Clearance of the asymptomatic cervical spine: a meta-analysis

Is older age an appropriate criterion alone for ordering cervical spine computed tomography after trauma

BACKGROUND

Cervical spine computed tomography (CSCT) scans are frequently performed in older emergency department (ED) trauma patients based on the 65-year-old high-risk criterion of the Canadian Cervical Spine Rule (CCR). We sought to determine the positivity rate of CSCT scans in symptomatic and asymptomatic patients to assess the current applicability of age in the CCR.

METHODS

We reviewed CSCT ED reports from two institutional hospitals from 2018 to 2023. The primary variable was age; however, we also recorded fracture types and sites and type of treatments. Patients were separated into symptomatic and asymptomatic cohorts. We used a Fisher's exact test to compare variables between the asymptomatic and symptomatic groups and chi-square tests for comparison between age groups.

RESULTS

Of 9455 CSCTs performed in patients ≥ 65 years, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic patients. The rates of fractures (1.6%) and asymptomatic fractures (0.18%) were lowest in the 65- to 70-year age group. There were no distinguishing features as to the level or part of the vertebra fractured or surgical treatment rate between asymptomatic and symptomatic patients.

CONCLUSIONS

Cervical spine fractures in posttrauma patients ≥ 65 years are uncommon, with the lowest incidence in those 65 to 70 years old. Excluding asymptomatic individuals aged 65-70 from routine CSCT presents a minimal risk of missed fractures (0.18%). This prompts consideration for refining age-based screening and integrating shared decision making into the clinical protocol for this demographic, reflecting the low incidence of fractures and the changing health profile of the aging population.

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.

Facial Fractures and Their Relation to Head and Cervical Spine Injuries in Hospitalized Bicyclists

Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.

Cervical spine injury: clinical and medico-legal overview

Spinal trauma is an important cause of disability worldwide. Injury to the cervical spine (CS) occurs frequently after major trauma. 5-10% of patients with blunt trauma have a cervical spine injury. The cervical spine accounts for ~ 50% of all spinal injuries. Determination of CS stability is a common challenge in the acute care setting of patients with trauma. Several issues, indeed, are of particular concern: who needs CS imaging; what imaging should be obtained; when should computed tomography (CT), magnetic resonance imaging (MRI), or flexion/extension (F/E) radiographs be obtained; and how is significant ligamentous injury excluded in the comatose patient. CT and MRI both have roles to play. This article aims to present the different imaging to frame techniques to be used with greater precision in the acute event also for the purpose of planning the next therapeutic process. An overview of the applicability of the same methods in forensic pathology is also provided highlighting possible future biomarker to ease in diagnosis of acute TBI.

Low-value injury care in the adult orthopaedic trauma population: A systematic review

OBJECTIVES

Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices.

METHODS

We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes.

RESULTS

Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias.

CONCLUSION

In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

BACKGROUND

Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI.

METHODS

We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement.

RESULTS

Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10).

CONCLUSION

Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI.

LEVEL OF EVIDENCE

Diagnostic, level II.

Risk Factors for Wound-Related Complications After Surgery for Primary and Metastatic Spine Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

We systematically reviewed the literature to compare risk factors for postoperative complications at the surgical wound site in primary and metastatic tumor operations.

METHODS

We screened English-language publications on the outcomes of primary and metastatic spinal tumor operations. Pooled analyses and meta-analyses with random-effects modeling were performed comparing patients with and without wound complications, which were defined as surgical site infection or sterile wound dehiscence.

RESULTS

Our search identified 5471 unique citations, from which we included 23 studies describing 5104 patients. A total of 1936 patients underwent surgery for primary tumors, with a wound complication rate of 8.1%. Subgroup analysis of benign and malignant primary tumors yielded significantly different wound complication rates of 7.8% and 26.9%, respectively. The metastatic tumor cohort included 168 patients and a complication rate of 6.6%. In a pooled analysis of primary tumors, higher wound complication rates were associated with sacral operations and the use of instrumentation. In the metastatic tumor cohort, higher complication rates were associated with female sex, smoking history, preoperative chemotherapy, preoperative radiotherapy, corticosteroid use, and previous spine surgery. Instrumentation remained a statistically significant risk factor for primary tumors with the addition of random-effects meta-analysis.

