Clearing the cervical spine in the blunt trauma patient

The Management of Cervical Spine Injuries - A Literature Review

Due to the inherent bony instability of the cervical spine, there is an over-reliance on ligamentous structures for stability, making this segment of the vertebral column most prone to traumatic injuries. The frequently occurring mechanisms of injury include axial compression, hyper-flexion, hyper-extension, and rotational type injuries. Good pre-hospital care and a thorough assessment in the emergency department of patients suspected to have a cervical spine injury (CSI) leads to improved clinical outcomes. The objective of the initial evaluation of a patient with a suspected CSI is to identify the presence of injuries through thorough clinical and radiologic assessments as missed injuries are potentially catastrophic. The treatment of cervical spine injuries can be conservative, pharmacological, or surgical, and aims to halt SCI progression, stabilize the spine, and to allow rehabilitation of the patient.

Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting

This Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery Clinical Practice Guideline (CPG) is designed to provide guidance to the deployed provider when they are treating a combat casualty who has sustained a spine or spinal cord injury. The CPG objective for the treatment and the movement of these patients is to maintain spinal stability through transport, perform decompression when urgently needed, achieve definitive stabilization when appropriate, avoid secondary injury, and prevent deterioration of the patient's neurological condition. Thorough and accurate documentation of the patient's neurological examination is crucial to ensure appropriate management decisions are made as the patient transits through the evacuation system. The use of this CPG should be in conjunction with good clinical judgment.

The Unstable Spine: A Surgeon's Perspective

Instability of the spine is a complex clinical entity that exists on a wide spectrum encompassing many aspects of spinal pathology including traumatic, neoplastic, infectious, and degenerative processes. The importance of determining stability is paramount in the decision-making process regarding the need for operative or nonoperative care. Defining clinical instability can be a challenging and requires careful attention to the pathology involved, findings of necessary imaging, and a thorough clinical exam. Several classification systems have been developed to aid in surgical decision making, but certain limitations exist. Various imaging modalities play a crucial role in the evaluation of suspected instability. Computed tomography is the initial imaging modality of choice in the traumatic setting. Magnetic resonance imaging is an important adjunct in the setting of suspected ligamentous injury and the modality of choice in suspected infectious and neoplastic processes. Upright radiographs can be particularly useful in the setting of acute or subacute instability to glean information about how the spine responds to gravity and weightbearing. The clinical exam is also of critical importance in the determination of stability. The presence of a neurologic deficit is highly suggestive of a potentially unstable spine and appropriate spinal precautions should be maintained until instability and injury has been ruled out. Certain clinical entities, such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, are at high risk for instability particularly in the traumatic setting. In these situations, the spine should be considered unstable until proven otherwise. Ultimately, the determination of spinal stability, and subsequent need for surgical treatment, should be based on the individual case. Combining information from the clinical exam and imaging findings, including upright radiographs when appropriate, allows for the appropriated determination of spinal stability.

Delay in clearing cervical spine injuries in obtunded trauma patients and its implications

Introduction

Prompt recognition of cervical spine injuries may limit spinal cord damage. This prospective audit assessed the time needed to formally confirm the status of cervical spine using a computed tomography scan, the reasons for any delays, and the subsequent outcomes.

Methodology

Prospective audit analysed the data of 100 consecutive unconscious trauma patients, admitted over a seven-month period, to ascertain whether there was a ‘weekend’ effect in validating the cervical spine status radiologically, and whether the delays were associated with an increased risk of pneumonia and other complications. The sensitivity and specificity of using bony fractures and mal-alignment on the computed tomography scans to diagnose cervical spine injuries were calculated.

Results

Significant radiological evidence of cervical spine injuries occurred in 37 patients (37%). A delay in >48 h to ascertain the cervical spine status occurred in 36 patients, mostly due to logistical (58%) reasons, and this was associated with an increased risk of pneumonia requiring antibiotics (p < 0.001). A ‘weekend’ effect and presence of cervical spine injuries were not significantly related to the time to confirm the cervical spine injury status radiologically. The specificity (98%) of using bony fractures and mal-alignment on the computed tomography to diagnose cervical spine injuries was high, but its sensitivity (83.8%) was only modest.

Conclusions

A delay to confirm the cervical spine injury status was common and associated with an increased risk of pneumonia in unconscious trauma patients, particularly among those who did not sustain any cervical spine injuries. The low sensitivity of computed tomography to exclude non-bony cervical spine injuries suggests that selective early use of magnetic resonance imaging scans for high-risk unconscious trauma patients may improve patient outcomes.

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.

