6/1/2013 Cervical Spine Trauma Cervical Spine Trauma Cervical Spine Injury Cervical Spine Injury Screening the Patient with Neck Pain Screening the Patient with Neck Pain � 7000-10.000 � 7000-10.000 present for present for treatment treatment Murat Pekmezci, MD Murat Pekmezci, MD � 5.000 die at the � 5.000 die at the Assistant Clinical Professor Assistant Clinical Professor scene scene University of California San Francisco University of California San Francisco Distribution of Cervical Spine Injury Distribution of Cervical Spine Injury Cervical Spine Injury Cervical Spine Injury � NEXUS Study � NEXUS Study � 33.922 BTP → 818 � 33.922 BTP → 818 Injuries (2.4%) Injuries (2.4%) � Male, 71% � Male, 71% Lowery DW et al, Ann Emerg Med, 2001 Lowery DW, et al, Ann Emerg Med, 2001 1
6/1/2013 Neurologic Deterioration Secondary to Unrecognized Neurologic Deterioration Secondary to Unrecognized Neurologic Injury Neurologic Injury Spinal Instability Following Trauma Spinal Instability Following Trauma � Significant Source of Morbidity for the patient � Significant Source of Morbidity for the patient � 8 Level I trauma centers � 8 Level I trauma centers � High cost to the Society � High cost to the Society � Incidence � Incidence � Medical Care � Medical Care � 0.21% among patients with spine fractures � 0.21% among patients with spine fractures � Litigation � Litigation � 0.025% among all trauma patients � 0.025% among all trauma patients Levi AD et al, Spine, 2006 Litigation of unrecognized cervical Litigation of unrecognized cervical Lifetime Cost of Spinal Cord Injury Lifetime Cost of Spinal Cord Injury spine injuries spine injuries � Mean cost of litigation � Mean cost of litigation $ 2.9 million $ 2.9 million � $153.000 – $8.9 million � $153.000 – $8.9 million Type I Error: Tests were Type I Error: Tests were � � inadequate/improper inadequate/improper Type II Error: Tests were Type II Error: Tests were � � adequate but misread/not read adequate but misread/not read Type III Error: Tests were Type III Error: Tests were � � adequate and read correctly but adequate and read correctly but not sensitive enough not sensitive enough www.spinalcord.uab.edu/factsandfiguresataglance Lekovic et al, Neurosurgery, 2007 Mar;60(3):516-22 2
6/1/2013 Cost to Society Cost to Society C-Spine Clearance Protocols C-Spine Clearance Protocols � Improve evaluation of patients at high risk � Improve evaluation of patients at high risk ED Visits in CA 52.000 Missed injury rate 0.03% � Decrease (eliminate) missed injuries � Decrease (eliminate) missed injuries Litigation Cost $2.900.000 Medical Care $3.100.000 � Standardize the clearance process � Standardize the clearance process Total Cost to CA $90 M EAST PROTOCOL EAST PROTOCOL 3 Common Scenarios 3 Common Scenarios Cervical Spine Injuries Cervical Spine Injuries � Boney Injuries � Boney Injuries � Ligamentous Injuries � Ligamentous Injuries � Occipital Condyle Fractures � Occipital Condyle Fractures � Atlantooccipital dislocation � Atlantooccipital dislocation Mental Status � Atlas Fractures � Atlas Fractures � Transverse atlantal � Transverse atlantal ligament injury ligament injury � Axis Fracture � Axis Fracture � Flexion-distraction injuries � Flexion-distraction injuries � Flexion-Compression injuries � Flexion-Compression injuries Alert, awake Obtunded � Extension Compression � Extension Compression injuries injuries GCS=15 GCS <14 � Transverse foramen fractures � Transverse foramen fractures � Lateral Mass fractures � Lateral Mass fractures � Lamina fractures � Lamina fractures � Spinous process fractures � Spinous process fractures Asymptomatic Symptomatic Remove Hard Collar as soon as feasible after trauma 3
