My Approach to Clearing C-Spines

In Clinical Questions, Medical Concepts by Nadim LalaniLeave a Comment

I gave a talk the other day on clearing C-Spines, with Prezi linked here. As a disclaimer, this is my approach based on my clinical experience and from reading the literature – you should discuss this amongst your colleagues and review the literature to see if you reach the same conclusions.  I would appreciate some comments – peer review if you will.

Objectives of the Talk:

  1. Apply the Canadian C-Spine Rule and NEXUS criteria to aid in the use of clearing C-spines in Adults
  2. Gain an approach to clearing C-Spines in Pediatric Patients
  3. Understand when further imaging with CT and MRI may be indicated

Introduction:

  • Canadian ER physicians see 200, 000 alert, stable trauma victims per year
    • Of these, 1% will end up having a clinically important C-Spine injury [CSI]
    • If you consider just patients going for neck X-Rays, 2.5% will have a CSI [from NEXUS]
    • A large variation in clearing c-spine practice continues to exist
    • Although there is literature to guide our approach – much of it is confusing and contradictory
    • Persistent medico-legal fear continues to influence our practice.
    • 2 validated rules exist that can help identify the need for radiography and clear C-Spines safely.

Clinical decision rules [CDRs]:

CDRs usually include a mix of history, physical findings and tests.

Advantages of using CDRs

  • CDRs are useful where diagnostic uncertainty.
  • CDRs allow physicians to provide a standardized approach to problems.
  • CDRs allow physicians to make efficient and bias-free clinical decisions

Challenges with CDRs

  • Applicability to the patient you are seeing [e.g. CCR – excluded pediatric patients]
  • Designed by academics and applied by mostly non-academics
  • Fail if doc cannot remember nuances of inclusion/exclusions
  • Publish best case sensitivity [need to look at the confidence intervals] 

PEARL: You do not have to memorize CDR’s – know where to look. I sometimes show/discuss them with patients so that they understand my thinking process. In the following cases we will apply the two major CDRs to guide our decision making.

 

C-Spine

CASE 1:

65 year-old F driver rear-end collision on highway at 100 kmh

  • Did NOT lose consciousness.
  • Was wearing her seat-belt & the airbags deployed.
  • Walks into the ER.
  • Is complaining of left wrist, left ankle and chest wall tenderness.

On examination:

  • Alert, oriented. No complaints of neck pain or neurologic deficits.
  • Moving her neck to show you that she is okay.
  • Mild seat-belt abrasion to chest.
  • Abrasion to her wrist and ankle.

What would your approach be? What about the next case?

CASE 2:

12 year-old passenger seated in the back seat of a vehicle that was hit by another car while changing lanes. The car was spun around and then hit a light pole. The patient did not lose consciousness. He was wearing his seat belt.

  • The patient has been brought to the ER in a C-Spine collar.
  • He is complaining of mild headache from a bruise to his right temple.

On Examination:

  • Alert oriented.
  • In a C-spine Collar.
  • No complaints of neck pain or neurologic deficits.
  • Small bruise to Right temple.

NEXUS Rule1

Prospective observational study in 34000 patients in 21 centres in USA

  • Results:
    • 818 patients had C-Spine fractures on x-ray
    • Rule missed 8/818. BUT only 2/818 were clinically significant
    • Sensitivity = 99.6% (98.6‐100%,95%CI)
  • Commentary:
    • Largest study that we have.
    • Subsequent validation by Steill et al 93% sensitive
    • Useful in children [see below]
    • Useful in those that fail CCR by criteria [age and mechanism] 

Bottom Line

Patients have virtually ZERO risk of CSI if they have:

    • NO Mid-line tenderness
    • NO Altered mentation
    • NO intoxication [alcohol or drugs]
    • NO neurologic deficits
    • NO distracting injury
      • Long bone fracture
      • Large: crush/degloving/burn/laceration
      • ER docs opinion

For more information on distracting injuries

  • Most recently Rose et al 20122 showed that only 1/464 [0.2%] of patients with no neck pain and a distracting injury had a c-spine injury on CT scan
  • Another study3 shows that 95% of CSI patients with distracting injuries WILL STILL HAVE NECK PAIN despite the “distracting injury”
  • Good Summary can be found at: ALIEM blog 

Spine Injuries in children

  • Children < 3 years of age will not comply with 3-view radiographs
    • Fortunately injuries below C1-C3 level are almost non-existent [until 6 years of age]
    • AP and Lateral radiographs + “clinical assessment” is the standard of care
    • High Risk: BIG mechanism, multiply injured, head injury.