Utility of Adding Magnetic Resonance Imaging to Computed Tomography Alone in the Evaluation of Cervical Spine Injury: A Propensity-Matched Analysis

STUDY DESIGN

Adult patients who received computed tomography (CT) alone or CT-magnetic resonance imaging (MRI) for the evaluation of cervical spine injury.

OBJECTIVE

To evaluate the utility of CT-MRI in the diagnosis of cervical spine injury using propensity-matched techniques.

SUMMARY OF BACKGROUND DATA

The optimal evaluation (CT alone vs. CT and MRI) for patients with suspected cervical spine injury in the setting of blunt trauma remains controversial.

METHODS

The primary outcome was the identification of a cervical spine injury, with decision for surgery and change in management considered secondarily. A propensity score was developed based on the likelihood of receiving evaluation with CT-MRI, and this score was used to balance the cohorts and develop two groups of patients around whom there was a degree of clinical equipoise in terms of the imaging protocol. Logistic regression was used to evaluate for significant differences in injury detection in patients evaluated with CT alone as compared to those receiving CT-MRI.

RESULTS

Between 2007 and 2014, 8060 patients were evaluated using CT and 693 with CT-MRI. Following propensity-score matching, each cohort contained 668 patients. There were no significant differences between the two groups in baseline characteristics. The odds of identifying a cervical spine injury were significantly higher in the CT-MRI group, even after adjusting for prior injury recognition on CT (odds ratios 2.6; 95% confidence interval 1.7-4.0; P < 0.001). However, only 53/668 patients (8%) in the CT-MRI group had injuries identified on MRI not previously recognized by CT. Only a minority of these patients (n = 5/668, 1%) necessitated surgical intervention.

CONCLUSION

In this propensity-matched cohort, the addition of MRI to CT alone identified missed injuries at a rate of 8%. Only a minority of these were serious enough to warrant surgery. This speaks against the standard addition of MRI to CT-alone protocols in cervical spine evaluation after trauma.

LEVEL OF EVIDENCE

3.

Cervical collars and immobilisation: A South African best practice recommendation

INTRODUCTION

The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context.

RECOMMENDATIONS

Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable.

CONCLUSION

The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.

Secondary neurological deterioration in traumatic spinal injury: data from medicolegal cases

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT

Clearance of cervical spine injury (CSI) in the obtunded or comatose blunt trauma patient remains controversial. In patients with unreliable physical examination and no evidence of CSI on computed tomography (CT), magnetic resonance imaging of the cervical spine (CS-MRI) is the typical follow-up study. There is a growing body of evidence suggesting that CS-MRI is unnecessary with negative findings on a multi-detector CT (MDCT) scan. This review article systematically analyzes current literature to address the controversies surrounding clearance of CSI in obtunded blunt trauma patients. A literature search through MEDLINE database was conducted using all databases on the National Center for Biotechnology Information (NCBI) website (www.ncbi.nlm.nih.gov) for keywords: "cervical spine injury," "obtunded," and "MRI." The search was limited to studies published within the last 10 years and with populations of patients older than 18 years old. Eleven studies were included in the analysis yielding data on 1535 patients. CS-MRI detected abnormalities in 256 patients (16.6%). The abnormalities reported on CS-MRI resulted in prolonged rigid c-collar immobilization in 74 patients (4.9%). Eleven patients (0.7%) had unstable injury detected on CS-MRI alone that required surgical intervention. In the obtunded blunt trauma patient with unreliable clinical examination and a normal CT scan, there is still a role for CS-MRI in detecting clinically significant injuries when MRI resources are available. However, when a reliable clinical exam reveals intact gross motor function, CS-MRI may be unnecessary.

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.

Traditional threshold for retropharyngeal soft-tissue swelling is poorly sensitive for the detection of cervical spine injury on computed tomography in adult trauma patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To examine the diagnostic value of prevertebral soft-tissue swelling in the setting of cervical spine trauma.

SUMMARY OF BACKGROUND DATA

In adult patients with trauma, an increase in the thickness of the retropharyngeal soft tissues is commonly used as a potential indicator of occult injury, but no studies have examined this parameter using computed tomography (CT) as a screening modality.

METHODS

A total of 541 patients with trauma with injuries at any level of the spine underwent CT. Patients with cervical injury were divided into those requiring noninvasive (observation or cervical collar, n = 142) management, and those requiring invasive (surgery or halo, n = 61) treatment. A control group of patients with isolated thoracic or lumbar injuries was used for comparison (n = 542). Retropharyngeal soft tissues were measured at the cranial and caudal endplates of all cervical levels on sagittal and axial CT. Sensitivity and specificity were calculated for +1, +2, and +3 standard deviations from mean values.

