Trauma ConferenceTrauma ConferenceEvaluation and Evaluation and Clearance of Clearance of

Cervical Spine Cervical Spine Injuries: An UpdateInjuries: An Update

Facts and FiguresFacts and Figures 12,000 spinal cord injuries annually in US12,000 spinal cord injuries annually in US 250,000 Americans living with spinal cord 250,000 Americans living with spinal cord

injuriesinjuries Annual cost of $4 billion Annual cost of $4 billion >50% occur between age 16 and 30 years old>50% occur between age 16 and 30 years old >80% male>80% male

Assault

MVA

Accidents /

falls

National Spinal Cord Statistics Center, 2001

HistoryHistory 1700 BC: first reported by Egyptians on papyrus 1700 BC: first reported by Egyptians on papyrus

describing 2 neck injuries causing paralysis that describing 2 neck injuries causing paralysis that were “not to be treated.” were “not to be treated.”

460-377 BC: Hippocrates employed rudimentary 460-377 BC: Hippocrates employed rudimentary traction devises traction devises

1543 – Vesalius published complete anatomy of 1543 – Vesalius published complete anatomy of spinal cord and consequences of injury at each spinal cord and consequences of injury at each level (coined terms cervical, thoracic, lumbar level (coined terms cervical, thoracic, lumbar and sacral)and sacral)

1920 – X-ray enables surgeons to better localize 1920 – X-ray enables surgeons to better localize fracturefracture

1990’s – methylprednisolone added to early 1990’s – methylprednisolone added to early treatmenttreatment

National Spinal Cord Statistics Center, 2001

Types of C-spine Types of C-spine FracturesFractures

Atlas Fractures (C1): 5%Atlas Fractures (C1): 5%- - Jefferson fractureJefferson fracture: burst : burst

fx caused by axial loading fx caused by axial loading

causing disruption of causing disruption of

anterior and posterior ringsanterior and posterior rings

of C1 w/ lateral of C1 w/ lateral

displacement. Unstable.displacement. Unstable.

ATLS Student Course Manual, 2008

Types of C-spine Types of C-spine FracturesFractures

Axis (C2) FracturesAxis (C2) Fractures Odontoid fx: 60% of C2 fx. Odontoid fx: 60% of C2 fx.

Type I involves tip of Type I involves tip of odontoid (uncommon), odontoid (uncommon), Type II involves base of Type II involves base of dens (most common), Type dens (most common), Type III extends obliquely III extends obliquely through body of axisthrough body of axis

““Hangman’s fx:” Posterior Hangman’s fx:” Posterior elements of C2 (pars elements of C2 (pars interarticularis). interarticularis). Extension injury. Unstable.Extension injury. Unstable.

Types of C-spine Types of C-spine FracturesFractures

C3-C7C3-C7 C3 fx: very uncommonC3 fx: very uncommon C5/C6: Most common level of fx and C5/C6: Most common level of fx and

subluxation (site of greatest subluxation (site of greatest flexion/extension)flexion/extension)

Most common injuries: vertebral body, Most common injuries: vertebral body, laminae, spinous processes or pedicle laminae, spinous processes or pedicle fracturesfractures

Role of Trauma TeamRole of Trauma Team

Properly identify those who warrant Properly identify those who warrant C-spine precautions and evaluationC-spine precautions and evaluation

Obtain prompt spinal surgery Obtain prompt spinal surgery consultation if an injury is diagnosedconsultation if an injury is diagnosed

Clear and remove C-collar ASAP to Clear and remove C-collar ASAP to minimize harmful effects of minimize harmful effects of prolonged C-collar useprolonged C-collar use

Effects of Prolonged C-Collar Effects of Prolonged C-Collar (CC) Use(CC) Use

Length of CC use directly proportional to risk of Length of CC use directly proportional to risk of CC decubitus ulcersCC decubitus ulcers 7-38% overall risk of decubitus ulcers in SICU 7-38% overall risk of decubitus ulcers in SICU

patients in CC who survived >24 hourspatients in CC who survived >24 hours CC use increases ICPCC use increases ICP

90% of TBI patients have been shown to have 90% of TBI patients have been shown to have documented elevations in ICP after application documented elevations in ICP after application of CCof CC

Early CC removal associated with decreased Early CC removal associated with decreased ventilator days, SICU LOS, hospital LOC, health-ventilator days, SICU LOS, hospital LOC, health-care associated pneumonia, and deliriumcare associated pneumonia, and delirium

