Evidence in the ED: “Pain in the Neck” Clearing the C-Collar

1. Evidence in the ED:“Pain in the Neck” Clearing the C-Collar Yolanda Michetti Dept of EM University of Pennsylvania

2. Eastern Association for the Surgery of Trauma • For the neurologically intact awake and alert patient complaining of neck pain with a negative CT: • A. Continue cervical collar. • B. Cervical collar may be removed after negative MRI (level 3). • C. Cervical collar may be removed after negative and adequate F/E films (level 3)

3. References • Goodnight, TJ, et al. A comparison of flexion and extension radiographs with computed tomography of the cervical spine in blunt trauma. Am Surg. 2008 Sep;74(9):855-7. • Khan, SN, et al. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma 2011 Jan;25(1): 51-6. • Tran, B, et al. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan? J Surg Res. 2013 Sep;184(1):411-3. • Como, J, et al. Cervical spine injuries following trauma. J Trauma. 2009 Sep;67 (3): 651-9.

4. Goodnight, TJ, et al. A comparison of flexion and extension radiographs with computed tomography of the cervical spine in blunt trauma. Am Surg. 2008 Sep;74(9):855-7.

5. Methods • Retrospective study • 2 years (2003-2004) • Patient population: • Patients admitted to a Level I trauma center • Blunt trauma • Received Cervical Spine (CS) CT and Flexion and Extension films (FEF) for continued cervical pain • Exclusion criteria • Neuro deficits c/w cervical cord injury • Obtunded patients • Penetrating mechanism • Age < 18 y.o. • Radiologists assessed CT for suspicion of ligamentous injury • MRI obtained for pt w/ negative CS CT and positive FEF

6. Results • 379 pts had FEF after CT showed no fracture • Mean age: 39 yrs • Etiology: 53% MVC • 16 pts (4.2%) had positive FEF • 8 pts (50%) had neg CS CT • MRI was negative for ligamentous injury • 8 pts had positive CS CT for ligamentous injury • 2 had negative MRI • 5 had positive MRI • 1 did not have an MRI

7. Results Cont’d • CT identifying ligamentous injury • 360 true-negatives • 6 true-positives • 13 false-positives • 0 false-negatives • FEF indentifying ligamentous injury • 363 true-negatives • 6 true-positives • 10 false-positives • 0 false-negatives

8. Conclusions • NPV for CS CT is 100% • If CS CT is positive for signs of ligamentous injury further imaging is required with an MRI

9. Khan, SN, et al. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma 2011 Jan; 25(1): 51-6.

10. Methods • Retrospective study • 12 months • Patient Population: • All patients admitted to Level I trauma center • Blunt trauma • Inclusion Criteria: • GCS 15 • Normal CS CT • Persistent posterior midline neck pain and tenderness • No neuro deficit • FEF taken during hospitalization to r/o acute instability • Exclusion Criteria: • Pre-existing cervical spondylosis with signs and symptoms of chronic myeloradiculopathy

11. Methods Cont’d • FEF obtained with active movement • Adequacy of FEF assessed: • Complete visualization from occiput to end plate of first thoracic vertebra • Adequate ROM greater than 30⁰ from neutral • Supplementation with swimmer’s view if cervicothoracic jxn poorly seen • No evidence of rotational deformity

12. Results • 311 pts met inclusion criteria • 306 (98%) had high energy trauma • Ave. age: 38.8 yrs • Etiology: 64% MVC; 11% Falls; 9% Assaults; 5% Autoped; 5% MCC; 3% bicycle accidents • 97 (31%) studies deemed adequate by criteria • 214 (69%) deemed inadequate but interpreted as normal by radiologists • 0 film identified with evidence of acute instability • 1 FEF recorded as positive by radiologist • Did not have adequate ROM • MRI negative for pathology

13. Results Cont’d • 171 (55%) had f/u within 3 mos • 1 pt was symptomatic • reimaged w/ FEF – noted to have a kyphotic deformity w/ splaying at C6-7 • Taken to OR for posterior stabilization, doing well 15 mos out • Use of FEF to identify acute instability w/ normal CS CT • Sensitivity 0%, Specificity 99%, PPV 0%, NPV 31%

14. Conclusions • In the presence of normal CS CT scan, pts with persistent posterior neck pain and clinical concern • manage conservatively in a c-collar • Re-examine in 7 – 10 days with clinical exam and adjunct radiology

15. Tran, B, et al. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan? J Surg Res. 2013 Sep;184(1):411-3.

16. Methods • Retrospective study • March 2011 -2012 • Patient Population: • All patients who underwent FEF • Level 1 trauma center • Inclusion criteria • Blunt trauma • Awake, GCS 15 • Neurologically intact • Nonintoxicated • FEF performed for persistent neck pain after negative CS CT scan • All radiologic studies read by in-house radiology Attending

17. Methods Cont’d • Neurological outcomes were followed during hospital stay and outpatient follow-ups • FEF identified as “abnormal” were noted for possibility of ligamentous injury

18. Results • 464 pts underwent FEF • 354 pts met criteria • Mean age: 43yo • Etiology: 50% MVC, 34% falls, 16% other • Incidental degenerative changes: 37% • 5 pts (1.4%) FEF “abnormal” • 2 pts had CS MRI: negative • C-collar removed • 3 pts spine surgery consulted • Managed nonoperatively • No neuro deficits • C-collar removed within 3 wks, dx “degenerative changes”

19. Conclusions • FEF leads to false positives • Support eliminating FEF after a negative CS CT in awake, alert, neuro intact pts • Adds cost • FEF : $485.60 • For 354 pts : $171,902.40 • Pts w/ “abnormal” FEF incurred additional costs

20. HUPism • Pts who have sustained blunt trauma c/o persistent posterior neck pain with GCS of 15, no neuro deficits, and a normal CS CT do not require a FEF. • Depending on clinical concern, may have c-collar remain and follow up as an outpatient for clinical reassessment.