CONCLUSIONS

Risk factors for wound complications after primary tumor operations were related to tumor histology and the spinal location of the operation. Risk factors for metastatic tumors may be related to several systemic preoperative treatments and baseline comorbidities. Random-effects meta-analysis showed the limited generalizability of these findings because of the small heterogenous primary literature.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Towards Evidence-Based Guidelines in Neurological Surgery

Neurological surgery practice is based on the science of balancing probabilities. A variety of clinical guidance documents have influenced how we collectively practice our art since the early 20th century. The quality of the science within these guidelines varies widely, as does their utility in positively shaping our practice. The guidelines development process in neurological surgery has evolved significantly over the last 30 yr. Historically based in expert opinion, as a specialty we have increasingly relied on objective medical evidence to guide our clinical practice. We assessed the changing practice guidelines development process and the impact of scientifically robust guidelines on patient care. The evolution of the guidelines development process in neurological surgery was chronicled. Several subspecialty guidelines were extracted and reviewed in detail. Their impact on practice patterns was evaluated. The importance of evidence-based research and practice guidelines development was discussed. Evidence-based practice guidelines serve to chronicle multiple acceptable treatment options and help us move towards more standardized care for specific disease processes. They help refute false "standards of care." Guidelines-based care supported by solid medical evidence has the potential to streamline patient care and improve patient outcomes. The guidelines development process identifies areas, issues, and strategies for which little medical evidence exists, as well as topics that need focused scientific investigation and future study. The production of evidence-based practice recommendations is a vital part of furthering our specialty. Guidelines development advances our science, augments the resident education process, and protects our practice from undue external influence.

Evaluating the Cervical Spine in the Blunt Trauma Patient

Following a blunt trauma, the goal of the cervical spine evaluation is to identify any injuries that might require active management: either through continued use of a collar or surgical stabilization. This is achieved through a step-wise approach that considers the nature of the patient's trauma, presenting complaints, distracting injuries and capacity to cooperate with the examination. In the last 15 to 20 years, technological advances in radiographic imaging have improved clinicians' abilities to certify the cervical spine as free of injury following blunt trauma. Within the last decade, the use of CT has supplanted plain radiograph imaging as the standard screening modality. Although MRI is more sensitive than CT in identifying occult cervical injury, particularly ligamentous or soft-tissue trauma, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries.

Cervical Spine Injury in Burned Trauma Patients: Incidence, Predictors, and Outcomes

Cervical spine injuries (CIs) carry significant morbidity and mortality; hence, cervical spine immobilization is used liberally in trauma patients, including burns. The incidence, predictors, and outcomes of CI in burn patients are unknown. A retrospective cohort from the National Trauma Data Bank between 2007 and 2012 included all burned patients with and without CI. Predictors of CI were identified by logistic regression. Outcomes with and without CI were compared with Wilcoxon rank sum test. A total of 94,964 patients were identified with burn injuries. The incidence of CI was 0.79% (n = 745). Mechanism of injury, age, and injury severity score (ISS) were significant predictors of CI. Odds of CI were 109.4 (95% CI: 61.2-195.3, P < .0001) for motor vehicle injury, 87.8 (95% CI: 47.0-164.0, P < .0001) for falls, 1.2 (95% CI: 0.6-2.3, P = .66) for fire/flame, and 2.4 (95% CI: 1.0-5.5, P < .0001) for explosion compared with reference of hot object/substance. For every year increase in age, there were 1.02 higher odds of CI (95% CI: 1.01-1.02, P < .0001). For each point increase in ISS, there were 1.05 higher odds of CI (95% CI: 1.04-1.05, P < .0001). Patients with CI had higher mortality (10.3% vs 2.9%, P < .0001), longer total length of stay (12.0 vs 2.0 days, P < .0001), intensive care unit length of stay (4.0 vs 0.0 days, P < .001), and ventilator days (1.0 vs 0.0 days, P < .0001). The incidence of CI in burn patients is low, especially when due to fire, flame, or scalds; however, CI is associated with higher mortality and worse outcomes.

