Cervical Spine Clearance Research Articles

Cervical Spine Clearance in Obtunded Blunt Trauma Patients: A Prospective Study

This prospective study of 402 obtunded blunt trauma patients compared the accuracy of computed tomography (CT) scanning vs. dynamic radiographs for the detection of unstable cervical spine (C-spine) injuries. Patients included in the study underwent both a CT scan and flexion-extension radiographs of the C-spine. There was one injury that was missed on CT scan but detected on dynamic radiographs, resulting in a percentage of missed injury of 0.25%. Subsequent independent review of the CT scan showed that pathologic changes indicative of injury were present on the initial CT scan.

Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines

An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

Cervical Spine Clearance in Children <3 Years of Age

Cervical Spine Clearance in Children <3 Years of Age

Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department

The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses. We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form. Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases. Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.

Perceived facilitators and barriers to clinical clearance of the cervical spine by emergency department nurses: A major step towards changing practice in the emergency department

We conducted a validation study on use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (N=3633). This survey sought to identify potential facilitators and barriers to an implementation policy that would allow nurses to clinically clear the c-spine of minor trauma patients. We conducted a prospective quantitative survey of ED nurses in six hospitals. Questions were developed from a previous qualitative survey at the same validation study EDs. 158 ED nurses were surveyed and 137 (86.7%) responded. Nurses strongly endorsed potential facilitators for nursing clearance of the c-spine, including 'Like to try new things at work' (96.4%) and 'Easy for me to take on new responsibilities' (96.4%). Most respondents were comfortable applying the rule (89.1%). Nurses endorsed potential barriers but at much lower rates, with the most common being 'Heavy workload makes it difficult to use the rule' (37.2%). Variation existed among hospitals for the facilitator 'Use of the rule would be useful to my practice', ranging from 81.8% to 100% endorsement (P=0.004). This survey was an important step towards the goal of empowering ED nurses to clinically clear the c-spine of alert and stable trauma patients. There was a high rate of endorsement of facilitators and a low rate of endorsement of barriers. We found variation between hospitals, emphasizing the importance of understanding local beliefs when seeking to change clinical practice. We are conducting an implementation trial based on this feedback.

Cervical Spine Clearance in Obtunded Blunt Trauma Patients: A Prospective Study

: An acceptable algorithm for clearance of the cervical spine (C-spine) in the obtunded trauma patient remains controversial. Undetected C-spine injuries of an unstable nature can have devastating consequences. This has led to reluctance toward C-spine clearance in these patients. : To objectify the accuracy of computed tomography (CT) scanning compared with dynamic radiographs within a well established C-spine clearance protocol in obtunded trauma patients at a level I trauma center. : This was a prospective study of consecutive blunt trauma patients (18 years or older) admitted to a single institution between December 2004 and April 2008. To be eligible for study inclusion, patients must have undergone both a CT scan and dynamic plain radiographs of their C-spine as a part of their clearance process. : Among 402 patients, there was one injury missed on CT but detected by dynamic radiographs. This resulted in a percentage of missed injury of 0.25%. Subsequent independent review of the CT scan revealed that in fact pathologic changes were present on the scan indicative of the injury. : Our results indicate that CT of the C-spine is highly sensitive in detecting the vast majority (99.75%) of clinically significant C-spine injuries. We recommend that CT be used as the sole modality to radiographically clear the C-spine in obtunded trauma patients and do not support the use of flexion-extension radiographs as an ancillary diagnostic method.

Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age

Cervical spine clearance after trauma in children 0-3 years of age is deceptively difficult. Young children may not be able to communicate effectively, and severe injuries may require intubation and sedation. Currently, no published guidelines are available to aid in decision-making in these complex situations. The purpose of this study was to determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age. Children 0-3 years of age, including intubated patients, who were admitted after trauma activation at Primary Children's Medical Center in Salt Lake City or the Children's Hospital of New York from 2002 to 2006 were managed according to a cervical spine clearance protocol. Data were collected in a prospective fashion. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were recorded. A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children <or= 3 years of age who were admitted to the hospital. To facilitate clearing the cervical spine in these children, plain radiographs (100%), CT studies (14%), and MR images (10%) were obtained. Nineteen ligamentous injuries (3.3%) and 9 fractures/dislocations (1.5%) were detected, with 4 patients requiring operative stabilization (0.7%). No late injuries have been detected. The protocol used has been effective in detecting cervical spine injuries in noncommunicative children after trauma. The combination of clinical information and radiographic studies is essential for safely clearing the cervical spine in these complex situations. Clearance of the cervical spine without CT or MR imaging studies is possible in the majority of cases, even in very young patients.

