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)
Check out the c-spine guidelines from the Eastern Assoc of Surgeons for Trauma (EAST)