Cervical Spine Injuries in the ED
In this episode, I discuss the diagnosis of c-spine injuries. I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, it should be with a 3-view reconstructed CT scan. And even after that is done, you still need a clearance exam before removing the collar.
The Fine Print of the NEXUS rule
The folks from Virginia think (J Trauma. 2011 Apr;70(4):829-31. & J Trauma2011;70(4):829-831) Nexus can't be used, but I think if you follow my advice in the podcast, you are probably going to come as close to 100% as a rule can provide. The Canadians also showed less than 100% Sens when using NEXUS (N Engl J Med. 2003 Dec 25;349(26):2510-8), but I would make the same argument–did they really do it the same as the NEXUS study advocates? Do you do it the same? If not, you may be missing injuries.
Then add the Canadian C-Spine Rule if there is Midline Tenderness, but no other NEXUS Criteria
Plain Films Suck!
Want the evidence, check out the Spinal Cord Injury chapter at CrashingPatient
Injuries Missed on CT scan
Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. (Ann Emerg Med. 2011 Dec;58(6):521-30)
Guidelines
Check out the c-spine guidelines from the Eastern Assoc of Surgeons for Trauma (EAST)
Additional New Information
More on EMCrit
- EMCrit Wee – More on C-Spine Imaging(Opens in a new browser tab)
- The Adventure of the Crooked Man(Opens in a new browser tab)
- More on a Diagnostic Strategy for C-Spine Injuries(Opens in a new browser tab)
- A Secondary Analysis of the Adventure of the Crooked Man(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I am not a true blue believer in the xray as the perfect modality. However if used judiciously it still has place, I believe, in screening and initial evaluation of neck injury. The material that you refer to in your links seems to support the fact that. I do not think there would be too many people arguing that in a patient with significantly depressed mental status or one with depressed mental status. Again the paper in your reference seems to support the same fact – there is insufficient evidence that CT scan should replace xray in patients with low… Read more »
Well that is really the question–what is a low risk patient? I would argue if you fail Canadian, you are not low risk by definition.
In a blog post later this week, I’ll give my take on the existing evidence; let me know what you think.
scott
Scott, I know a lot of people are saying that plain films are dead but I hear some of the NEXUS authors claim otherwise. Their argument is that although CT will show fractures not seen on plain films, those plain films are not completely normal or are inadequate. They say that in patients who fail NEXUS but are still at relatively low risk, a completely NORMAL and ADEQUATE plain film is enough. It seems to me this discussion of plain films v. CT really needs to include a description of which patients we are talking about. I don’t see much… Read more »
Greg-I hear what you are saying, as above let me lay out the evidence in a blog post and you tell me what you think.
One wonders what the cost of this quest for perfection will be. In lives, cancer and dollars. Why bother with exam or judgement, anyone who ever has fallen down should immediately go and have ct followed by mri. Of course then the quuestion will be, how do we diagnose the missed injuries from those two studies (I assure you, there will be some)
I personally use nexus as written with the exception of waiting for tox studies and feel that i am within the standard of care.
Thoughts,
Mike jasumback
Mike, not sure what you mean. I thought I had stressed repeatedly that the clinical judgment comes in by clearing the patients without imaging whenever possible. This means using NEXUS and I would argue Canadian as well. If your patient doesn’t clear by NEXUS secondary to midline tenderness, and you get plain films and they are inadequate, you then order a CT. This seems to me the place where the patient is getting over-radiated if they would have cleared by Canadian. I think if you use NEXUS, have perfect plain films, the tenderness is not at C1 or C7, and… Read more »
Scott, Excellent piece. As always, something I can take to my practice and use. -One comment about the use of clinical decision rules: -You mention that clinical decision rules should be objective and that clinical judgement often comes into play. Also, you mention that clinical judgement is the pretest probability that should bring us to use a rule. I don’t disagree. However, one thing I like about clinical decision rules and encourage my residents to do is use gestalt in conjunction with the rule. I actually think that using judgement with a rule is the correct way to utilize CDRs.… Read more »
I responded by audio here: Audio Response
The other week in Journal Club we reviewed Duane et al’s validation study of the Canadian rule where they applied the rule to all trauma team activations, and found the CDR was positive in all but 18 of 3201 patients screened. (http://www.ncbi.nlm.nih.gov/pubmed/21825938) Now, it’s a little difficult to apply/extrapolate this to other places since the sparsely-written paper doesn’t describe the parameters for trauma team activation at the study center. Still, would it be reasonable to say that with any fair amount of trauma it would be a pointless trying to apply the currently existing CDR’s since they cast such a… Read more »
Oops, wrong link (and sorry Ryan)! The correct link to the C-spine shot is here: http://dreapadoir.wordpress.com/2011/12/22/spinal-precautions/