Clearing the Cervical Spine in the Blunt Trauma Patient

The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. The temporarily nonassessable patient may have short-term mental status changes (eg, intoxication, painful distracting injuries) and can be evaluated by two methods. When there is urgency, the evaluation is similar to that for the obtunded patient. Alternatively, the patient can be reevaluated within 24 to 48 hours, after return of mentation or following treatment of painful injuries. The patient then can be assessed as the asymptomatic patient is. The symptomatic patient requires advanced imaging. The obtunded patient should undergo, at minimum, a multidetector CT scan. Two methods are advocated. One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.

Decreased use of cervical spine clearance in blunt trauma: The implication of the injury mechanism and distracting injury

Background Cervical spine injury (CSI) can be ruled out based on clinical examination and no X-ray is required if patient is awake, alert, and examinable. This is known as a clinical clearance (CC). Clinicians have decreased the use and reliance of CC and relied more upon X-ray, especially now that computerized tomography (CT) is fast and readily available. The objective of this study was to identify clinical factors, in particular, the injury mechanism and the distracting injuries, which may be associated with CSI. The knowledge may help to improve the use of CC. Methods We retrospectively reviewed the records of all blunt trauma patients who were awake, alert, and examinable, with a Glasgow Coma Scale of 14–15, and who were admitted to our Level 1 Trauma Center during January 1 to December 31, 2005. We excluded patients who presented with gross neurological deficit or who died within 72 h. From the chart review, we collected the demographics; the injury severity score (ISS); the injury mechanism; the presence of distracting injuries (DI) which were defined as bony fractures (divided into upper body, lower body, or both); and the radiographs obtained. Patients who did not receive CC underwent a 3-view plain film X-ray, with or without CT scan. We then divided the group into those with CSI (Case) and those without (Control). We compared the two group variables and performed a multiple logistic regression analysis to identify clinical factors associated with CSI. Statistical significance was accepted with p-value <0.05. Results Of the 985 patients evaluated, only 179 (18%) received CC. The remaining did not receive CC and went on to have radiographs. Of these, 76 were diagnosed CSI (Case). On a univariate analysis, the ISS, a motor vehicle collision (MVC) with rollover; MVC with rollover and ejection, the absence of DI, and a lower-body DI were significantly associated with CSI. However, on a multivariate analysis, only an MVC with rollover (odds ratio [OR], 2.326; 95% confidence interval [CI], 1.36–3.97) and a lower-body distracting injury (OR, 0.20; 95% CI, 0.07–0.55) were significantly associated with CSI. Conclusion The injury mechanism of MVC with rollover may prevent clinicians from utilizing CC, while the presence of a lower-body DI should not. A future and prospective study is needed to better understand the role of the injury mechanism and the distracting injury in relation to CSI.

Implementation of the Canadian C-Spine Rule：prospective 12 centre cluster randomised trial

Implementation of the Canadian C-Spine Rule：prospective 12 centre cluster randomised trial

Clearance of the Asymptomatic Cervical Spine: A Meta-analysis

To perform a comprehensive review of the literature and subsequent meta-analysis of data regarding appropriate clearance of the asymptomatic cervical spine in blunt trauma patients. The goal is to identify an asymptomatic patient group that can safely be cleared of cervical spine immobilization without radiographic evaluation. The National Library of Medicine was searched for English-language articles published between 1966 and December 2004. The key words spinal injury, spinal fracture, spinal injuries, cervical, clearance, diagnosis, and radiography were used to perform the search. Inclusion criteria were 1) a prospectively applied protocol; 2) reported outcomes to allow calculation of sensitivity, specificity, negative predictive value, and positive predictive value; and 3) follow up to determine the status of potential injuries with minimum of a 2-week telephone call or a computerized tomography scan. No exclusion criteria were applied. The three senior authors independently confirmed the validity of the included papers for meeting appropriate criteria for the meta-analysis. True-positives, true-negatives, false-positives, and false-negatives were extracted from these studies. Original scale and log odds meta-analysis were performed using random effects methodology to calculate sensitivity, specificity, positive predictive value, and negative predictive value. An alert, asymptomatic patient without a distracting injury or neurologic deficit who is able to complete a functional range-of-motion examination may safely be cleared from cervical spine immobilization without radiographic evaluation (sensitivity = 98.1%, negative predictive value = 99.8%).

40-Slice Multidetector CT: Is MRI Still Necessary for Cervical Spine Clearance after Blunt Trauma?