Guidelines on How to Perform a Meta-Analysis in Spine Surgery: Strengths and Weaknesses of Design

There are many questions in the literature that remain unanswered due to the paucity of available subjects or the large sample size needed to detect a difference. A meta-analysis consists of integrating together data from multiple studies into one larger data set in order to increase the subject size and power of a paper. In essence, it is a systematic review in which one uses statistical methods to summarize the results of these studies. It is important that a meta-analysis be performed in a systematic and orderly manner with the assistance of a statistician. When carried out correctly, these studies serve as powerful tools to help us better address our knowledge. Because of their complexity, they are prone to bias at multiple levels. This article will discuss the steps involved in performing a meta-analysis, select good studies, as well as explain the statistics conducted in these studies. Furthermore, we will discuss examples from the literature that demonstrate a good meta-analysis.

Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from 1987 to 2010

BACKGROUND

Fall-induced injuries in patients are increasing in number, and they often lead to serious consequences, such as cervical spine injuries (CSI). CSI diagnostics remain a challenge despite improved radiological services.

PURPOSE

Our aim is to define the incidence and risk factors for diagnostic errors among patients who died following a CSI.

STUDY DESIGN/SETTING

A retrospective death certificate-based study of the whole population of Finland was carried out.

PATIENT SAMPLE

We identified 2,041 patients whose death was, according to the death certificate, either directly or indirectly caused by a CSI.

OUTCOME MEASURES

Demographics, injury- and death-related data, and adverse event (AE)-related data were the outcome measures.

METHODS

All death certificates between the years 1987 and 2010 from Statistics Finland that identified a CSI as a cause death were reviewed to identify preventable AEs with the emphasis on diagnostic errors.

RESULTS

Of the 2,041 patients with CSI-related deaths, 36.5% (n=744) survived at least until the next day. Errors in CSI diagnostics were found in 13.8% (n=103) of those who died later than the day of injury. Those with diagnostic errors were significantly older (median age 79.4 years, 95% confidence interval 75.9-80.1 vs. 74.9, 95% confidence interval 70.2-72.9, p<.001) and the mechanism of injury was significantly more often a fall (86.4%, n=89 vs. 69.7%, n=447, p=.002) compared with those who did not have a diagnostic error. The incidence of diagnostic errors increased slightly during the 24-year study period.

CONCLUSIONS

Cervical spine injury diagnostics remain difficult despite improved radiological services. The majority of the patients subjected to diagnostic errors are fragile elderly people with reduced physical capacity. In our analysis, preventable AEs and diagnostic errors were most commonly associated with ground-level falls.

Head injuries and the risk of concurrent cervical spine fractures

BACKGROUND

Cervical spine injuries of variable severity are common among patients with an acute traumatic brain injury (TBI). We hypothesised that TBI patients with positive head computed tomography (CT) scans would have a significantly higher risk of having an associated cervical spine fracture compared to patients with negative head CT scans.

METHOD

This widely generalisable retrospective sample was derived from 3,023 consecutive patients, who, due to an acute head injury (HI), underwent head CT at the Emergency Department of Tampere University Hospital (August 2010-July 2012). Medical records were reviewed to identify the individuals whose cervical spine was CT-imaged within 1 week after primary head CT due to a clinical suspicion of a cervical spine injury (CSI) (n = 1,091).

RESULTS

Of the whole cranio-cervically CT-imaged sample (n = 1,091), 24.7% (n = 269) had an acute CT-positive TBI. Car accidents 22.4% (n = 244) and falls 47.8% (n = 521) were the most frequent injury mechanisms. On cervical CT, any type of fracture was found in 6.6% (n = 72) and dislocation and/or subluxation in 2.8% (n = 31) of the patients. The patients with acute traumatic intracranial lesions had significantly (p = 0.04; OR = 1.689) more cervical spine fractures (9.3%, n = 25) compared to head CT-negative patients (5.7%, n = 47). On an individual cervical column level, head CT positivity was especially related to C6 fractures (p = 0.031, OR = 2.769). Patients with cervical spine fractures (n = 72) had altogether 101 fractured vertebrae, which were most often C2 (22.8, n = 23), C7 (19.8%, n = 20) and C6 (16.8%, n = 17).

CONCLUSIONS

Head trauma patients with acute intracranial lesions on CT have a higher risk for cervical spine fractures in comparison to patients with a CT-negative head injury. Although statistically significant, the difference in fracture rate was small. However, based on these results, we suggest that cervical spine fractures should be acknowledged when treating CT-positive TBIs.