Chendrasekhar, Am Surg, 1998Powers, J Trauma Nurse, 2006Mobbs, ANZ J Surg, 2002

Patient do NOT need CS Patient do NOT need CS imaging if…imaging if…

Low-risk mechanism of injuryLow-risk mechanism of injury Neurologically intactNeurologically intact No distracting injuriesNo distracting injuries No midline tenderness or pain on No midline tenderness or pain on

full ROMfull ROM Penetrating neck trauma (unless Penetrating neck trauma (unless

trajectory suggest possible direct trajectory suggest possible direct injury to CS)injury to CS)

Eastern Association for the Surgery of Trauma, 2009

Who Needs CS Imaging? Who Needs CS Imaging?

The National emergency X-radiography The National emergency X-radiography Utilization Study (NEXUS) Utilization Study (NEXUS)

Prospective, observational study of 21 US Prospective, observational study of 21 US centers evaluating 34,069 stable patients with centers evaluating 34,069 stable patients with blunt trauma blunt trauma

Identified 5 findings that indicated increased risk Identified 5 findings that indicated increased risk for CS injury requiring radiographic evaluationfor CS injury requiring radiographic evaluation1. Tenderness at the posterior midline of the CS1. Tenderness at the posterior midline of the CS2. Focal neurologic deficit2. Focal neurologic deficit3. Decreased level of alertness3. Decreased level of alertness4. Evidence of intoxication4. Evidence of intoxication5. Distracting injury5. Distracting injury

Hoffman et al, N Engl J Med, 2000

Radiological EvaluationRadiological Evaluation

Axial CT from occiput to T1 with Axial CT from occiput to T1 with coronal and sagittal reconstructioncoronal and sagittal reconstruction

Plain radiographs of C-spine are no Plain radiographs of C-spine are no longer standardlonger standard

MRI recommended to evaluate any MRI recommended to evaluate any neurologic deficits attributable to a neurologic deficits attributable to a C-spine injury regardless of CT C-spine injury regardless of CT findingsfindings

If C-spine CT demonstrates If C-spine CT demonstrates an injury…an injury…

Prompt spinal surgery consultationPrompt spinal surgery consultation C-spine MRI (if associated neuro C-spine MRI (if associated neuro

deficits)deficits)

Clearance of C-spine after Clearance of C-spine after negative CS imagingnegative CS imaging

C-collar may be removed if:C-collar may be removed if:1.1. Neurologically intact (no organic or Neurologically intact (no organic or

toxic alterations)toxic alterations)

2.2. No distracting injuries No distracting injuries

3.3. No vertebral tendernessNo vertebral tenderness

4.4. No pain on full ROMNo pain on full ROM

Eastern Association for the Surgery of Trauma, 2009

Clearance of C-spine after Clearance of C-spine after negative CS imagingnegative CS imaging

If neurologically intact but fails clinical If neurologically intact but fails clinical clearance exam (ie, midline tenderness)clearance exam (ie, midline tenderness) Continue C-collar, orContinue C-collar, or Obtain flexion/extension X-ray (Level 3), or Obtain flexion/extension X-ray (Level 3), or Obtain MRI (Level 3)Obtain MRI (Level 3)

If flex/ex or MRI are negative, CC may be If flex/ex or MRI are negative, CC may be removed and a soft collar may be removed and a soft collar may be provided for comfort (Level 2)provided for comfort (Level 2)

Eastern Association for the Surgery of Trauma, 2009

Clearance of C-spine after Clearance of C-spine after negative CS imagingnegative CS imaging

If not neurologically intact or has If not neurologically intact or has distracting injuries:distracting injuries: If deficits are transient (EtOH, post-If deficits are transient (EtOH, post-

ictal, other fx s/p reduction, ect.), wait ictal, other fx s/p reduction, ect.), wait for them to resolve then clear C-spine for them to resolve then clear C-spine clinicallyclinically

But what if they are unlikely to resolve But what if they are unlikely to resolve soon?soon?

C-spine Clearance in C-spine Clearance in Obtunded PatientObtunded Patient

Previous guidelines mandated MRI Previous guidelines mandated MRI for all obtunded patients prior to C-for all obtunded patients prior to C-collar removal to r/o collar removal to r/o ligamentous/soft tissue injury ligamentous/soft tissue injury

Flexion/extension fluoroscopy Flexion/extension fluoroscopy studies?studies?

Is a negative CT alone sufficient?Is a negative CT alone sufficient?