Great podcast Scott. A personal favourite. This is a topic I’ve ranted about for years and it’s only in the last couple of years that people are finally giving up on the plain films when imaging is actually warranted for all the reasons you outlined. The clearance of the obtunded ICU trauma pt with a normal CT C-Spine is a prickly one and at my institution we are still undecided on the best way to clear. If you’re waiting for clear sensorium for a clinical clearance you’ll be waiting for weeks, and after 12 hours in a collar (even a… Read more »
responded to these EXCELLENT comments in podcast 63.5 just published
Hello Scott, Thankyou for this podcast. You have helped me once again. The great points that you make about the specifics of clearing the C spine and using NEXUS prompted me to buy the Medcalc Pro App (I am in no way affiliated with anyone smart enough to develop an iphone app). I have been using the standard free medcalc app for a long time, but the Pro App allowed me to add in the info section for NEXUS and Canadian C-Spine all of the good gen from your podcast on the specifics. I wanted to post this for your… Read more »
great rec, Daryl
Scott,
Great podcast as always. The hardest patients are the ones with a minor MOI but have “persistent mid-line tenderness” or are tender to light touch but have no neuro deficits and have full ROM in their neck. In the past I would get a CT and when its negative, confirm my clinical gestalt that they were fine. What would you do, would you send all of these people home with Philly Collar or Miami J with FU at PCP for potential MRI or do you reserve that for the obtunded etc…
To what extent are we prepared to directly equate spinal injury (as evidenced by clinical findings, or on imaging, or whatever you will) with clinically significant and/or unstable spinal injury?
That is, how many of the potential “misses” (say, from a less rigorous clearance process) actually matter? All of them? Less than all?
This was an awesome podcast Scott. you ,for once, actually CLARIFIED how to examine for ‘midline’ tenderness. Pretty much everyone has got ‘neck tenderness’ However, its not like ‘everyone who is tender has got a C-spine fracture’ and you were very clear on that. And I fully agree that X-rays are pretty much waste of time. And another thing while we are at it: with a HUGE geriatric population, no radiologist is gonna ‘clear’ the C-spine X-rays because of age-related changes. At least in this patient group , CT spine is the way to go coupled with clinical assessment for… Read more »
absolutely agree, no cancer worries in the elderly–ct is the way to go
Scott-great podcast- quick question. If you determine someone needs a CT scan and it turns out to be negative, you then go back and try to clinically clear them one more time per the podcast. Are there any studies that say giving narcotic pain medicine alters your exam after negative CT? Does that change anything from your standpoint, if a patient gets narcotics, in terms of clearing C-spine after a negative CT?
Great question. AFAIK, no studies have been done. Every other area that this has been looked at in, pain meds make the exam more not less reliable. Assuming you did not shlog the patient to the point of heroin stupor. I think if you documented the pt was awake, alert, interactive, etc. you are in good shape.
Scott – I’m all on board with this way of approaching possible c-spine injuries. I have one question though in your algorithm. What about putting “and no dangerous mechanism” in the first box with the other “nexus” rules. My thinking here is that if you don’t, then you could potentially clear someone with a “dangerous mechanism” going straight down if they don’t have midline tenderness. This would violate Canadian rules. If that part goes in the first box, you’re golden. Love the blog, going into CC fellowship next year after I finish up my EM residency, can’t wait!
CP
Scott: Thank you for clarification on this subject. I definitely learned some pearls on the finer points of the NEXUS criteria. Even with the sensitivity listed of plain films, I still believe they have a role in the lower risk patient. We know there are some patients in a low risk MVC for example, who will just not move their neck or complain of pain no matter how we touch them. I cannot see doing a CT scan in the 20 year old who was rear-ended, there was no damage to the car, and c/o diffuse and non-specific neck pain… Read more »
Hi Scott ,
Great podcast. Do you take your patients off the spine board after your primary survey or ct c-spine? If ct c spine negative and suspect ligamentous injury after reassessing and considering MRI do u still keep them on the spine board or take them off and leave c-collar on? Do u have good reference on how long a trauma patient should stay a spine board? I understanding taking off in 30 mins reduce the risk of pressure sore but can they go up to 2 hours.
Thanks again in advance for great education thoughts.
Sillah
@ChuckWurster @grahamwalker @mdaware @embasic Nice. BTW – for more on clearing C-spine, great recent post from @emcrit http://t.co/GOJySitx
What is the evidence for waiting to clear the c-spine of an intoxicated patient after a normal CT until they are sober? My personal practice is to wait until they are sober, but a colleague does not wait, which I think is dangerous. I could not, however, find any official recommendation for waiting until sober in the literature.
