Distracting painful injuries associated with cervical spinal injuries in blunt trauma

Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review

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There is a need for a patient-centred approach to the prehospital spinal management approach, which considers the associated risks, available personnel and limited resources.

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There is limited evidence supporting the use of the NEXUS and CCR decision tools in the prehospital setting.

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Prehospital spinal motion restriction decision tools should focus on reducing unnecessary spinal motion restriction and its associated adverse effects

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Developing a decision tool with more context-specific prehospital instructions for selective spinal motion restriction is of value.

Introduction

The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners.

Method

We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis.

Results

Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting.

Conclusion

This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.

Peripheral Nerve Injury in Thoracic Surgery Detected by Automated Somatosensory Evoked Potential Monitoring

Study Objective. Our objectives were to estimate the incidence of symptoms of peripheral nerve injury (sPNI) in thoracic surgical patients undergoing video-assisted thoracic surgery or open thoracotomy and to determine whether intraoperative somatosensory evoked potentials (SSEPs) waveform changes correlate with postoperative peripheral neuropathic symptoms. Methods. We conducted a prospective observational study in the operating room of a tertiary hospital. We measured SSEPs intraoperatively and assessed patients for sPNI postoperatively. Results. Forty-four patients consented. Six were excluded from analysis. We found that 42% (95% confidence interval [CI] = 26% to 57%) of patients undergoing thoracic surgery had significant changes in SSEP amplitude and latency. Furthermore, 16% (95% CI = 4% to 28%) of patients had new postoperative symptoms of sensory or motor deficits in an upper extremity. We calculated a sensitivity of 66.7% (95% CI = 29.0% to 100%) and a specificity of 50% (95% CI = 33% to 67.3%) for the identification of sPNI based on automated intraoperative SSEP changes. Conclusions. We identified the incidence of SSEP changes in thoracic surgery (42%) and the incidence of postoperative sPNI after thoracic surgery (16%). We identified a positive correlation between intraoperative SSEP changes and postoperative sPNI, which after multivariate analysis was not significant given the small sample size of the study. By the time sensory and/or motor changes are detected postoperatively, it may be too late to reverse the nerve damage. Future versions of the EPAD device could provide anesthesiologists a way to monitor for the development of sPNI, and make changes before a potential injury becomes permanent.

Routine pelvic X-rays in asymptomatic hemodynamically stable blunt trauma patients: A meta-analysis

INTRODUCTION

There is no consensus on how pelvic X-rays should be ordered selectively in blunt trauma patients which may save time, reduce radiation exposure and costs. The aim of this systematic review and meta-analysis was to assess the need for routine pelvic X-rays in awake, respiratory and hemodynamically (HD) stable blunt trauma patients without signs of pelvic fracture. Criteria to identify patients who could safely forgo pelvic X-ray were evaluated.

METHODS

A literature search was performed for prospective comparative cohort studies. Inclusion criteria were: blunt force trauma, hemodynamically and respiratory stable and awake patients, physical examination (PE) for pelvic fractures was adequately described, and the reliability of negative PE findings could be evaluated. Primary outcome was the negative predictive value (NPV) of PE for all and for clinically relevant pelvic fractures. Additionally sensitivity, specificity and positive predictive value (PPV) were calculated.

RESULTS

Ten studies were included; yielding a total of 11,423 patients. The NPV of PE for all pelvic fractures ranged from 0.96 to 1.00 with a median of 0.996. Combining studies, total NPV was 0.991. For clinically relevant fractures, the NPV of PE ranged from 0.996 to 1.00 with a median of 1.00. In patients with negative findings during PE, 0.9% had fractures, and 0.1% had clinically relevant fractures, none requiring surgical management.

CONCLUSIONS

In awake, hemodynamically and respiratory stable blunt trauma patients, PE could identify those patients who could safely forgo pelvic X-ray. Selective ordering of pelvic X-ray may lead to a decrease in patient work-up time, lower radiation exposure, and reduce costs. A decision making flow chart is proposed..

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.

Emergency Neurological Life Support: Traumatic Spine Injury

Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Alhough the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, is also covered.

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.

Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

BACKGROUND

Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined.

METHODS

Hospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI.

RESULTS

Among 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥ 65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status).

CONCLUSIONS

C-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.

Evaluation of distracting pain and clinical judgment in cervical spine clearance of trauma patients

BACKGROUND

The concept of distracting pain (DP) is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine (C-spine). This study attempted to define DP more objectively and assess its true potential to mask the presence of C-spine injury. It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck (PP).

METHODS

This prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a C-spine collar. Demographics, mechanism of injury, severity and location of all pain, and C-spine imaging data were obtained. Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale (VNRS) along with the examiner's clinical opinion as to the presence of a fracture.

