Cite this post as:
Scott Weingart, MD FCCM. More on a Diagnostic Strategy for C-Spine Injuries. EMCrit Blog. Published on January 2, 2012. Accessed on October 3rd 2023. Available at [https://emcrit.org/emcrit/why-should-we-kill-off-plain-films-c-spine/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: January 2, 2012
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Scott: Awesome 2 parter, as always. My comment concerns a problem I think I see almost every day. The uncooperative drunk who fell down a flight of stairs/crashed his car/got beat up. These guys never want to keep on the collar, often end up wearing it like medieval battle gear, or hurting themselves trying to rip it off. So how do you play this? How much or little effort do you put into keeping the drunks in a collar? After their CT is negative and they want to crawl up in the fetal position to sleep, do you let them?… Read more »
Steve,
excellent question. at this stage of the game, the chance that they have an unstable injury and they remove the collar, and their alcohol has worn off enough that they are moving around, but still drunk enough that they would move their neck despite the insane feeling that instability in that area causes is inordinately small. Not zero, but probably not worth worrying about.
Wow haven’t done a MRI for neck pain in a while maybe we should be paying more attention to people with persistent symptoms. Difficult to weed out the drug seekers sometimes but, in the right setting would appear useful. Wonder if the results change using a 64 slice CT. Last time I sent someone home with a Miami j collar I watched them take it off as they went out the door!
We would find it impossible to get an MRI at most times of the day. So I guess we can just tell the patients the deal and let them decide for themselves whether to heed our words.
Scott A question regarding your two podcasts on c-spine injuries . Would degenerative changes on plain films be deemed abnormal and therefore thrown out ? Many patients have early DDD on plain films . Did NEXUS discard these as abnormal or are you unsure. I am Canadian trained and have practiced in both the US and Canada . I blend Nexus and CCS as you do but rarely do CT . Hoffman would argue( if your approach were correct ) what happened to all the broken necks we missed before CT scans were around . I remember doing tomograms on… Read more »
I thought sharing an “interesting” C-spine case that I saw two yrs ago might add to your valuable pod casts on the same topic; A big, muscular, 39 year old guy, A-grade rugby player (yes, in Australia), was tackled 5 minutes before final whistle. He described it a “usual” tackle, nothing too special. Got up, finished the game, had a bit of chit chat with his mates, walked to his car and sat in passenger seat. His wife drove the car for about 5 minutes when he felt pain in neck for the first time. Pain was at upper neck… Read more »
Wow, great and scary case!
What do you recommend for rural hospital that wodn’t have accesss to ct?
plain films
if perfect and negative
range neck
continued pain, can’t range, or crappy plain films–d/c in collar and f/u for CT scan at academic center
Dr. Weingart, My question involves a patient I saw recently. The patient was a toddler who initially presented as a trauma activation after being involved in an MVC. Restrained in car seat. Initial CT cervical spine was read as negative. Pt was hospitalized for several days and reportedly did well without a c-collar. Reported to have some limited motion at first, but mom later reports that the patient was dancing and playing almost back to normal after discharge. However the toddler would report neck pain occasionally. 2 weeks later is when I saw the patient when they returned back to… Read more »
Greg-That sounds like a horrible case. I only talk about what I know and I know jack about pediatric emergency med. Clearing an infant scares the hell out of me. Any listeners able to comment?
I must really be misunderstanding something basic. In Scott’s podcast he talks about using nexus and if midline is tender then go to Canadian when u jump in and rotate pt 45 degree. But This does not make sense to me bc Canadian uses absence of midline tenderness as a low risk criteria if which the answer is “no” then we should X-ray. So this Is different than Scott’s decision tree where he says if there is midline tenderness then we should rotate 45 either direction. And then Scott says if they still have tenderness after cr then they need… Read more »
Andy, you lost me. In Canadian, if there midline tenderness AND there is at least 1 low risk and no high risk, then you can have patient rotate. If they can’t rotate you get imaging. Then you must recheck persistent moderate tenderness and again if they can rotate. The thought is initially, the patient would have been splinting or uncooperative, but then by the time films or ct has come back negative the patient will rotate (this is allowed to be painful, they just need to do it. I personally would not clear a patient who can’t rotate regardless of… Read more »
Scott, I was a little confused as in your podcast you state that you can not clear someone WITH a negative ct scan if when they return from CT and they still have “significant” midline tenderness. You stated you would still leave them in a collar and follow up with Neurosurgery or MRI. Therefore to me it just does not seem to make intuitive sense that a patient who has one low risk criteria (fender bender, sitting in ER, walked after accident), yet moderate midline tenderness and can rotate 45 degree with pain can be cleared WITHOUT imaging. Seems that… Read more »
There are 2 differences in those groups. In the Canadian study, these were already lower risk patients to be included, they excluded trauma room patients. Then you go through further risk strat with the rule itself. Then the idea is that a fully alert patient with an injury will stop themselves before causing damage when rotating with a fracture or ligament tear. The clearing after xrays or CT, asks about significant midline tenderness. I would argue that even with canadian, if a distracted patient yelps when I push on one of their vertebra, they are not clinically clearable. Now a… Read more »
Hey Scott, Re the point you make above about the cohort of patients who can’t be excluded with CCR having a risk of 4% which is too high for plain films: – this assumes you treat this group homogeneously. Of course in practice amongst that group you may have a young guy whose has no neck tenderness and has been walking around fine but his mechanism was high risk so you couldn’t clear by CCR v’s the elderly chap with a serious mechanism and really severe tenderness whose not walked since accident. So first guy might be 1% risk and… Read more »
Absolutely; that is the natures of a Bayesian approach, but not a decision rule at that point so each clinician must make their own choice. I can only give the grouped numbers, the doc on the spot must go from there.
Hi Scott, what about alert patient who is well, alert, no neuro signs from a seemingly low risk mechanism but still fails NEXUS and CCR where you not only get 3 adequate plain films but also do obliques and flexion / extension films. ( all of which you deem adequate and even sit them up carefully for these films for better quality films). Furthermore get a radiologist to double check the films and obviously any hint including loss of lordosis – get a CT. Surely for either those that can’t get CT’s ( remote) or the patient wishes not to… Read more »
no data, but that seems pretty low risk to me