lateral cervical spine dislocation and vertebral artery injury

Although anterior and posterior traumatic displacement of cervical vertebrae are commonly noted, and the devastating neurological deficits associated with these injuries have been amply defined, lateral displacement with fractures has been rarely recognized, and the clinical significance of this injury has been overlooked. This report describes five cases of cervical spine fractures with lateral dislocation. All patients had lateral and anteroposterior cervical spine radiographs as well as cervical angiography or postmortem study demonstrating either complete occlusion or significant impairment of flow of the vertebral arteries. Two cases had traumatic vertebral artery occlusion with secondary medullary and cerebellar infarction resulting in the patient's death. Vertebral artery injury apparently is not uncommon in this particular type of fracture. The diagnosis of these vascular injuries may require angiography or magnetic resonance angiography. A vertebral occlusion or dissection is a problem of considerable complexity, requiring individualized management depending on the patient's symptomatology, location and nature of the injury, and time lapsed since the injury.