RESULTS

A total of 160 patients were studied: 65 % male, mean age 39 years, and 44 % presenting after a motor vehicle crash. In all, 16 % complained of neck pain (NP) and 82 % of PP. There were 134 patients without NP, 110 of whom (82 %) had PP. The mean VNRS in patients with no NP was 4.2; in patients with NP it was 4.8. When examined, 14 patients without NP exhibited posterior cervical tenderness, one of whom had a fracture (7 %). Of the patients with PP, 10 % stated it was DP. The mean VNRS described as DP by all patients was 7.5 but by clinician 6.5. VNRS described as not DP was 4.8 for both patients and clinicians. Overall, 8 of the 160 patients (5 %) had confirmed C-spine injuries. Regardless of NP or PP and its potentially distracting nature, clinicians believed no fracture was present in 95 % of all cases. Clinical impression was 98 % accurate. For patients with NP, clinical impression had a 91 % negative predictive value (NPV) and a 100 % a positive predictive value (PPV). In those without NP, the NPV was 99 % and the PPV 25 %.

CONCLUSIONS

The concept of DP is subjective and unreliable as a method to mitigate missed C-spine injuries. If it is to be considered for use, DP should be defined as VNRS ≥5. Reliance on clinical impressions regardless of the presence or absence of NP or PP, distracting or otherwise, is accurate and safe.

Decreased use of cervical spine clearance in blunt trauma: the implication of the injury mechanism and distracting injury

BACKGROUND

Cervical spine injury (CSI) can be ruled out based on clinical examination and no X-ray is required if patient is awake, alert, and examinable. This is known as a clinical clearance (CC). Clinicians have decreased the use and reliance of CC and relied more upon X-ray, especially now that computerized tomography (CT) is fast and readily available. The objective of this study was to identify clinical factors, in particular, the injury mechanism and the distracting injuries, which may be associated with CSI. The knowledge may help to improve the use of CC.

METHODS

We retrospectively reviewed the records of all blunt trauma patients who were awake, alert, and examinable, with a Glasgow Coma Scale of 14-15, and who were admitted to our Level 1 Trauma Center during January 1 to December 31, 2005. We excluded patients who presented with gross neurological deficit or who died within 72 h. From the chart review, we collected the demographics; the injury severity score (ISS); the injury mechanism; the presence of distracting injuries (DI) which were defined as bony fractures (divided into upper body, lower body, or both); and the radiographs obtained. Patients who did not receive CC underwent a 3-view plain film X-ray, with or without CT scan. We then divided the group into those with CSI (Case) and those without (Control). We compared the two group variables and performed a multiple logistic regression analysis to identify clinical factors associated with CSI. Statistical significance was accepted with p-value <0.05.

RESULTS

Of the 985 patients evaluated, only 179 (18%) received CC. The remaining did not receive CC and went on to have radiographs. Of these, 76 were diagnosed CSI (Case). On a univariate analysis, the ISS, a motor vehicle collision (MVC) with rollover; MVC with rollover and ejection, the absence of DI, and a lower-body DI were significantly associated with CSI. However, on a multivariate analysis, only an MVC with rollover (odds ratio [OR], 2.326; 95% confidence interval [CI], 1.36-3.97) and a lower-body distracting injury (OR, 0.20; 95% CI, 0.07-0.55) were significantly associated with CSI.

CONCLUSION

The injury mechanism of MVC with rollover may prevent clinicians from utilizing CC, while the presence of a lower-body DI should not. A future and prospective study is needed to better understand the role of the injury mechanism and the distracting injury in relation to CSI.

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.

Clearance of the asymptomatic cervical spine: a meta-analysis

OBJECTIVES

To perform a comprehensive review of the literature and subsequent meta-analysis of data regarding appropriate clearance of the asymptomatic cervical spine in blunt trauma patients. The goal is to identify an asymptomatic patient group that can safely be cleared of cervical spine immobilization without radiographic evaluation.

DATA SOURCES

The National Library of Medicine was searched for English-language articles published between 1966 and December 2004. The key words spinal injury, spinal fracture, spinal injuries, cervical, clearance, diagnosis, and radiography were used to perform the search.

STUDY SELECTION

Inclusion criteria were 1) a prospectively applied protocol; 2) reported outcomes to allow calculation of sensitivity, specificity, negative predictive value, and positive predictive value; and 3) follow up to determine the status of potential injuries with minimum of a 2-week telephone call or a computerized tomography scan. No exclusion criteria were applied.

DATA EXTRACTION

The three senior authors independently confirmed the validity of the included papers for meeting appropriate criteria for the meta-analysis. True-positives, true-negatives, false-positives, and false-negatives were extracted from these studies.

DATA SYNTHESIS

Original scale and log odds meta-analysis were performed using random effects methodology to calculate sensitivity, specificity, positive predictive value, and negative predictive value.

