C-Spine Injuries in the ED: Essentials & Updates. Charles Khoury MD

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1 C-Spine Injuries in the ED: Essentials & Updates Charles Khoury MD

2 C-Spine Injuries in the ED: Essentials & Updates Charles Khoury MD

3 Questions We ll Answer How should I clear a patient s c-collar? When can I actually take the c-collar off? What if the patient is drunk? Are plain films dead? What exactly is whiplash?

4 American Data There are >1 million visits to EDs annually for blunt trauma patients who present with a concern for possible cervical spine injury Many of these undergo imaging of their c-spine, with overwhelming majority (98%) of the studies being negative for a fracture

5 Two Competing Objectives Catch every significant injury Avoid unnecessary imaging

6 First way to avoid imaging: NEXUS Criteria NEJM: Hoffman, et al. (2000) Prospective, multicenter, observational study ~34,000 patients

7 NEXUS You HAVE to get imaging unless: No posterior midline tenderness No evidence of intoxication Normal level of alertness No focal neurological deficit No painful distracting injuries

8 No evidence of intoxication Can t even have the odor of alcohol They have to be pristine in their sobriety

9 Normal level of alertness In the study: Needed to be able to remember 3 objects at 5 min In other words, need to be really, really with it Need to have no delayed or inappropriate response to external stimuli Can t be even a little slow or off or sleepy

10 No focal neurological deficit

11 No painful distracting injuries This is where it gets tricky Subjectivity in clinical decision rules?

12 No painful distracting injuries The literature offers us some guidance on this Long bone fracture Visceral injury requiring surgical consultation Large laceration Degloving injury or crush injury Large burns The criteria use the presence of these particular painful distracting injuries, not necessarily whether the patient is distracted by them

13 No painful distracting injuries One last criterion Any injury producing acute functional impairment, meaning that if the patient is distracted even by a relatively minor injury, you can t clear them. In other words, distraction is key If distracted can t clear

14 NEXUS in a trauma? IV s Fingers in orifices Exposed patient Yelling

15 No midline tenderness I m talking about this one last deliberately

16 No midline tenderness Does this hurt? Get in front of the patient & look at their face Push on each of the vertebrae Look for grimaces/facial expressions/closing of eyes

17 What Now? Let s say that the NEXUS criteria are all negative EXCEPT the midline TTP Do you send them to CT? I think that at this point, you can apply the Canadian C-spine Rules So if a patient has negative NEXUS except midline TTP, you can feed them into Canadian

18 Canadian C-spine Rule More complex than other c-spine clinical decision rules (NEXUS) More sensitive Can potentially be used on patients who cannot be cleared using other rules

19 Canadian C-spine Rule Three conditions

20 Condition One: Perform radiography in patients with any of the following high-risk factors: Age 65 or older Dangerous mechanism of injury Fall from 1 meter or five stairs Axial load to the head MVC at >100 km/hr Motorized recreation vehicle accident Ejection from vehicle Bicycle collision with immovable object Paresthesias in the extremities

21 Condition Two: In patients with none of the high-risk factors, assess for any low-risk factor that allows for safe assessment of neck range of motion: Simple rear-end MVC Sitting position in ED Ambulatory at any time Delayed onset of neck pain Absence of midline cervical TTP

22 Condition Three: If a patient has ANY of the Condition Two (low-risk) factors, test active ROM Perform radiography in patients who are not able to rotate their neck actively 45 degrees both left and right Patients able to rotate their neck, regardless of pain, do not require imaging

23 If patient is and has any of the low-risk criteria Simple rear-end collision OR sitting position in ED OR ambulatory at any time OR delayed onset of pain OR absence of midline TTP AND no dangerous mechanism THEN you can range their neck Need to see if they re able to actively range 45 degrees It s allowed to hurt; are they able to range left & right If they have ligamentous injury, they will stop

24 The Sequence NEXUS negative no imaging NEXUS shows midline TTP Canadian If they fail Canadian CT scan

25 When can I actually take the collar off? If the CT is negative, you re not done yet You still have to CLEAR the c-spine There are still ligamentous injuries that may not be picked up by CT

26 What if they re still really tender? You can t clear a patient with significant persistent TTP with just a CT scan The next step (if no pain or minimal pain) is again to have them range 45 degrees If they re able to do so, with negative CT, you are done

27 What if they re still really tender? If they can t range, you have two options Orthotics neurosurgery follow up MRI Flexion/extension?

28 What if the patient is drunk? What do you do if the CT is negative on an obtunded or drunk patient? You LEAVE THE COLLAR ON Never in the ED should you ever clear the collar of an obtunded patient in the presence of a negative CT

29 Griffen study Are plain films dead?

30 Griffen Study 1199 blunt trauma pts underwent both plain film & CT imaging 116 patients had bony injury on CT 75 on plain films More importantly, all injuries missed by cervical spine radiographs required treatment Conclusion? C-spine CT All radiologic societies EAST (Eastern Association of Surgeons for Trauma)

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32 Whiplash A type of cervical strain resulting from cervical acceleration-deceleration injury A strain or spasm of the muscles that run up and down the sides of the spine in the neck

33 Whiplash Caused by sudden back and forth motion of the head and neck that occurs in a MVC Symptoms are often minor immediately after the accident (stress, adrenaline) On second & third day after the accident, the stiffness and tension in the muscles tends to become much more apparent

34 Whiplash Various interventions have been advocated Systematic reviews and randomized controlled studies have shown: Early mobilization as compared to immobilization or rest plus use of a cervical collar significantly reduces pain Advice to act as usual plus anti-inflammatory drugs versus immobilization plus 14 days sick leave improves mild subjective symptoms

35 Soft Collar? No! What are they good for?

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37 Meds I prescribe

38 Meds I prescribe Ibuprofen

39 Meds I prescribe Anaprox DS (naproxen/naprosyn)

40 Meds I prescribe Meloxicam

41 Meds I prescribe Methocarbamol (Robaxin)

42 Things I Tell The Patient You ll be more sore tomorrow than today Narcotic pain medications won t help A neck brace won t help Scheduled, not as needed meds are essential Massages work

43 Wrapping Up Use NEXUS & Canadian in sequence to avoid unnecessary imaging Midline TTP should be found on physical exam If you re going to image use CT, not plain films Take a few minutes to counsel the patient

44 References Holmes JF, Akkinepalli R. Computed Tomography versus Plain Radiography to Screen for Cervical Spine Injury: a Meta-analysis. Journal of Trauma May; 58(5): Stiell, et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. New England Journal of Medicine December; 349: Ham, et al. Pressure Ulcers from Spinal Immobilization in Trauma Patients: A Systematic Review. J Trauma Acute Care Surg April; 76(4): Griffen MM, et al. Radiographic Clearance of Blunt Cervical Spine Injury: Plain Radiograph or Computed Tomography Scan. Journal of Trauma. 2005; 55:2227. Verhagen AP, Peeters GG, et al. Conservative treatment for whiplash (Cochrane Review). In: The Cochrane Library, Issue 2, 2002.