Clinical Practice Guideline for Cervical Spine Injury

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Clinical Practice Guideline for Cervical Spine
Injury

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CPG for C-spine injury

• Evidence-based informations
• Practicality for Thai CPG
• Participation-brain storm from audience

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Evidence class

• Class I Evidence from one or more well-designed,
  randomized controlled clinical trials
• Class II Evidence from one or more well-designed
  non-randomized study
• Class III Evidence from case series, case
  reports, expert opinion

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Topics of Discussion

• Pre-hospital care
• Recognition
• Proper transportation, immobilization
• In-hospital care
• Recognition, clinical assessment
• Evidence-based clinical informations
• Proper treatments, guidelines, specific conditions

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Pre-hospital care

• Immobilization before hospital
• Transportation
• Clinical assessment

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C-spine immobilization

• Evidence class III
• All patients with spinal injury should be
  immobilized at the scene and during transport
• Rigid collar and supportive blocks on a backboard
  with straps is effective in limiting motions of
  the C-spine and is recommended

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Transportation

• Evidence class III
• Expeditious and careful transport of the victim
  by the most appropriate mode of transportation
  available to the nearest capable definitive care
  facility is recommended

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Clinical assessment

• General physical examinations
• Vital signs
• Other injuries
• Neurological examinations
• ASIA score
• Functional outcome assessment
• Modified Barthel index

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In-hospital care

• Clinical assessment and resuscitation
• Investigations
• Initial closed reduction of C-spine
• Management of ASCI
• Management of specific conditions

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Radiographic investigations

• Asymptomatic patients
• Class I evidence
• Not recommended in victim who is awake, alert and
  not intoxicated who is without neck pain or
  tenderness without significant other injuries
  which detract neurological assessment

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Radiographic investigations

• Symptomatic patients
• Class I and II evidence
• Three-view C-spine x-rays recommended
• Supplement CT scan for areas not well-visualized
• Normal Flex/extension films or normal MRI within
  48 hours discontinues immobilization

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Initial closed reduction

• Class III evidence
• Early closed reduction with traction is
  recommended to restore anatomic alignment in an
  awake patient
• Not recommended in patients with additional
  rostral injury
• Pre-reduction MRI is not necessary except in
  patients who cannot be examined
• MRI is recommended after failure of initial
  closed reduction

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Management of ASCI

• Class III evidence
• Monitoring in ICU (or similar) for severe SCI
  patients is recommended
• Cardiac, hemodynamic and respiratory monitoring
  devices

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Blood pressure management in ASCI

• Class III evidence
• SBP lt 90 mmHg should be avoided
• Maintenance of MAP at 85-90 mmHg for the first 7
  days after injury to improve spinal cord
  perfusion is recommended

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Pharmacological Therapy after ASCI

• Class III evidence
• Methylprednisolone treatment is recommended as an
  option
• GM-1 ganglioside is recommended as an option

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Deep venous thrombosis and thromboembolism

• Class I and II evidence
• Prophylactic use of low-molecular-weight
  heparins, rotating beds, adjust dose heparin,
  pneumatic compression stockings or combination is
  recommended

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After diagnosis is established
Methylprednisolone(optional if given within 8 hrs
post-injury) Care for hemodynamics and
respiratory MAP gt 85-90 mm Hg (optional ) DVT
prophylaxis
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Guideline for specific conditions

• Pediatric spine injury
• Spinal cord injury without radiographic
  abnormality ( SCIWORA )
• Atlanto-occipital dislocation
• Occipital condyle fractures
• Isolated Atlas fracture
• Isolated Axis fracture
• Combination of C1-C2 fracture
• OS odontoideum
• Subaxial C-spine injury
• Vertebral artery injury

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Management of Pediatric C-spine injury

• Same as adult if alert, conversant, no deficit or
  tenderness and no painful distracting injury and
  not intoxicated
• AP and lateral ( or open-mouth view if older than
  9 year-old ) C-spine x-rays in those who are not
  as above

