C-Spine Evaluation: Who do you image?

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C-Spine Evaluation Who do you image?

• Steven A. Godwin MD, FACEP
• Assistant Professor
• and Program Director
• Department of Emergency Medicine
• University of Florida HSC/Jacksonville

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Flexion Teardrop Fracture
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Case Presentation

• 30 yo helmeted motorcyclist presents to the ED
  fully immobilized with c-spine precautions
  following an accident. He states he was ejected
  approximately 25-30 feet from the vehicle. He
  recalls most of the accident but believes he may
  have lost consciousness briefly.
• Physical exam is normal with a non-tender
  c-spine. GSC 15

4
Case Questions

• Does he need neuroimaging of the c-spine prior to
  clearing the c-collar?
• What if he were intoxicated or he had an altered
  mental status?
• What if he had a distracting injury?

5
Background

• Prevalence of Disease
• Findings of NEXUS
• 818 patients identified (2.4) of 34,069 patients
  with blunt trauma
• 1,496 distinct cervical spine injuries to 1,285
  different spine structures
• 27 (.08) identified via MRI with SCIWORA2

1 Goldberg W, Mueller C, Panacek E, Tigges S et
al. for the NEXUS Group. Distribution and
patterns of blunt traumatic cervical spine
injury. Ann Emerg Med. 20013817-21. 2 Hendley
G, Wolfson A, William R et al. for the NEXUS
Group. Spinal cord injury without radiographic
abnormality Results of the national emergency
x-radiography utilization study in blunt cervical
trauma. J Trauma. 2002531-4.
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Distribution and patterns of injury

• Most common level of injury-
• C2 vertebra- 286 (24) fractures including
  92 odontoid fractures
• C6 and C7 vertebra- 235 (39.3) fractures
• Most common site of fracture-
• Vertebral body

1 Goldberg W, Mueller C, Panacek E, Tigges S et
al. for the NEXUS Group. Distribution and
patterns of blunt traumatic cervical spine
injury. Ann Emerg Med. 20013817-21 (I)
7
Lowery et al. (NEXUS)

• Demographics of c-spine trauma
• 818/33,922 patients
• Age gt 65 yo- RR 2.09 95 CI 1.77-2.59
• Other ethnicity- RR 1.79, 95 CI 1.46-2.19
• Male sex -RR 1.72, 95 CI 1.48-2.00
• White ethnicity- RR 1.50, 95 CI 1.32-1.52

3 Lowery D, Wald M, Browne B et al.,for the NEXUS
Group. Epidemiology of cervical spine injury
victims, Ann Emer Med. 20013812-16 (I)
8
Truth grows and evolves over time. Harvey
and His Discovery, In An Alabama
Student, 296.
9
Previous Recommendations

• Who should we image?
• ATLS 1997
• Indications
• Every patient with multiple trauma
• All patients with trauma above the clavicle

4 American College of Surgeons. Advanced Trauma
Life Support for Doctors Provider Manual. 6th
ed. Chicago, IL American College of Surgeons
1997
10
Previous Recommendations

• Frohna 1999 an evidence based review
• Neuroimaging-
• Neurologic deficits c/w cord lesion
• Altered mental status from head injury or
  intoxication
• Patients complaining of neck pain or tenderness
• Low threshold for imaging in trauma pts with
  painful, distracting injuries

5 Frohna WJ. Emergency department evaluation and
treatment of the neck and cervical spine
injuries. Em Med Clin North Am,
199917(4)739-91(Review)
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Most Recent Recommendations

• Clinical Decision Rules
• NEXUS (N Engl J Med, 2000)6
• Canadian C-Spine Rule (JAMA, 2001)7

6 Hoffman JR, Mower WR, Wolfson AB, et al., for
the NEXUS Group. Validity of a set of clinical
criteria to rule out injury to the cervical spine
in patients with blunt trauma. N Engl J Med
200034394-99. 7 Stiell IG, Wells GA, Vandemheen
KL, et al. The Canadian C-spine rule for
Radiography in alert and stable trauma patients.
JAMA 20012861841-1848.
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NEXUS

