C-Spine Evaluation: Who do you image?

1. C-Spine Evaluation: Who do you image? Steven A. Godwin MD, FACEP Assistant Professor and Program Director Department of Emergency Medicine University of Florida HSC/Jacksonville

2. Case Presentation • 30 yo helmeted motorcyclist presents to the ED fully immobilized with c-spine precautions following an accident. He states he was ejected approximately 25-30 feet from the vehicle. He recalls most of the accident but believes he may have lost consciousness briefly. • Physical exam is normal with a non-tender c-spine. GSC 15

3. Case: Questions • Does he need neuroimaging of the c-spine prior to “clearing the c-collar”? • What if he were intoxicated or he had an altered mental status? • What if he had a “distracting injury”?

4. Background Prevalence of Disease • Findings of NEXUS: • 818 patients identified (2.4%) of 34,069 patients with blunt trauma • 1,496 distinct cervical spine injuries to 1,285 different spine structures • 27 (.08%) identified via MRI with SCIWORA2 1 Goldberg W, Mueller C, Panacek E, Tigges S et al. for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17-21. 2 Hendley G, Wolfson A, William R et al.; for the NEXUS Group. Spinal cord injury without radiographic abnormality: Results of the national emergency x-radiography utilization study in blunt cervical trauma. J Trauma. 2002;53:1-4.

5. Distribution and patterns of injury • Most common level of injury- • C2 vertebra- 286 (24%) fractures including 92 odontoid fractures • C6 and C7 vertebra- 235 (39.3%) fractures • Most common site of fracture- • Vertebral body 1 Goldberg W, Mueller C, Panacek E, Tigges S et al. for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17-21 (I)

6. “Truth grows and evolves over time.” Harvey and His Discovery, In An Alabama Student, 296.

7. Previous Recommendations • Who should we image? • ATLS 1997 • Indications: • Every patient with multiple trauma • All patients with trauma above the clavicle 4 American College of Surgeons. Advanced Trauma Life Support for Doctors Provider Manual. 6th ed. Chicago, IL: American College of Surgeons; 1997

8. Most Recent Recommendations • Clinical Decision Rules • NEXUS (N Engl J Med, 2000)6 • Canadian C-Spine Rule (JAMA, 2001)7 6 Hoffman JR, Mower WR, Wolfson AB, et al., for the NEXUS Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-99. 7 Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for Radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.

9. NEXUS • Prospective observational study at 21 centers across the US (n= 34,069) • Validation of a clinical criteria for indications for c-spine imaging • A “decision instrument” • The ‘instrument’ identified all but 8/818 patients with cervical spine injury

10. NEXUS So what does 8/818 patients mean? • Sensitivity= 99% (95% CI, 98-99.6%) • NPV= 99.8% (95% CI, 99.6-100%) • Specificity= 12.9%

11. NEXUS Were any of the 8 missed injuries clinically significant? • 2 patients met preset definitions of clinically significant injuries (n=576) • An asymptomatic 54 yo s/p motorcycle accident • Fracture of anteroinferior C2 w/no soft tissue swelling • ? Extensor tear drop fracture • 57 yo s/p head on MVC w/ transient LOC; pain in R shoulder w/ tenderness at paraspinous muscles, R clavicle and scapula • Fracture of R lamina of C6 –developed R arm parasthesias and required laminectomy/fusion

12. NEXUSDecision Instrument- 5 criteria • Absence of posterior midline cervical tenderness • Absence of focal neurologic deficit • A normal level of alertness • No evidence of intoxication • Absence of clinically apparent distracting injury

13. NEXUS Conclusions • Application of the decision instrument would have decreased overall imaging by 12.6% • A simple decision rule can reliably predict patients who need neuroimaging following blunt trauma with very high sensitivity • There may still be compelling reasons to order c-spine images outside of the criteria in individual cases

14. Canadian C-Spine Rule7 • Prospective cohort study at 10 community and university hospitals • Convenience sample of 8924 adults Objective- To derive a clinical decision rule to detect C-spine injury and allow more selective use of radiography in alert and stable blunt trauma patients

15. Canadian C-Spine Rule • 151/8924 (1.7%) patients identified with clinically significant injury Decision rule results • Sensitivity- 100% (95% CI, 98-100%) • Specificity- 42% (95% CI, 40-44%) • Ordering rate utilizing criteria- 58%