Management of acute traumatic spinal cord injuries

Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.

On-scene treatment of spinal injuries in motor sports

Because spinal cord injuries can have fatal consequences for injured race car drivers, prehospital treatment of spinal injuries is a major concern in motor sports. A structured procedure for assessing trauma patients and their treatment should follow established ABCDE principles. Only then, a stable patient could be further examined and appropriate measures can be undertaken. For patients in an acute life-threatening condition, rapid transport must be initiated and should not be delayed by measures that are not indicated. If a competitor must first be extricated from the racing vehicle, the correct method of extrication must be chosen. To avoid secondary injury to the spine after a racing accident, in-line extrication from the vehicle and immobilization of the patient are standard procedures in motor sports and have been used for decades. Since immobilization can be associated with disadvantages and complications, the need for immobilization of trauma patients outside of motor sports medicine has become the subject of an increasing number of reports in the scientific literature. Even in motor sports, where specific safety systems that offer spinal protection are present, the indications for spinal immobilization need to be carefully considered rather than being blindly adopted as a matter of course. The aim of this article is to use recent literature to present an overview about the treatment of spinal injuries in motor sports. Further, we present a new protocol for indications for immobilizing the spine in motor sports that is based on the ABCDE principles and takes into account the condition of the patient.

Outcomes and characteristics of non-immobilised, spine-injured trauma patients: a systematic review of prehospital selective immobilisation protocols

OBJECTIVES

This review assesses prehospital selective immobilisation protocols across a range of outcomes, including neurological deterioration and characteristics of injured, non-immobilised patients.

METHODS

Six electronic reference databases and eight grey literature sources were systematically searched. We included studies that enrolled acute trauma patients in the prehospital setting who were assessed for spine injury according to predefined clinical criteria and either immobilised or not. Data items included instances of neurological deterioration among patients with spine injuries, as well as available characteristics of those who were injured and not immobilised. Available data and study heterogeneity prevented meta-analyses. Bias was assessed for both individual studies and across studies by outcome.

RESULTS

604 unique articles were retrieved, of which 7 met inclusion criteria. There was moderate or high risk of bias across studies in all outcomes. Of 76 patients with spine injuries who were not immobilised, 72 had no neurological deficit that appeared after emergency medical services contact, and the remaining four were not followed. Within this group, there appears to be a trend towards elderly patients who suffered a thoracic or lumbar injury from a low-risk mechanism of injury. Among studies that report both the results of the protocol assessment and immobilisation status, there is variable correspondence between the two.

CONCLUSIONS

Data limitations and study biases suggest caution when interpreting and applying the results of this review. Its findings are consistent with the conclusions of individual studies. The characteristics of injured, non-immobilised patients point to areas of future research to investigate apparent trends.

Development of a new Emergency Medicine Spinal Immobilization Protocol for trauma patients and a test of applicability by German emergency care providers

Background

In order to match the challenges of quickly recognizing and treating any life-threatening injuries, the ABCDE principles were established for the assessment and treatment of trauma patients. The high priority of spine protection is emphasized by the fact that immobilization of the cervical spine is performed at the very first step in the ABCDE principles. Immobilization is typically performed to prevent or minimize secondary damage to the spinal cord if instability of the spinal column is suspected. Due to increasing reports about disadvantages of spinal immobilization, the indications for performing spinal immobilization must be refined.

The aim of this study was (i) to develop a protocol that supports decision-making for spinal immobilization in adult trauma patients and (ii) to carry out the first applicability test by emergency medical personnel.

Methods

A structured literature search considering the literature from 1980 to 2014 was performed. Based on this literature and on the current guidelines, a new protocol that supports on scene decision-making for spinal immobilization has been developed. Parameters found in the literature concerning mechanisms and factors increasing the likelihood of spinal injury have been included in the new protocol. In order to test the applicability of the new protocol two surveys were performed on German emergency care providers by means of a questionnaire focused on correct decision-making if applying the protocol.

Results

Based on the current literature and guidelines, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients was developed. Following a fist applicability test involving 21 participants, the first version of the E.M.S. IMMO Protocol has to be graphically re-organized. A second applicability test comprised 50 participants with the current version of the protocol confirmed good applicability. Questions regarding immobilization of trauma patients could be answered properly using the E.M.S. IMMO Protocol.

