Clearing the cervical spine Jules Blackham Speciality Registrar

Clearing the cervical spine Jules Blackham Speciality Registrar Emergency Medicine BASICS Avon Great Western Air Ambulance

Clinically clearing Cervical Spine 2 major studies

Reviews of “current” practice n Number of authors noted the patients with [Neifield 1988 , Saddison 1991, Hoffman 1992, Zabel 1997] : – – – Normal level of consciousness, no focal neurological deficit, no intoxication, no distracting injury and no neck pain/tenderness Did not have a c-spine injury n Most studies were not very large (up to 1000 patients), and only had relatively few c-spine fractures(3%). n

NEXUS GROUP Hoffman JR, et al. “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 -9 n 21 centres across US n 34, 069 patient underwent C-spine radiography after blunt trauma. n All patient with blunt trauma undergoing cervical radiography were included n

5 low risk criteria No midline cervical tenderness n No focal neurological deficit n Normal alertness n No intoxication n No painful distracting injury n

Results Identified all but 8 of the 818 patients with Cspine injury n Sensitivity 99%[98 -99. 6%] n Sensitivity 12. 9% n

Paediatric Subgroup analysis of NEXUS [Viccellio and colleagues 2001] n 3, 065 patients under 18 – 88 under 2 years – 817 aged 2 -8 years – 2, 160 aged 8 -17 yrs n 30 (0. 98%) had cervical spine injuries – Lower incidence than in adult population – ? due to lower threshold to x-ray children

n No cases of CSI who were negative to all 5 nexus criteria n No cases of SCIOWRA n 45. 9% of injuries occurred in lower cervical spine (C 5 -7) n However – No CSI in under 2 s, and only 4 in under 8 s

n NEXUS should be used with caution in under 8 s – Case report of 3 year old child with a PEG fracture, who was low risk, § but high mechanism of injury (RTC, fatality in same vehicle) n Recommended that consider mechanism of injury in young children and advised to return if child becomes reluctant to move head.

Canadian C-Spine rules Stiell IG, et al. “The Canadian C-spine rule for radiography in alert and stable trauma patients. ” JAMA. 2001 Oct 17; 286(15): 1841 -8. Prospective cohort study in 10 large EDs 20 standardized clinical findings were noted prior to radiography 8, 924 patients, including 151 (1. 7%) clinically significant CSI. Excluded children <16 and all patients with GCS <15

Resultant model asks 3 questions: Is there any high risk factor present which mandates radiography Is there any low risk factor that allows safe assessment of range of motion Is the patient able to actively rotate neck 45⁰ to left and right By cross validation › Sensitivity = 100% [98 -100%] › Specificity 42. 5% [40 -44%]

High risk factors yes to any mandates x-ray Age >65 years OR Dangerous Mechanism › Fall from ≥ 1 metre/5 stairs › Axial load to head e. g. diving › MVC High speed (>100 km/hr), rollover, ejection › Motorized recreational vehicles › Bicycle collision OR Paraesthesia in Extremities

low risk factor that allows safe assessment of range of motion n n Simple read-end MVC – Excludes § Pushed into oncoming traffic § Hit by bus/large truck § Rollover § Hit by high-speed vehicle Or Sitting position in ED Or Ambulatory at any time Or Delayed onset of neck pain Or Absence of midline c-spine tenderness

Able to actively rotate neck n 45º to left and right n If able to do above then no radiograph is required.

Independent judgement or CCR [Bandiera et al. 2003] Prospective cohort study (10 EDs) n Compared physician’s judgement with CCR in 6, 265 patients n Physicians asked to estimate probability of unstable c-spine # from 0 -100% n Judgement – sensitivity = 93% n CCR = 100% n Poor correlation between physicians for “zero probability of injury” Kappa=0. 46 [0. 28 -0. 65] n

2 studies comparing NEXUS with CCR n Dickenson et al [2004] applied retrospectively the NLC to the original CCR data. – Did not accurately apply the rules as differences in definitions § e. g. “no evidence of intoxication “ and “unreliable findings due to alcohol or drugs” – Sensitivity of 92%

Stiell et al 2003 Prospective cohort study in 9 Canadian Eds. patient’s were examined with both guidelines 10% did not have range of movement applied CCR was more sensitive than the NLC (99. 4% cf. 90. 7%) CCR missed 1 clinically significant C-spine injury, while NLC missed 16. Problems › Definition of distracting injury is difficult and is not defined in study (or original NLC) › Study performed in Canada by CCR investigators - ? bias

2 studies comparing NEXUS with CCR n Dickenson et al [2004] applied retrospectively the NLC to the original CCR data. – Did not accurately apply the rules as differences in definitions § e. g. “no evidence of intoxication “ and “unreliable findings due to alcohol or drugs” – Sensitivity of 92%

Stiell et al 2003 Prospective cohort study in 9 Canadian Eds. patient’s were examined with both guidelines 10% did not have range of movement applied CCR was more sensitive than the NLC (99. 4% cf. 90. 7%) CCR missed 1 clinically significant C-spine injury, while NLC missed 16. Problems › Definition of distracting injury is difficult and is not defined in study (or original NLC) › Study performed in Canada by CCR investigators - ? bias