CONCLUSIONS

An alert, asymptomatic patient without a distracting injury or neurologic deficit who is able to complete a functional range-of-motion examination may safely be cleared from cervical spine immobilization without radiographic evaluation (sensitivity = 98.1%, negative predictive value = 99.8%).

Detection of Cervical Spine Injuries in Alert, Asymptomatic Geriatric Blunt Trauma Patients: Who Benefits from Radiologic Imaging?

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 ± 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.

Distracting injuries in patients with vertebral injuries

To describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. A prospective cohort study was conducted at an urban Level I trauma center. All patients undergoing radiographic evaluation of the cervical, thoracic, or lumbar vertebrae after blunt trauma were enrolled. Patients had a data collection form completed by the treating physician before radiographic imaging and were evaluated for the following upon initial presentation: tenderness to the cervical, thoracic, or lumbar spine, distracting injuries, altered mental status, alcohol or drug intoxication, or neurological deficits. Patients with distracting injuries as the sole documented indication for vertebral radiographs were reviewed for the types of injuries present. A total of 4698 patients were enrolled in the study. There were 336 (7.2%) patients who had distracting injuries as the sole documented indication for obtaining radiographic studies of the vertebrae. Eight (2.4%, 95% CI 1.0-4.6%) of the 336 patients had 14 acute vertebral injuries including compression fractures (5), transverse process fractures (7), spinous process fracture (1), and cervical spine rotatory subluxation (1). There were 13 thoracolumbar injuries and one cervical spine injury. Distracting injuries in the eight patients with acute vertebral injuries included 13 bony fractures. Distracting injuries in those patients without vertebral injuries included bony fractures (333), lacerations (63), soft tissue contusions (62), head injuries (15), bony dislocations (12), abrasions (11), visceral injuries (8), dental injuries (5), burns (3), ligamentous injuries (3), amputation (1), and compartment syndrome (1). In conclusion, in patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries.

Can nurses, working in the emergency department, independently clear cervical spines?: a review of the literature

The prompt clearance of a patient's cervical spine is extremely beneficial both to the patients and the department however correct guidelines and education must be established before this can be undertaken safely. This paper examines whether nurses given the appropriate training and education using appropriate diagnostic and clinical criteria can safely, effectively clear cervical spines without consulting a medical practitioner. The paper explores the use of the Nexus Guidelines [J.R. Hoffman, W.R. Mower, A.B. Wolfson, New England Journal of Medicine 343 (2) (2000) 94-99] as a clinical prediction tool and presents evidence for its use.

How distracting is distracting pain?

The study was to determine the effect of preexisting pain on the perception of a painful stimulus. We conducted a cross-section study at an urban ED using convenience sampling. Adult patients who had a 20-g IV catheter placed as part of their ED care were eligible for the study. Patients were excluded for the following reasons: more than one IV attempt, altered mental status, visual impairment, intoxication, or a physical abnormality at the IV site. Patients were asked to indicate on a 10-cm visual analog scale (VAS) the amount of pain they had at baseline immediately before IV placement. They were then asked to indicate on a separate VAS the amount of pain caused by the IV placement. Correlation between baseline pain and pain of the IV was assessed using Pearson's rho. One hundred patients were enrolled in the study. The pain of IV placement did not differ significantly by gender, race, who placed the IV, or the location of the IV. The correlation between baseline pain and pain of the IV placement was poor (rho =.14, confidence interval:-.06-.33). The response to a standardized painful stimulus among ED patients does not correlate highly with the severity of preexisting pain.

Multicenter prospective validation of prehospital clinical spinal clearance criteria

BACKGROUND

Spine immobilization is one of the most frequently performed prehospital procedures. If trauma patients without significant risk for spine injury complications can be identified, spine immobilization could be selectively performed. The purpose of this study was to evaluate five prehospital clinical criteria-altered mental status, neurologic deficit, spine pain or tenderness, evidence of intoxication, or suspected extremity fracture-the absence of which identify prehospital trauma patients without a significant spine injury.

METHODS

Prospectively collected emergency medical services data items included the above-listed criteria. Outcome data include spine fracture or cord injury, and also the level and management of injuries.

RESULTS

A total of 295 patients with spine injuries were present in 8,975 (3.3%) cases. Spine injury was identified by the prehospital criteria in 280 of 295 (94.9%) injured patients. The criteria missed 15 patients. Thirteen of 15 had stable injuries, the majority of which were stable compression or vertebral process injuries. The remaining two would have been captured by more accurate prehospital evaluation.

CONCLUSION

Absence of the study criteria may form the basis of a prehospital protocol that could be used to identify trauma patients who may safely have rigid spine immobilization withheld. Evaluation of such a protocol in practice should be performed.