6/1/2013 Cervical Collar in ICU Cervical Collar in ICU Cervical Collar in ICU Cervical Collar in ICU � Increased ICP ( 5 mmHg) � Increased ICP ( 5 mmHg) � IV access � IV access � Difficulty in airway management � Difficulty in airway management � Gastrostasis and aspiration with associated prolonged � Gastrostasis and aspiration with associated prolonged supine positioning supine positioning � Increased likelihood of thromboembolism � Increased likelihood of thromboembolism � Nerve palsy � Nerve palsy � Increased nursing needs � Increased nursing needs Ackland HM, 2007, Spine 32;4:423-428. Richards PJ, Injury 2005; Morris JGT et al, BMJ 2004 Collar Type Collar Type TAKE HOME MESSAGE #1 TAKE HOME MESSAGE #1 � Restriction of ROM � Restriction of ROM � Use MIAMI-J or ASPEN if you need to use � Use MIAMI-J or ASPEN if you need to use � Philadelphia = Miami J � Philadelphia = Miami J collars long term collars long term � Occipital pressure � Occipital pressure � Miami J, Miami J Occian < Philadelphia, Aspen � Miami J, Miami J Occian < Philadelphia, Aspen � 89% decrease in CRU � 89% decrease in CRU � Philadelphia should be replaced as soon as � Philadelphia should be replaced as soon as possible possible Jacobson TM et al, J Nurs Care Qual, 2008 4
6/1/2013 Physical Examination Physical Examination Why ? Why ? Part of Clearance Process � 36 y.o. F, fell from a � 36 y.o. F, fell from a � Inspection � Inspection bike bike � Palpation � Palpation � Presented with neck � Presented with neck and shoulder pain and shoulder pain � Detailed neurologic examination � Detailed neurologic examination � Associated injuries � Associated injuries 3 Common Scenarios 3 Common Scenarios Who needs Imaging? Who needs Imaging? � Algorithms to identify patients who can � Algorithms to identify patients who can Mental Status undergo clinical clearance undergo clinical clearance Alert, awake Obtunded � NEXUS Criteria � NEXUS Criteria GCS=15 GCS <14 � Canadian C-Spine Rules � Canadian C-Spine Rules Asymptomatic Symptomatic 5
6/1/2013 NEXUS Criteria NEXUS Criteria NEXUS Criteria NEXUS Criteria � Distracting Injury � Distracting Injury � Normal level of alertness (GCS 15) � Normal level of alertness (GCS 15) � a long bone fracture; � a long bone fracture; � No evidence of intoxication � No evidence of intoxication � a visceral injury requiring surgical � a visceral injury requiring surgical consultation; consultation; � Absence of tenderness in the posterior midline � Absence of tenderness in the posterior midline � a large laceration, degloving injury, or crush � a large laceration, degloving injury, or crush injury; injury; � Absence of a neurological deficit � Absence of a neurological deficit � large burns; � large burns; � any other injury producing acute functional � any other injury producing acute functional � No distracting pain elsewhere � No distracting pain elsewhere impairment. impairment. Hoffman JR et al, N Engl J med, 2000 Hoffman JR et al, N Engl J med, 2000 � 406 patients � 778 patients � 778 patients � 34% had DI � 34% had DI � 40 patients had CSI � 37 patients had CSI � 37 patients had CSI � 7 had normal CE = All had upper torso DI � 54% had DI � 54% had DI � 8% DI was the only indication for X-ray � 8% DI was the only indication for X-ray � Incidence of CSI in patients with neck pain � 18.9% 6
6/1/2013 Canadian C-Spine Rules Canadian C-Spine Rules Canadian C-Spine Rules Canadian C-Spine Rules � 8924 patients enrolled � 8924 patients enrolled Any high-risk factor that mandates radiography? • Age>65yrs, or � 100 % sensitivity � 100 % sensitivity • Dangerous mechanism, or • Paresthesias in extremities YES � identifying 151 clinically important C-spine injuries � identifying 151 clinically important C-spine injuries NO � 42.5 % specificity � 42.5 % specificity Any low-risk factor that allows safe assessment of range of motion? NONE • Simple rear-end MVC, or Radiography • Sitting position in ED, or • Am bulatory at any time, or � Deemed a highly sensitive decision rule for � Deemed a highly sensitive decision rule for • Delayed onset of neck pain, or • Absence of midline C-spine tenderness use of C-spine radiography in alert and use of C-spine radiography in alert and NO YES stable trauma patients stable trauma patients Able to actively rotate neck? • 45 degrees left and right YES Stiell IG et al, JAMA, 2001 No Radiography TAKE HOME MESSAGE #2 TAKE HOME MESSAGE #2 Alert patient with normal cervical spine exam Alert patient with normal cervical spine exam and painless ROM and painless ROM (Mechanism of Injury) (Mechanism of Injury) C-Spine can be cleared on clinical basis C-Spine can be cleared on clinical basis http://www.east.org/tpg/cspine2009.pdf 7
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