• Prospective observational study at 21 centers
  across the US (n 34,069)
• Validation of a clinical criteria for indications
  for c-spine imaging
• A decision instrument
• The instrument identified all but 8/818
  patients with cervical spine injury

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NEXUS

• So what does 8/818 patients mean?
• Sensitivity 99 (95 CI, 98-99.6)
• NPV 99.8 (95 CI, 99.6-100)
• Specificity 12.9

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NEXUS

• Were any of the 8 missed injuries clinically
  significant?
• 2 patients met preset definitions of clinically
  significant injuries (n576)
• An asymptomatic 54 yo s/p motorcycle accident
• Fracture of anteroinferior C2 w/no soft tissue
  swelling
• ? Extensor tear drop fracture
• 57 yo s/p head on MVC w/ transient LOC pain in R
  shoulder w/ tenderness at paraspinous muscles, R
  clavicle and scapula
• Fracture of R lamina of C6 developed R arm
  parasthesias and required laminectomy/fusion

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NEXUS Decision Instrument- 5 criteria

• Absence of posterior midline cervical tenderness
• Absence of focal neurologic deficit
• A normal level of alertness
• No evidence of intoxication
• Absence of clinically apparent distracting injury

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NEXUS Conclusions

• Application of the decision instrument would have
  decreased overall imaging by 12.6
• A simple decision rule can reliably predict
  patients who need neuroimaging following blunt
  trauma with very high sensitivity
• There may still be compelling reasons to order
  c-spine images outside of the criteria in
  individual cases

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Anterior Occipitoaltlantal Subluxation
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Canadian C-Spine Rule7

• Prospective cohort study at 10 community and
  university hospitals
• Convenience sample of 8924 adults
• Objective- To derive a clinical decision rule to
  detect C-spine injury and allow more selective
  use of radiography in alert and stable blunt
  trauma patients

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Canadian C-Spine Rule

• 151/8924 (1.7) patients identified with
  clinically significant injury
• Decision rule results
• Sensitivity- 100 (95 CI, 98-100)
• Specificity- 42 (95 CI, 40-44)
• Ordering rate utilizing criteria- 58

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Canadian C-Spine Rule7

• Decision rule results
• Clinically insignificant injury
• 28/8924 patients (0.3)
• 1/28 missed
• 63 yo with unidentified C3 osteophyte avulsion fx
  

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Canadian C-Spine Rule

• Decision Rule- 3 questions
• Is there a high risk factor present mandating
  radiography ?
• Defined as
• age gt 65y,
• dangerous mechanism, or
• parasthesias in extremities

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Canadian C-Spine Rule

• Decision Rule-
• Is there low-risk factor present that allows for
  safe assessment of ROM?
• Defined as
• simple rear-end MVC,
• sitting position in ED,
• ambulatory at any time since injury,
• delayed onset of neck pain, or
• absence of midline C-spine tenderness

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Canadian C-Spine Rule

• Decision Rule-
• Is the patient able to actively rotate neck 45o
  to R and L

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Canadian C-Spine Rule

• Dangerous Mechanisms
• Fall gt 1 meter/ 5 stairs
• Axial load
• MVC high speed (gt100 km/hr), rollover, ejection
• Motorized recreational vehicles
• Bicycle collision

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Canadian C-Spine Rule

• Conclusions
• Potential sensitive rule for identifying patients
  requiring c-spine radiography following blunt
  trauma
• Potential c-spine radiography rate of 58.2
• Relative reduction of 15.5 from 68.9

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Recommendations

• Both the Canadian and Nexus clinical decision
  rules provide sensitive and reliable indicators
  for identification of patients at risk for
  cervical injury following blunt trauma
• Use of clinical decision rules may reduce the
  number of imaging test performed

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Summary

• Which study to use?
• Does it really matter?
• Dont get caught up in the hype!
• Might be as simple as finding the one you can
  best remember and follow it!