Evidence is the same as for clearing an uncon with CT alone. UK believes CT is enough; most of the US believes it is not. I think the inebriated pt has more likelihood to splint than an uncon, so it is probably even safer. I could not say your colleague is wrong.
Scott – great podcasts series. I do have some concerns about your recommended sequential use of the Nexus and Canadian C-spine rules. They were never designed to be used that way and to do so reduces their statistical value – you end up with a test that has no proven increase in sensitivity but almost certainly very low specificity. Because these are ultra high sensitivity and only low/moderate specificity. It doesn’t matter if they fail one rule – as long as they can pass 1 rule you maintain the high sensitivity of the rule. Each rule can and should be… Read more »
Anand,
I believe you are missing how the algorithm above actually functions. If you run the following imaginary patients through each of the rules individually vs. the algorithm, I think it will make more sense.
Run each of these three patients through NEXUS, CCR, and then the algorithm and see what happens.
yep so, assuming all non-stated information was normal/negative 1.Nexus – image, CCR-clear,Algo-clear 2. Nexus – clear, CCR – image, Algo- clear 3. Nexus – image, CCR – clear, Algo image Is that correct? If so then this shows the Algo imaged 1 out of 3 patients when if you had used either one of the Nexus or CCR you could have cleared all 3 patients. The fundamental problem is that the Algo compared with the CCR is that it adds an additional overlay of intoxication/altered mental state/distracting injury that are not required so this reduces the specificity without any evidence… Read more »
That is correct, so you are using the algo already when you evaluate the pt and pick between the two rules. This is the purpose of the algorithm. Most people will not commit 2 rules to memory and pick and choose based on the patient; screening for the variety of factors that make 1 rule capable of clearance while the other is not. NEXUS is by far the predominant rule in the States. Therefore people are unnecessarily getting imaging solely b/c of midline tenderness. By branching off at that point to CCR we sig. decrease imaging. You could do the… Read more »
yep ok, I think we are on the same page. I didn’t realise you were coming from a position of NEXUS being predominant and thus trying to stop everyone with midline tenderness being imaged. In Australia, or at least in my state, they are both used and perhaps CCR seems to predominate. That might be in part due to the state health system endorsing them in their official imaging guidelines and not mentioning nexus at all initially (though recently they’ve amended to include both as options). See here: http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/cspine/chart.html Until recently they didn’t have the NEXUS box. Also Australia seems… Read more »
Hey Scott, In the above scenario number 3 ” An inebriated patient who fell off his barstool, no neck pain. Lac on his forehead. ” I’m not totally clear as to what you are espousing/practicing with these patients: In the podcast, you describe how in the original NEXUS article, the patient shouldn’t even really smell like beer, or you have evidence of intoxication right there, and they don’t pass that one… , but in your above response you seem to be saying that you are not excluding patients who had a couple of drinks, but rather the patients that are… Read more »
yep the latter approach, but you better write a damn good note on why the pt’s drinking doesn’t stop clearance.
Totally agree from a medico-legal standpoint. It’s interesting how the whole intoxication thing isn’t really discussed with the CCR- this aspect of the assessment really does become subjective for the clinician. The way of thinking I don’t understand with the application of clinical decision rule out criteria is the following: “the patient has a + on the list and therefore we must now image.” Rule out criteria are designed and validated to be highly sensitive. Their specificity is inherently terrible. The specificity of the NEXUS criteria is terrible. This was never the intent. The guy who had a few beers,… Read more »
I work in a major US trauma center. Most people here use NEXUS, but I like using CCR first for the same reason you include it: the ability to clear patient with midline tenderness who at very low risk for significant injury. I kinda branch out to NEXUS in the case of the clinically intoxicated patient though; I do not routinely clear intoxicated patients with any degree of suspicion for injury.
same here Nathan
same here Nathan
New study has been published from USC trauma center. Clinical Relevance of Magnetic Resonance Imaging in Cervical Spine Clearance, JAMA surgery 2014 article argues that CT is 100% sensitive for detecting ‘clinically significant’ cervical spine injury and they argue against MRI for persistent midline tenderness or sensory deficit expressed by Pt after normal CT. Now, I am not arguing against MRI based on this single study. There are lots of limitations here but I just wanted to throw this article in.
I think i mentioned it somewhere in the podcast, but based on the internal QA data of the trauma center, MRI will find a clinically sig. injury missed by CT 1 in 3000 patients. So the JAMA study is obviously severely underpowered for this injury. I have absolutely no problem if as either an institution or a country we say that is way too much wasted resources to detect such a rare injury. I don’t think the individual clinician should have to be exposed to that risk. I think the clever way to go is to make a policy for… Read more »
Scott, Any new thoughts on this algorithm . I have been using for years. With the East and West trauma studies coming out? thx
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