Journal Meeting

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Journal Meeting
19th October 2002

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• 91-10-19

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Validity of a Decision Rule to Reduce Cervical
Spine Radiography in Elderly Patients With Blunt
Trauma

• Annals of Emergency Medicine
• September 2002 Volume 40 Number 3

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Background

• Estimated 800,000 c-spine x-ray (CSXR) was taken
  for victims of blunt trauma annualy in US, only
  2.4 have c-spine injuries (CSI)
• Selective criteria (NEXUS decision instrument)
  was developed to safely improve the yield of CSXR
• National Emergency X-radiography Utilization
  Study

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NEXUS Decision Instrument

• Clinical criteria in excluding cervical spine
  injuries after blunt trauma if all the followings
  are absent
• S severe distracting pain
• P posterior midline tenderness
• I intoxication
• N neurologic deficit
• A altered consciousness
• C-spine x-ray should be appropriate if any one of
  the above findings is present

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• In this prospective observational study
  (involving 34,069 pts) the NEXUS decision
  instrument criteria were shown to offer potential
  12.6 reduction in CSXR while maintaining a
  sensitivity of 99.6 for clinically significant
  CSI

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Question to be answered

• Geriatric patients might be more vulnerable to
  CSI than the younger age group due to
• Osteopenia
• Physical debility
• Diminished pain perception
• Dementia
• Other age-related comorbidity
• Is the the NEXUS criteria retained their safety
  and efficacy in the geriatric?

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Objectives

• Examine the the operator characteristics of the
  NEXUS decision instrument in the subset of
  geriatric patients in the NEXUS database.
• It also explores some of the common features of
  CSI found in this group

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Methods and Materials

• A prospective, observational and multi-center (21
  institutions) study
• Before a minimum of 3-view c-spine X-ray (AP,
  Lat odontoid) was ordered, the presence or
  absence of each 5 criteria were records.
• Further imaging study was left to the discretion
  of the treating physician
• The presence of CSI was determined after final
  interpretation of all c-spine imaging studies.

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Methods and Materials

• True-positives
• CSI failed to meet any of the 5 NEXUS criteria
• False-negatives
• Meet all 5 criteria but with CSI
• True-negatives
• Meet all 5 criteria without CSI
• False-positives
• Without CSI but failed to meet any of the 5
  criteria
• Geriatrics means aged 65 or older

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Radiographically documented CSI categorized as
not clinically significant
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Results

• Total of 34069 patients were included
• 818 (2.4) with CSI, including fractures,
  dislocations, or spinal cord injuries,
• 2,943 (8.6) geriatric
• 31,126 (91.4) nongeriatric

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Distribution of the Incidence of CSI by Age
Total 34,069 CSI 818 (2.4)
Geriatric 2,943 (8.6) CSI 135 (4.59)
Nongeriatric 31,126 (91.4) CSI 683 (2.19)
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Geriatric vs non-geriatric injuries at each level
of cervical vertebra and interspace
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Results and Discussions

• Both groups have the similar mean number of
  injuries per patient of 1.8
• The more prevalent CSI in geriatric group was
  attributable to increased skeletal injury in
  these patient
• Whereas the incidence of spinal cord injury
  similar in both groups (0.3 in geriatrics vs
  0.2 in nongeriatrics)

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Results and Discussions

• More prevalence upper c-spine injury in geriatric
  patient
• 8 times more odontoid fracture in the geriatric
  than the nongeriatric patients.
• the narrowed caliber odontoid become more
  vulnerable in the osteopenic geriatric.

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Results and Discussions
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Operator Characteristics of the NEXUS Criteria
in Excluding CSI
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Conclusions

• The NEXUS decision instrument appears to perform
  comparably in the elderly as it does in other
  patients with blunt trauma.
• Application of the NEXUS criteria should allow
  avoidance of cervical spine radiography in
  approximately 14 of patients older than 64 years
  of age with blunt trauma, while maintaining a
  sensitivity that approaches 100 for clinically
  significant injury

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Impact on Our Daily Practice?

• Since upper c-spine injury, especially odontoid
  fracture is more prevalence in geriatric, in
  addition to the routine APLat views , open-mouth
  view should be considered in the geriatric
  patient with potential CSI
• So, AP LAT open-mouth view for next CSI
  screening.

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Thank You !