Flex/Ex FluoroscopyFlex/Ex Fluoroscopy

No longer recommended for No longer recommended for obtunded ptobtunded pt Only 4% are adequate studies due to Only 4% are adequate studies due to

logistical aspects of proper positioninglogistical aspects of proper positioning Incidence of ligamentous injury found Incidence of ligamentous injury found

on flex/ex is only 0.4% and of those, on flex/ex is only 0.4% and of those, none were found to have any none were found to have any neurological sequelae neurological sequelae

Bolinger, Trauma, 2004

David, J Trauma, 2001

MRIMRI

If negative, CC may be removedIf negative, CC may be removed Risk/benefit of MRI’s in all obtunded Risk/benefit of MRI’s in all obtunded

patient has been questionedpatient has been questioned $$$$$$ Risk associated with laying flat for the length Risk associated with laying flat for the length

of the study (elevations in ICP, aspiration, ect)of the study (elevations in ICP, aspiration, ect) MRI is most sensitive within 48-72 hrs of MRI is most sensitive within 48-72 hrs of

injury when the obtunded patient may not be injury when the obtunded patient may not be stable enough to be out of the ICU for length stable enough to be out of the ICU for length of studyof study

Is MRI needed after Is MRI needed after negative CT?negative CT?

366 prospectively enrolled obtunded pt’s 366 prospectively enrolled obtunded pt’s had a normal CT then received MRIhad a normal CT then received MRI 354 (96.7%) MRIs were negative354 (96.7%) MRIs were negative 7 (1.9%) showed cervical cord contusion; 4 7 (1.9%) showed cervical cord contusion; 4

(1.1%) showed ligamentous injury; 3 (0.8%) (1.1%) showed ligamentous injury; 3 (0.8%) showed intervertebral disk edema; 1 (0.3% showed intervertebral disk edema; 1 (0.3% had all 3 types of soft-tissue injuries.had all 3 types of soft-tissue injuries.

CT had NPV of 98.9% for ligamentous injuryCT had NPV of 98.9% for ligamentous injury CT had NPV of 100% for unstable CS injuryCT had NPV of 100% for unstable CS injury

Hogan et al, Radiology, 2005

Is MRI needed after Is MRI needed after negative CT?negative CT?

Several additional similar but Several additional similar but smaller series (N = 47-60) showed smaller series (N = 47-60) showed similar resultssimilar results

While additional ligamentous and While additional ligamentous and soft tissue injuries are occasionally soft tissue injuries are occasionally found (5-11%), no operative or found (5-11%), no operative or otherwise unstable injuries were otherwise unstable injuries were missed on CT and later found on missed on CT and later found on MRIMRI

Sarani, et al. J Trauma, 2007

Adams, et al. Am Surg, 2007

Is MRI needed after Is MRI needed after negative CT?negative CT?

Prospective randomized clinical trial Prospective randomized clinical trial of 215 consecutive obtunded trauma of 215 consecutive obtunded trauma patientspatients

140 required negative CT and MRI 140 required negative CT and MRI for CC removalfor CC removal

75 received only a CT prior to CC 75 received only a CT prior to CC removalremoval

Stelfox, et al. J Trauma, 2007

- Shorter ICU LOS (6 vs. 4, p = 0.028), Shorter ICU LOS (6 vs. 4, p = 0.028), and shorter hosptial LOS (16 vs. 4, p = and shorter hosptial LOS (16 vs. 4, p = 0.043).0.043). Stelfox, et al. J Trauma, 2007

Retrospective 5-year review Retrospective 5-year review of all MVC or fall victims of all MVC or fall victims

(14,755 patients)(14,755 patients) 2% of all patients had a CS injury2% of all patients had a CS injury 0.2% of all blunt trauma patients 0.2% of all blunt trauma patients

and 11% of all CS injury patients had and 11% of all CS injury patients had subluxation without fracturesubluxation without fracture

100% of all subluxations were 100% of all subluxations were diagnosed or highly suspected by diagnosed or highly suspected by plain radiograph and CS imaging plain radiograph and CS imaging alone.alone.