Nurses - NEXUS n Pitt et al. 2006 – More conservative than doctors – 59/112 removed by triage nurses, further 7 removed by Drs. – Reduced duration of immobilisation by a mean of 23 mins (p<0. 005) n Hsieh 2000 – 211 patients. Good agreement between nurses and doctors (k=0. 65) – Poor agreement on what was a distracting injury (k=0. 35)

Nurses - CCR n Kelly et al 2004 – Good agreement between doctors and nurses (K=0. 55) – Nurses less likely to – clear spine (P=<0. 001), reporting more tenderness – test range of movement – also noted in original study where 10% of patients did not have ROM tested. n Stiell et al 2006 – Trained 112 nurses in 6 EDs to use CCR – 47. 5% of pts could safely have c-spine cleared – Inter-observer agreement Excellent (second = nurse/physician) K=0. 81 n Miller et al 2006 – Good agreement between doctors and nurses K=0. 6

Pre-hospital Guidelines n EAST [Como et al 2009] – Based on NEXUS guidelines n NICE Head Injury guidelines Sept 2007 – section 5 – Based on NEXUS n JRCALC [Fisher et al. 2006] – Based on NEXUS

Pre-hospital Studies – NEXUS n Brown 1998 – EMS staff and Emergency Physicians completed a questionnaire on NEXUS findings for 451 patients – Reasonable agreement – kappa=0. 48 – 44 (9. 8%) of patients EMS would have removed c-spine protection, EM physicians wouldn’t. § No comments whether any had injuries n Sahni et al 1997 – 10 standardised patients examined by 10 paramedics and 10 EPs – Good agreement –Kappa=0. 62 -0. 77 for each criteria – 1 pt where 2 groups disagreed, EPs would have cleared, paramedics not

n One UK based study [Armstrong et al. 2007] – Based on NEXUS – 103 patients, of whom 67% would have had the c-spine cleared on scene with no cases of missed CSI

Stroh and Braude 2001 Retrospective chart review over 6 years. n Spinal immobilisation protocol of Fresno county EMS implemented at beginning of study period by by Ferno/Kings/ Madera (FKM) EMS service n n 861 patients discharged diagnosis of cervical spine injuries – 357 eliminated as inter-hospital transfers or not transferred by FKM EMS service – 504 transported by EMS § 495 immobilised

n 9 not immobilised: – 2 refused – 1 combatitive – 1 severe kyphosis – 2 protocol violations § C 6 # (stable) § Odontoid # (post chiropractor treatment) – 3 protocol misses n Sensitivity of immobilisation protocol for confirmed c-spine injury=99% (97. 7 -99. 7%)

Canadian prospective study Vaillancourt et al. 2007 Study of 2, 397 patients using CCR over 50 months in 10 Ontario cities n Patients examined by paramedics using CCR and then immobilised and transferred to hospital for assessment n clinically important c-spine injury 12 patients (0. 5%), n – Sensitivity =100%[74 -100] specificity 38. 2% [36 -40]. Kappa = 0. 94 n Comfortable in applying in 81. 5% of patients n Would have cleared 916 (38%) of spine prehospitally n

Examples CAN YOU CLEAR THE SPINE?

Example 1 n An 85 yr old woman reportedly unconscious after she fell over in her bathroom banging her forehead on the bath before falling to the ground, landing flat on her face. On your arrival she is conscious and talking complaining about the blood from her forehead making a mess on her bathroom floor and apologising profusely for wasting your time. She has a 3 cm vertical laceration in the centre of her forehead, and appears to have no other injuries. She is tender in the midline over the upper portion of her neck, but has no pain in her neck at rest.

Example 2 n You are called to a 25 yr old seat belted male driver who was involved in a rear ended shunt at traffic lights in the centre of Gloucester. His car was hit from behind by another car who had failed to spot that the car in front had stopped. The driver has got out of the car and is complaining of pain in the centre of his neck. He has no complaints of altered sensation or weakness in his limbs.

Example 3 n A 30 yr old man has had a “couple of drinks” this evening and has been involved in a fight. He has been punched in the face a number of times. He has not been knocked out, but has a black eye, bleeding nose and fractured right cheek. He has not neck tenderness and no distracting injuries. A private ambulance RRV has arrived on scene before you and the paramedic is applying a collar to the patient. He says as the patient has been drinking it is drunk it is not possible to clear his cervical spine and he has injuries above the clavicle so needs a collar applying.

Example 4 n You are called to a 20 yr old girl who has been thrown from a horse, landing on her back. She is complaining of severe pain in her lower back and pins and needles in the front of her thighs. She is unwilling to move as the pain is so severe.

Example 5 n. A 14 yr old boy has been pulled out of a swimming pool after diving in and hitting the bottom, by life guards. You find him lying on the side of the pool in the recovery position. He is conscious and complaining of a head ache. He is tender in his upper cervical spine, but has no neurology in his upper limbs.

Summary C-spine injuries are rare n C-spine immobilisation in a common procedure n Majority of c-spines can be cleared clinically. n

Any Questions?