Discussion

Current literature increasingly reports of disadvantages that may be associated with immobilization. Based on the requirements of the current guidelines, a new protocol that supports decision-making for indications for out-of-hospital spinal immobilization has been developed in this study. In contrast to established protocols, the new protocol offers different options for immobilization as well as a decicion-support.

Conclusions

The E.M.S. IMMO protocol provides a decision-support tool for indications for spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization method in particular.

The clinical significance of isolated loss of lordosis on cervical spine computed tomography in blunt trauma patients: a prospective evaluation of 1,007 patients

BACKGROUND

A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury after trauma. Loss of lordosis (LOL) is frequently found as the only CT abnormality. We investigated whether LOL should preclude c-spine clearance.

METHODS

All adult trauma patients with isolated LOL at our Level I trauma center (February 1, 2011 to May 31, 2012) were prospectively evaluated. The primary outcome was clinically significant injury on magnetic resonance imaging (MRI), flexion-extension views, and/or repeat physical examination.

RESULTS

Of 3,333 patients (40 ± 17 years, 60% men) with a c-spine CT, 1,007 (30%) had isolated LOL. Among 841 patients with a Glasgow Coma Scale score of 15, no abnormalities were found on MRI, flexion-extension views, and/or repeat examinations, and all collars were removed. Among 166 patients with Glasgow Coma Scale less than 15, 3 (.3%) had minor abnormal MRI findings but no clinically significant injury.

CONCLUSION

Isolated LOL on c-spine CT is not associated with a clinically significant injury and should not preclude c-spine clearance.

Cervical spine clearance protocols in Level I, II, and III trauma centers in California

BACKGROUND CONTEXT

Cervical spine clearance protocols were developed to standardize the clearance of the cervical spine after blunt trauma and prevent secondary neurologic injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in California is unknown.

PURPOSE

To evaluate the cervical spine clearance protocols in all trauma centers of California.

STUDY DESIGN

An observational cross-sectional study.

PATIENT SAMPLE

Included from Level I, II, III trauma centers in California.

OUTCOME MEASURES

The self-reported outcomes of each trauma center's cervical spine clearance protocols were assessed.

METHODS

Level I (n=15), II (n=30), and III (n=11) trauma centers in California were contacted. Each available protocol was reviewed for four scenarios: clearing the asymptomatic patient, the initial imaging modality used in patients not amenable to clinical clearance, and the management strategies for patients with persistent neck pain with a negative computed tomography (CT) scan and those who are obtunded. Results were compared with the 2009 Eastern Association for the Surgery of Trauma (EAST) cervical spine clearance guidelines.

RESULTS

The response rate was 96%. Sixty-three percent of California's trauma centers (Level I, 93%; Level II, 60%; Level III, 27%) had written cervical spine clearance protocols. For asymptomatic patients, 83% of Level I and 61% of Level II centers used National Emergency X-Radiography Utilization Study criteria with/without painless range of motion. For those requiring imaging, 67% of Level I and 56% of Level II centers stated a CT scan should be the first line of imaging. For obtunded patients and patients with persistent neck pain and a negative CT scan, more than 90% of Level I and more than 70% of Level II trauma centers incorporated the 2009 EAST recommendations. No institution recommended passive flexion-extension radiographs for the obtunded patient.

CONCLUSIONS

Written cervical spine clearance protocols exist in 63% of California's trauma centers and only 51% of the centers have protocols that follow current evidence-based guidelines. Standardization and utilization of these protocols should be encouraged to prevent missed injuries and secondary neurologic injuries.

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.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Cervical spine clearance protocols in level 1 trauma centers in the United States

STUDY DESIGN

Observational, cross-sectional.

OBJECTIVE

To evaluate cervical spine clearance protocols in level 1 trauma centers in the United States.

SUMMARY OF BACKGROUND DATA

Cervical spine clearance protocols were developed to prevent missed injuries that could result in neurological deficits. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the United States is unknown.

METHODS

Level 1 trauma (n = 191) centers in the United States were contacted. Each available protocol was reviewed for 4 scenarios: clearing the asymptomatic patient, the imaging used in patients not amenable to clinical clearance, the management strategies for patients with persistent neck pain with a negative computed tomographic (CT) scan, and those who are obtunded.