Demetriades Demetriades et al. et al. Trauma, 2000Trauma, 2000

EAST RecommendationsEAST Recommendations

Cannot make a definitive Cannot make a definitive recommend on need for MRI recommend on need for MRI following a negative CT in an following a negative CT in an obtunded trauma patientobtunded trauma patient

Left at discretion of each institutionLeft at discretion of each institution

Eastern Association for the Surgery of Trauma, 2009

SurgicalCriticalCare.net SurgicalCriticalCare.net RecommendationsRecommendations

Level 1:Level 1: Awake and alert patients may be cleared by H&P Awake and alert patients may be cleared by H&P

alonealone Level 2:Level 2:

CT from occiput to T1 including axial, sagittal, ad CT from occiput to T1 including axial, sagittal, ad coronal images should be used for CC clearancecoronal images should be used for CC clearance

CC clearance should be performed w/in 72 hrs of CC clearance should be performed w/in 72 hrs of injuryinjury

Level 3:Level 3: In the obtunded patient, CT is sufficient to allow In the obtunded patient, CT is sufficient to allow

clearance of the CSclearance of the CS

ReferencesReferences Spinal Cord Injury Information Center: http://www.spinalcord.uab.edu/ Spinal Cord Injury Information Center: http://www.spinalcord.uab.edu/ Chendrasekhar A, Moorman DW, Timberlake GA. An evaluation of the effects of semirigid cervical collars Chendrasekhar A, Moorman DW, Timberlake GA. An evaluation of the effects of semirigid cervical collars

in patients with severe closed head injury. in patients with severe closed head injury. Am Surg Am Surg 1998; 64:604-606.1998; 64:604-606. Powers J, Daniels D, McGuire C, et al. The incidence of skin breakdown associated with the use of Powers J, Daniels D, McGuire C, et al. The incidence of skin breakdown associated with the use of

cervical collars. cervical collars. J Trauma Nurs J Trauma Nurs 2006; 13:198-200.2006; 13:198-200. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial injury after head injury. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial injury after head injury.

ANZ J Surg ANZ J Surg 2002; 72:389-391.2002; 72:389-391. Como JJ, Diaz JJ, Dunham CM, Como JJ, Diaz JJ, Dunham CM, et al. et al. Practice management guidelines for identification of cervical spine Practice management guidelines for identification of cervical spine

injuries following trauma - update from the Eastern Association for the Surgery of Trauma Practice injuries following trauma - update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee http://www.east.org/tpg.asp Management Guidelines Committee http://www.east.org/tpg.asp

Hoffman, JR. Validity of a Set of Clinical Criteria to Rule Out Injury to the CervicalSpine in Patients with Blunt Trauma N Engl J Med 2000; 343: 94-9

Advanced Trauma Life Support for Doctors. ATLS Student Course Manual, 8Advanced Trauma Life Support for Doctors. ATLS Student Course Manual, 8thth Ed. American College of Ed. American College of Surgeons Committee on Trauma, 2008Surgeons Committee on Trauma, 2008

Bolinger B, Shartz M, Marion D. Bedside fluoroscopic flexion and extension cervical spine radiographs Bolinger B, Shartz M, Marion D. Bedside fluoroscopic flexion and extension cervical spine radiographs for clearance of the cervical spine in comatose trauma patients. for clearance of the cervical spine in comatose trauma patients. J Trauma J Trauma 2004; 56:132-136.2004; 56:132-136.

Demetriades D, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma 2000; 48:724-727.

Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. patients with dynamic fluoroscopy: a reappraisal. J Trauma J Trauma 2001; 50:1044- 1047.2001; 50:1044- 1047.

Hogan GJ, Mirvis SE, Shanmuganathan K, et al. Exclusion of unstable cervical spine injury in obtunded Hogan GJ, Mirvis SE, Shanmuganathan K, et al. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multidetector row CT findings are normal? patients with blunt trauma: is MR imaging needed when multidetector row CT findings are normal? Radiology Radiology 2005; 237:106-113.2005; 237:106-113.

Sarani B, Waring S, Sonnad S, et al. Magnetic resonance imaging is a useful adjunct in the evaluation of Sarani B, Waring S, Sonnad S, et al. Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients. the cervical spine of injured patients. J Trauma J Trauma 2007; 63:637-640.2007; 63:637-640.

Adams JM, Cockburn MIE, Difazio LT, et al. Spinal clearance in the difficult trauma patient: a role for Adams JM, Cockburn MIE, Difazio LT, et al. Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine. screening MRI of the spine. Am Surg Am Surg 2006; 72:101-105.2006; 72:101-105.

Stelfox HT, Velmahos GC, Gettings E, et al. Computed tomography for early and safe discontinuation of Stelfox HT, Velmahos GC, Gettings E, et al. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. cervical spine immobilization in obtunded multiply injured patients. J Trauma J Trauma 2007; 63:630-636.2007; 63:630-636.