Applying CDR in Children

  • NEXUS and kids4
    • 3,065 patients under 18
      • 88 under 2 years
      • 817 aged 2-8 years [Big cohort compared to Paeds Studies]
      • 2,160 aged 8-17 yrs [Big Cohort]
  • 30 kids had CSI
    • Almost all were in older kids [aged 11-17]
    • ZERO CHILDREN WERE MISSED BY APPLYING NEXUS RULE
  • Only 5/3065 kids with fractures were 9 and under
    • only 2 kids <3 had CSI [type 3 odontoid in a 2yo and Occipital fracture in a 3yo]
    • the 3 kids 6-9 yo had significant fractures that I  think would not have been missed [cranio-cervical dissociation, C1 ant/post arch fracture + type 2 odontoid, C4 flexion teardrop fracture]
    • As of my lit review – one case report of NEXUS miss, a 3yo who had a lap-belt sign [visceral (and therefore distracting) injury]
  • Although the authors do not recommend NEXUS application in the <8yo cohort, I feel that the number of kids 5-8 together with the reliability of a child >5yo means that it may be applicable.
  • My practice. I use it in the reliable > 5yo. I have low threshold for “distracting injury”. I consider High risk as: high risk mechanism & child has other injuries.
  • For kids that I cannot use the rule [e.g. toddlers and infants]:
    • ALL get immobilised with sandbags/tape/collar
    • ALL get bedside AP and Lateral Xray
    • If xrays look fine: COLLAR OFF
      • If child moves neck: CLEAR
      • If child has guarding/torticollis: CT Neck 

CASE 3:

40 yo Male who [drunk] fell down a flight of stairs.

  • He was knocked out briefly.
  • He is not complaining of any C –Spine tenderness.

On Examination:

  • Alert oriented [but drunk].
  • In a C-spine Collar.
  • No complaints of neck pain or neurologic deficits.
  • Small bruise to Right temple.

This patient fails NEXUS due to intoxication. What do you do with this guy?

The Canadian C Spine Rule [CCR]5:

  • Prospective study 8900 patients in 10 Canadian centres
    • Included:
      • GCS 15 and normal VS
      • neck pain from injury or
      • no neck pain and trauma above clavicles, worrisome mechanism for C spine, not ambulatory
  • Excluded < 16yo, presenting >48h, pregnant, unstable,  GCS <15, known spine dis [e.g. RA], trivial injury [laceration]
  • Defined CSI : any #, dislocation or ligamentous instability
  • Secondary outcome: clinically unimportant injury
  • 2700 patients did not get X-rays [14 day follow up phone call]
  • Results:
    • Sensitivity = 100% [98‐100]
    • Specificity = 42% [40-44]

How to Apply the Rule:  You have to ask yourself 3 questions?

1) Is there a high risk feature that mandates radiography? … if NOT …

2) Is there ANY low risk feature that will allow safe range-of-motion testing? If yes …

3) Can the patient move 45 deg left and right? If yes – CLEAR!

Here’s a visual representation of the CCR:

canadian-cspine

Common Problems with the CCR

What to do with midline tenderness?

What some of the literature shows:

  • No midline tenderness confers NPV of 98%
  • CCR applied as is shows that presence of ANY low risk feature allows for safe ROM
  • CCR did not exclude drunks. Only requisite is GCS 15.
  • [Duane et al J Trauma 20116] [Sicker patients 6.4% incidence of CSI]
    • Midline tender + sober + no distracting injury = 12% will have injury on CT scan
    • Midline tender + either intoxicated or with distracting injury = 8.4% injury on CT scan
    • NO comment on whether these injuries are clinically significant or not. 

