Trauma: Spine Trauma

Function

• To Immobilize the Neck & Prevent Further Injury
• *No Actual Data to Support Improved Neurologic Outcomes, Prevention of Further Injury or if Small Voluntary Spinal Movements Cause Harm

High-Quality CT

• Requirements:
  • < 3 mm Axial Slice Thickness
  • Read by an Attending Radiologist
• 2015 EAST Guidelines:
  • 91% Negative Predictive Value for Stable Injuries
  • 100% Negative Predictive Value for Unstable Injuries
• 2016 Western Trauma Association Study of Patients that Failed NEXUS Criteria
  • 0.03% False Negative Rate for Clinically Significant Injuries – However All Had a Focal Neurologic Abnormality on Their Index Clinical Examination Consistent with Central Cord Syndrome
  • For Clinically Significant Injuries:
    • 98.5% Sensitivity
    • 91.0% Specificity
    • 99.97% Negative Predictive Value

Clearing a Cervical Collar

• Determine if Patient Requires a CT (NEXUS Criteria or Canadian C-Spine Rules)
• Positive CT: Requires Neurosurgical Evaluation
• Negative CT:
  • Alert: Clinically Clear
  • Obtunded, Intoxicated or Non-Examinable: Controversial
    • No Neurologic Deficit: Clear
    • Neurologic Deficit: MRI vs Neurosurgical Evaluation
• Clinically Clear:
  • First: No Pain with Palpation Along C-Spine Midline (Not Lateral Paraspinous Muscles)
  • Second: No Pain with Range of Motion (Up/Down/Left/Right)
  • If Fails: Consider MRI vs Neurosurgical Evaluation

NEXUS (National Emergency X-Radiography Utilization Study) Criteria

• Low-Risk Criteria: Mn
  • No Neurologic Deficit
  • No C-Spine Tenderness (Not Perimuscular)
  • No AMS
  • Not Intoxicated
  • No Distracting Injury
• If All Criteria are Met: Can Clinically Clear Cervical Collar
• If Any Criteria are Not Met: Requires CT

Canadian C-Spine Rules

• Rules:
  • Rule 1. CT if Any High-Risk Factors
    • If None Look at Low-Risk Features
  • Rule 2. CT if No Low-Risk Factors Allowing Safe Assessment of Range of Motion
    • If At Least One Low-Risk Feature Assess Range of Motion
  • Rule 3. CT if Unable to Rotate Neck 45 Degrees Left/Right
    • If Able to Rotate Neck Ok to Clear
• High-Risk Features:
  • Age ≥ 65 Years
  • Dangerous Mechanism:
    • Fall ≥ 3 Feet or 5 Stairs
    • Axial Load to Head
    • High Speed MVC, Rollover or Ejection
    • Motorized Recreational Vehicles
    • Bicycle Struck or Collision
  • Extremity Paresthesia
• Low-Risk Features:
  • Simple Rear-Ended MVC
  • Sitting Position in ED
  • Ambulatory at Any Time
  • Delayed Onset of Neck Pain
  • No Midline C-Spine Tenderness

Complications

• Uncomfortable
• Increases ICP – Compression of Jugular Veins & Nociceptive Stimulus
• Impede Airway Management
• Increased Risk of Aspiration
• Skin Breakdown & Pressure Sores
• Challenge for Central Line Placement