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Evolving Literature

• Prospective study of 1,757 patients to develop
  decision rule (1,449 received plain films)
• With decision rule implementation 537 (30.6)
  studies were felt to be redundant
• Failure of C-spine to document injury
• 129 patients underwent CT with 33 positive
  findings
• 9/38 (23.7) fractures were not identified with
  plain films

8 Edwards M, Frankema S, Kruit M, et al. Routine
cervical spine radiography for trauma victims
Does everybody need it. J Trauma 2001 50529-534.
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Evolving Literature Griffen et al. 2003

• Cervical Spine Radiographs (CSR) vs CT
• Retrospective query of prospectively collected
  trauma database
• CSR and CT performed on all patients with
  posterior midline neck tenderness, altered mental
  status, or neurologic deficit (3,018 patients)
• 116 patients (9.5) identified with cervical
  spine injury (fracture or subluxation)

9 Griffen M, Frykberg E, Kerwin A, et al.
Radiographic clearance of blunt cervical spine
injury plain radiograph or computed tomography
scan? J Trauma. 2003 55(2)222-6.
30
Griffen et al. 2003

• C-spine injury was identified on both CSR and CT
  in 75/116 (65) patients
• Injury missed 41/116 (35) patients with CSR
• All these injuries required some form of
  treatment
• No identifiable factors predicted false negative
  CSR

9 Griffen M, Frykberg E, Kerwin A, et al.
Radiographic clearance of blunt cervical spine
injury plain radiograph or computed tomography
scan? J Trauma. 2003 55(2)222-6.
31
? Nexus/Canadian Rules

• Does the new literature cloud the results of the
  previous decision rules?

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General acceptance of truth takes time. On
The Study of Tuberculosis, Phila Med J
190061029-30
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Questions?
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Gracias
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References

• 1 Goldberg W, Mueller C, Panacek E, Tigges S et
  al. for the NEXUS Group. Distribution and
  patterns of blunt traumatic cervical spine
  injury. Ann Emerg Med. 20013817-21.(I)
• 2 Hendley G, Wolfson A, William R et al. for the
  NEXUS Group. Spinal cord injury without
  radiographic abnormality Results of the national
  emergency x-radiography utilization study in
  blunt cervical trauma. J Trauma. 2002531-4.(I)
• 3 Lowery D, Wald M, Browne B et al.,for the NEXUS
  Group. Epidemiology of cervical spine injury
  victims, Ann Emer Med. 20013812-16 (I)
• 4 American College of Surgeons. Advanced Trauma
  Life Support for Doctors Provider Manual. 6th
  ed. Chicago, IL American College of Surgeons
  1997 (III)
• 5 Frohna WJ. Emergency department evaluation and
  treatment of the neck and cervical spine
  injuries. Em Med Clin North Am,
  199917(4)739-91(Review)
• 6 Hoffman JR, Mower WR, Wolfson AB, et al., for
  the NEXUS Group. Validity of a set of clinical
  criteria to rule out injury to the cervical spine
  in patients with blunt trauma. N Engl J Med
  200034394-99.
• 7 Stiell IG, Wells GA, Vandemheen KL, et al. The
  Canadian C-spine rule for Radiography in alert
  and stable trauma patients. JAMA
  20012861841-1848.

36
References

• 8 Edwards M, Frankema S, Kruit M, et al. Routine
  cervical spine radiography for trauma victims
  Does everybody need it. J Trauma 2001
  50529-534.
• 9 Griffen M, Frykberg E, Kerwin A, et al.
  Radiographic clearance of blunt cervical spine
  injury plain radiograph or computed tomography
  scan? J Trauma. 2003 55(2)222-6.