The bottom line:

Midline tenderness does not trump any of the other “Low Risk Features” that allow safe range-of-motion testing. If persistent and significant this suggest enough risk to X-ray (and maybe CT depending on patient).

What to do with drunk patients?

  • Risk for C-Spine injury + GCS < 15 = Plain Radiographs.
  • Wait for them to have GCS 15 and try and clear clinically.
  • If they can’t comply with plain films go straight to CT.

Perception that CT is better for ALL?

  • CT Is NOT Better for ALL

I have heard from a couple of colleagues that “plain films miss 20-30% of C-Spine injuries”. I even attended a recent conference where a speaker [who I respect] suggested a “CT for all” approach for those we cannot clear with NEXUS and CCR because:

  1. It appears that there’s an epidemic of inadequate X-Rays of the C spine
  2. It appears that ER docs all of a sudden seem to suck at reading one of their bread and butter tests.

I took a look the “CT is better literature” and I do not agree:

  1. The incidence of CSI in these studies is 5-23%. [Compare that to 2.4% for NEXUS]
  2. They seem to include the sicker crowd that would not typically be able to be cleared clinically [unconscious, altered]
  3. They compare inadequate C-Spine Films to adequate CT scans!
  4. They have methodologic flaws or are making these recommendations based on weak evidence

The bottom line:

[1] Alert stable patients at risk of C-Spine injury with an incidence of about 2.5%
–> PLAIN FILMS ARE JUST FINE HERE

[2] Sicker patients with an incidence of greater than 5% [head injured, altered, polytrauma etc]

–> THESE PATIENTS MAY NEED CT

When CT may be necessary:

Reasonable indications for CT from my experience:

  • Suspicious looking X-Ray/inadequate X-Ray
  • Persistent significant midline tenderness
  • Polytrauma cases going for CT head since co-incidence of head/neck injuries 5%
  • Intubated patients / patients unable to comply with 3 views + swimmers’ view
  • Patients with existing C spine disease / elderly patients at risk for false positive X-Ray

When MRI may be necessary:

CT alone has been shown to be a reliable way to exclude unstable injuries; however studies like this from the CJEM7 are contradictory and incite fear in clinicians. Some of the challenges arise because:

  • Evidence suggests that 2% of patients with negative CT may have a neurosurgical lesion on an MRI
  • Surgeons do not have uniform practice in these patients
  • Often CT is negative but you have a symptomatic patient
  • Despite the utility of the Flex-Ex View in the CJEM article above, neck pain/symptoms despite Normal CT has a differential diagnosis – the most important of which may or may not be picked up on Flex-Ex!

Bottom line – MRI indicated for:

Negative CT and persistent significant pain/guarding or Neurologic deficit.

 

I would welcome your thoughts.

This post was originally published on the ERMentor Blog. It was revised by Riley Golby and Rob Carey and reposted on CanadiEM on XX XX XXXX.

References

1.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma. New England Journal of Medicine. 2000;343(2):94-99. doi:10.1056/nejm200007133430203.
2.
Rose M, Rosal L, Gonzalez R, et al. Clinical clearance of the cervical spine in patients  with distracting injuries: It is time to dispel the myth. J Trauma Acute Care Surg. 2012;73(2):498-502.
3.
Konstantinidis A, Plurad D, Barmparas G, et al. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011;71(3):528-532.
4.
Viccellio P, Simon H, Pressman B, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20.
5.
Stiell I, Wells G, Vandemheen K, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
6.
Duane T, Mayglothling J, Wilson S, et al. National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography. J Trauma. 2011;70(4):829-831.
7.
Grunau B, Dibski D, Hall J. The daunting task of “clearing” the cervical spine. CJEM. 2012;14(3):187-192.

 

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Nadim Lalani
Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.
Nadim Lalani
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