RESULTS

The response rate was 87%. Cervical spine clearance protocols existed in 57% of the institutions. National Emergency X-Radiography Utilization Study criteria to clear asymptomatic patients were recommended in 89% of protocols. Sixty percent of protocols used CT scans as the first line of imaging. In patients with persistent neck pain with negative CT scan flexion-extension plain radiographs were the most common (30%) next step for clearance. In patients who are obtunded, a CT scan followed by a magnetic resonance imaging was the most common method (31%) of clearance. Eight percent of the protocols recommended dynamic flexion-extension views in patients who are obtunded, which are contraindicated.

CONCLUSION

Written cervical spine clearance protocols exist in 57% of level 1 trauma centers in the United States. These protocols are highly variable and standardization and utilization of these protocols should be encouraged in all trauma centers to prevent missed injuries and neurological catastrophes.

LEVEL OF EVIDENCE

4.

Wilderness Medical Society practice guidelines for spine immobilization in the austere environment

In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients

BACKGROUND

Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information.

METHODS

We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30° of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed.

RESULTS

One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80% of the films either did not adequately demonstrate the C7/T1 junction or had less than 30° range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making.

CONCLUSION

Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.

Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review

BACKGROUND

There is uncertainty about the optimal approach to screen for clinically important cervical spine (C-spine) injury following blunt trauma. We conducted a systematic review to investigate the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria, 2 rules that are available to assist emergency physicians to assess the need for cervical spine imaging.

METHODS

We identified studies by an electronic search of CINAHL, Embase and MEDLINE. We included articles that reported on a cohort of patients who experienced blunt trauma and for whom clinically important cervical spine injury detectable by diagnostic imaging was the differential diagnosis; evaluated the diagnostic accuracy of the Canadian C-spine rule or NEXUS or both; and used an adequate reference standard. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies criteria. We used the extracted data to calculate sensitivity, specificity, likelihood ratios and post-test probabilities.

RESULTS

We included 15 studies of modest methodologic quality. For the Canadian C-spine rule, sensitivity ranged from 0.90 to 1.00 and specificity ranged from 0.01 to 0.77. For NEXUS, sensitivity ranged from 0.83 to 1.00 and specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. For both rules, a negative test was more informative for reducing the probability of a clinically important cervical spine injury.

INTERPRETATION

Based on studies with modest methodologic quality and only one direct comparison, we found that the Canadian C-spine rule appears to have better diagnostic accuracy than the NEXUS criteria. Future studies need to follow rigorous methodologic procedures to ensure that the findings are as free of bias as possible.

Imaging evaluation of adult spinal injuries: emphasis on multidetector CT in cervical spine trauma

As computed tomography (CT) technology has evolved, multidetector CT has become an integral part of the initial assessment of many injured patients, and the spine is easily included in the total body screening performed in patients with severe blunt polytrauma. Despite all the advantages of multidetector CT, clearing the spine in which injury is suspected continues to be a daily challenge in clinical practice. The purpose of this review is to present the evidence and the controversies surrounding the practice of imaging in patients suspected of having spine injury. The discussion is centered on the increasing reliance on multidetector CT in the work-up of these patients but also considers the important contributions of clinical trials to select patient for appropriate imaging on the basis of risk and probability of injury. Available protocols, injury classification systems, and issues awaiting future research are addressed.

MRI as an Adjunct to Cervical Spine Clearance: A Utility Analysis

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.

Clinical review: Spinal imaging for the adult obtunded blunt trauma patient: update from 2004

PURPOSE

Controversy exists over how to 'clear' (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004.

METHODS

Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed.

RESULTS

Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and 'false positive'. For studies comparing MDCT with MRI for OBTPs; MRI following 'normal' CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury.

CONCLUSIONS

Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.

Advanced trauma life support radiographic trauma series: part 1--The cervical spine radiograph

Plain cervical spine radiographs are the first line investigation in trauma patients to exclude cervical spine fractures and dislocations. Adequate views are essential to reduce the risk of missing diagnoses. Injuries may however not be visible on plain cervical spine radiographs despite adequate views. Additional imaging such as computer tomography scanning is indicated in the event of a normal plain radiograph if there is any clinical suspicion of injury.