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Pediatric spine injury

• Class II-III evidence
• Thoracic elevation or occipital recess to allow
  more neutral position of the spine when strapped
  to a flat backboard is recommended if younger
  than 8 year-old
• Immobilization by halo is recommended in C2
  synchondrosis injury if younger than 7 year-old
• Surgery if isolated ligamentous injury with
  deformity

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SCIWORA

• Class III evidence
• X-rays, CT and MRI to the suspected level of
  injury is recommended
• Angiography or myelography not recommended
• Immobilization ( up to 12 weeks ) until stability
  is confirmed by flex-extension films is
  recommended
• Avoidance of high-risk activities for up to 6
  months may be considered
• MRI may provide useful prognostic information

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Atlanto-occipital dislocation injury

• Class III evidence
• BAI-BDI is useful tool for diagnosis on lateral
  C-spine film
• Presence of prevertebral soft tissue swelling
  should prompt additional imaging
• CT or MRI is recommended if clinical suspicion is
  high in light of normal x-ray
• Treatment with internal fixation and arthrodesis
  is recommended
• Traction may be used although 10 of
  neurological risk is associated

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Occipital condyle injury

• Class III evidence
• Clinical suspicion in altered consciousness,
  occipital pain or tenderness, impaired cervical
  motion, lower cranial nerves paresis,
  retropharyngeal soft tissue swelling in blunt
  trauma patients with high-velocity injury
• CT is recommended, MRI is recommended to assess
  ligamentous integrity
• Immobilization is recommended treatment

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Isolated fracture of Atlas

• Class III evidence
• Fracture with intact transverse ligament is
  treated with immobilization
• Fracture with disruption of the ligament should
  be treated with immobilization with or with
  surgical fixation and fusion

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Isolated fractures of Axis

• Class III evidence
• Type II odontoid fracture in gt 50 year-old should
  be considered for surgical fixation-fusion
• Type I, II and III fractures may be initially
  treated with immobilization
• Type II and III should be considered for surgery
  if dens displacement gt 5mm, comminution of the
  dens(type IIA) or inability to achieve or
  maintain alignment

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Isolated fractures of Axis

• Class III evidence
• Hangmans fracture may be initially treated with
  immobilization
• Surgical fixation should be considered in severe
  angulation ( Francis II-IV, Effendi II),
  disruption of the disc ( Francis V, Effendi III)
  or inability to maintain alignment
• Immobilization is recommended for other types of
  Axis body fracture

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Combination Fx of C1 and C2

• Class III evidence
• Treatment should be based primarily on the
  characteristic of C2 Fx
• Immobilization for most of the Fx
• Surgery in Type II odontoid with ADI gt 5mm,
  hangmans with C2,3 angulation gt 11 degrees is
  recommended
• In some cases, surgical technique must be
  modified for loss of C1 ring integrity

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Os odontoideum

• 3-view x-rays with flex-extension is recommended
  for diagnosis with optional CT or MRI
• Asymptomatic patient can be observed
• Symptomatic patient can be managed with posterior
  fixation-fusion
• Halo immobilization is recommended unless
  transarticular screws are used
• Decompression may be necessary via
  anterior(transoral) or posterior (C1 laminectomy)

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Subaxial injury

• With facet dislocation
• Closed or open reduction is recommended
• Immobilization, fixation-fusion (anterior or
  posterior)
• Prolong bedrest if above not available
• Without facet dislocation
• Same as above except third option

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Acute central cord syndrome

• ICU or monitored setting is recommended
• Medical management, cardiopulmonary and
  hemodynamic care, MAP gt 85mmHg to improve
  perfusion
• Early reduction of fracture-dislocation
• Surgical decompression especially if focal and
  anterior

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Vertebral artery injury

• Angiography or MRA for diagnosis is recommended
• Anticoagulant is recommended for evidence of
  posterior circulation stroke
• Observation or anticoagulant for evidence of
  ischemia
• Observation for no evidence of ischemia