RESULTS

Sensitivity for detection of injury was found to be universally poor for all measurement groups. This ranged from 14.4% to 21.2% at +1 SD to 5.3% to 8.7% at +2 SD. Positive and negative predictive values for injury were also universally poor, ranging from 38% to 75%. Soft-tissue swelling as a sentinel sign of cervical spine injury demonstrates consistently high specificity and low sensitivity, precisely the opposite of what would be desired in a screening test. This study shows at best a sensitivity of 21.6% when using this parameter for the detection of these injuries in adult patients with trauma.

CONCLUSION

On the basis of the results of this study, we recommend against the routine use of measurement of the prevertebral soft tissues on CT as a screening tool for cervical spine injury in adult patients with trauma.

LEVEL OF EVIDENCE

3.

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.

The daunting task of "clearing" the cervical spine

The evaluation of the cervical spine in the emergency department is a common and often challenging task. We report the case of a 70-year-old female who presented intoxicated with evidence of a recent fall. A 64-slice computed tomographic (CT) scan with sagittal and coronal reconstructions revealed no acute injury. The patient was re-examined when alert and had persistent neck pain. Flexion-extension static views revealed severe subluxation of C5 on C6 with jumped facets, and subsequent magnetic resonance imaging confirmed significant ligamentous injury. The evidence available suggests that although CT with reconstruction is highly sensitive for clinically significant cervical injury, the possibility of severe injury remains.

Brachial plexus injury mimicking a spinal-cord injury

Objective: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.

Clinical presentation: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.

Intervention: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.

Conclusion: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.

Evaluation and management of combat-related spinal injuries: a review based on recent experiences

BACKGROUND CONTEXT

The current approach to the evaluation and treatment of military casualties in the Global War on Terror is informed by medical experience from prior conflicts and combat encounters from the last 10 years. In an effort to standardize the care provided to military casualties in the ongoing conflicts, the Department of Defense (DoD) has published Clinical Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal injury. However, the combat experience with spine injuries in the present conflicts remains incompletely described.

PURPOSE

To describe the CPGs for the care of the combat casualty with suspected spine injuries and discuss them in light of the published military experience with combat-related spinal trauma.

STUDY DESIGN

Literature review.

METHODS

A literature review was conducted regarding published works that discussed the incidence, epidemiology, and management of combat-related spinal trauma. The CPGs, established by the DoD, are discussed in light of actual military experiences with spine trauma, the present situation in the forward surgical teams and combat support hospitals treating casualties in theater, and recent publications in the field of spine surgery.

RESULTS

In the conventional wars fought by the United States between 1950 and 1991 (Korea, Vietnam, Gulf War I), the incidence of spine injuries remained close to 1% of all combat casualties. However, in the Global War on Terror, the enemy has relied on implements of asymmetric warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices. The increase in explosive mechanisms of injury has elevated the number of soldiers exposed to blunt force trauma and, consequently, recent publications reported the highest incidence of combat-related spinal injuries in American military history. Wounded soldiers are expeditiously evacuated through the echelons of care but typically do not receive surgical management in theater. The current CPGs for the care of soldiers with combat-related spinal injuries should be re-examined in light of data regarding the increasing number of spine injuries, new injury patterns, such as lumbosacral dissociation and low lumbar burst fractures, and recent reports within the field of spine surgery as a whole.

CONCLUSIONS

American and coalition forces are sustaining the highest spine combat casualty rates in recorded history and previously unseen injuries are being encountered with increased frequency. While the CPGs provide useful direction in terms of the evaluation and management of combat casualties with spine injuries, such recommendations may warrant periodic re-evaluation in light of recent combat experiences and evolving scientific evidence within the spine literature.

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.

The spine-injured patient: initial assessment and emergency treatment

Failure to recognize spinal column or spinal cord injuries, or improper treatment of them, can have catastrophic and often irreversible neurologic consequences. Although the initial assessment is often shared with emergency care personnel, an orthopaedic surgeon's perspective can elevate the priority of spinal care to the level that is warranted. An accurate early appraisal, including complete neurologic assessment, is critical. All aspects of emergent care, including optimal immobilization precautions, resuscitation, and choice of imaging modalities, should be systematically reviewed, and practice guidelines should be adopted by each institution. Increased vigilance is required in patients with underlying ankylosing spinal conditions. The use of CT in the symptomatic patient is established, but the use of cervical MRI in the obtunded individual is contentious. By informing decisions around appropriate preliminary treatment, particularly for persons with neurologic deficits or those at high risk for developing neurologic impairment, long-term outcomes can be optimized.

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.