16. Canadian C-Spine Rule7 Decision rule results • Clinically insignificant injury • 28/8924 patients (0.3%) • 1/28 missed • 63 yo with unidentified C3 osteophyte avulsion fx

17. Canadian C-Spine Rule Decision Rule-3 questions • Is there a high risk factor present mandating radiography ? • Defined as: • age > 65y, • dangerous mechanism*, or • parasthesias in extremities

18. Canadian C-Spine Rule Decision Rule- • Is there low-risk factor present that allows for safe assessment of ROM? • Defined as: • simple rear-end MVC, • sitting position in ED, • ambulatory at any time since injury, • delayed onset of neck pain, or • absence of midline C-spine tenderness

19. Canadian C-Spine Rule Decision Rule- • Is the patient able to actively rotate neck 45o to R and L

20. Canadian C-Spine Rule Conclusions • Potential sensitive rule for identifying patients requiring c-spine radiography following blunt trauma • Potential c-spine radiography rate of 58.2% • Relative reduction of 15.5% from 68.9%

21. Recommendations • Both the Canadian and Nexus clinical decision rules provide sensitive and reliable indicators for identification of patients at risk for cervical injury following blunt trauma • Use of clinical decision rules may reduce the number of imaging test performed

22. Summary • Which study to use? • Does it really matter? • Don’t get caught up in the hype! • Might be as simple as finding the one you can best remember and follow it!

23. Evolving Literature • Prospective study of 1,757 patients to develop decision rule (1,449 received plain films) • With decision rule implementation 537 (30.6%) studies were felt to be redundant • Failure of C-spine to document injury • 129 patients underwent CT with 33 positive findings • 9/38 (23.7%) fractures were not identified with plain films 8 Edwards M, Frankema S, Kruit M, et al. Routine cervical spine radiography for trauma victims: Does everybody need it. J Trauma 2001; 50:529-534.

24. Evolving Literature: Griffen et al. 2003 • Cervical Spine Radiographs (CSR) vs CT • Retrospective query of prospectively collected trauma database • CSR and CT performed on all patients with posterior midline neck tenderness, altered mental status, or neurologic deficit (3,018 patients) • 116 patients (9.5%) identified with cervical spine injury (fracture or subluxation) 9 Griffen M, Frykberg E, Kerwin A, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55(2):222-6.

25. Griffen et al. 2003 • C-spine injury was identified on both CSR and CT in 75/116 (65%) patients • Injury missed 41/116 (35%) patients with CSR • All these injuries required some form of treatment • No identifiable factors predicted false negative CSR 9 Griffen M, Frykberg E, Kerwin A, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55(2):222-6.

26. ? Nexus/Canadian Rules • Does the new literature cloud the results of the previous decision rules?

27. “General acceptance of truth takes time.”On The Study of Tuberculosis, Phila Med J 1900;6:1029-30

28. Questions?

29. Gracias

30. References 1 Goldberg W, Mueller C, Panacek E, Tigges S et al. for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17-21.(I) 2 Hendley G, Wolfson A, William R et al.; for the NEXUS Group. Spinal cord injury without radiographic abnormality: Results of the national emergency x-radiography utilization study in blunt cervical trauma. J Trauma. 2002;53:1-4.(I) 3 Lowery D, Wald M, Browne B et al.,for the NEXUS Group. Epidemiology of cervical spine injury victims, Ann Emer Med. 2001;38:12-16 (I) 4 American College of Surgeons. Advanced Trauma Life Support for Doctors Provider Manual. 6th ed. Chicago, IL: American College of Surgeons; 1997 (III) 5 Frohna WJ. Emergency department evaluation and treatment of the neck and cervical spine injuries. Em Med Clin North Am, 1999;17(4):739-91(Review) 6 Hoffman JR, Mower WR, Wolfson AB, et al., for the NEXUS Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-99. 7 Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for Radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.

31. References 8 Edwards M, Frankema S, Kruit M, et al. Routine cervical spine radiography for trauma victims: Does everybody need it. J Trauma 2001; 50:529-534. 9 Griffen M, Frykberg E, Kerwin A, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55(2):222-6.