We have recently demonstrated that 16-slice multidetector CT (MDCT) is insufficient for cervical spine (CS) clearance in patients with unreliable examinations after blunt trauma. The purpose of this study was to determine if a negative CS CT using 40-slice MDCT is sufficient for ruling out CS injury in unreliable blunt trauma patients or if MRI remains necessary for definitive clearance. In addition, we sought to elucidate the frequency by which MRI alters treatment in patients with a negative CS CT who have a reliable examination with persistent clinical symptoms. The trauma registry was used to identify all patients with blunt trauma who had a negative CS CTon admission using 40-slice MDCT and a subsequent CS MRI during their hospitalization from July 2006 to July 2007. Two hundred thirteen patients were identified. Overall, 24.4 per cent patients had abnormal MRIs. Fifteen required operative repair; 23 required extended cervical collar; and 14 had collars removed. A total of 8.3 per cent of patients with an unreliable examination and 25.6 per cent of reliable patients had management changed based on MRI findings. Overall, MRI changed clinical practice in 17.8 per cent of all patients. Despite newer 40-slice CT technology, MRI continues to be necessary for CS clearance in patients with unreliable examinations or persistent symptoms.

Detection of Cervical Spine Injury in Pediatric Trauma Patients

Introduction: Significant cervical spine injuries in pediatric trauma patients are rare. The evaluation for cervical spine injuries is difficult in patients unable to participate in a physical exam and is complicated by behavior and cooperation in young children. The MRI scan is often used in patients unable to cooperate with the exam or with neck tenderness despite negative imaging. In order to determine the utility of this costly approach, we reviewed our experience using MRI scans for evaluation of cervical spine injuries in pediatric trauma patients. Methods: A retrospective analysis of our most recent 5-year experience with cervical spine evaluation in trauma patients was performed. Mechanism of injury, results of diagnostic tests, and management of identified injuries were recorded. Results: From January 2003 through December 2008, 198 patients underwent cervical spine MRI as part of the evaluation for possible trauma-related injury. No injury was identified in 128 patients. A possible injury was identified in 70 patients. Fifty-one of these patients had undergone the MRI for further evaluation of an injury identified on plain films or CT scan. Of the 19 patients with a new diagnosis found with MRI, 9 had a finding on physical exam (usually tenderness) that prompted the MRI. These were all stable with a collar used for comfort in 5 patients. The other 10 patients with potential injuries identified with MRI had no evidence of injury on initial films. The majority of these patients could not participate in physical exam due to neurologic impairment as the indication for MRI. The finding on MRI did not alter the management of any of these patients. Conclusions: The routine use of MRI for evaluation of cervical spine injuries does not significantly affect the management of pediatric trauma patients. These data suggest MRI is not a worthwhile technique for cervical spine clearance but might be best used for further evaluation of a documented injury.

Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients

Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients

Safety of percutaneous tracheostomy in trauma patients

Percutaneous tracheostomy is a common procedure in many trauma ICUs. A concern about the safety of performing percutaneous tracheostomy in patients with no cervical spine clearance or cervical spine injury has limited its adoption for some surgeons. Most experts recommend the use of fiberoptic bronchoscopy during the insertion of percutaneous tracheostomy.

The Canadian C-spine rule safely reduces imaging rates for cervical spine injuries

The Canadian C-spine rule safely reduces imaging rates for cervical spine injuries

The use of dynamic CT surview for cervical spine clearance in comatose trauma patients: A pilot prospective study

The use of dynamic CT surview for cervical spine clearance in comatose trauma patients: A pilot prospective study

Measuring Acceptability of Clinical Decision Rules: Validation of the Ottawa Acceptability of Decision Rules Instrument (OADRI) in Four Countries

Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ''all of the time'' v. ''most of the time'' v. ''some of the time,'' and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ''protorules'' during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.

Journal Club: Clinical Prediction Rules

WHAT IS ALREADY KNOWN ON THIS TOPIC: Previous out-of-hospital studies indicate that selective spinal immobilization may miss patients with cervical injury. WHAT QUESTION THIS STUDY ADDRESSED: Can paramedics apply the Canadian C-Spine Rule in alert, stable, cooperative, blunt-trauma patients to reserve spinal immobilization for high-risk patients while avoiding immobilization for low-risk patients? WHAT THIS STUDY ADDS TO OUR KNOWLEDGE: In this 1,949-patient cohort, paramedics achieved 100% sensitivity and 38% specificity for important cervical fractures. HOW THIS MIGHT CHANGE CLINICAL PRACTICE: Use of the Canadian C-spine Rule by paramedics may safely avoid unnecessary spinal immobilization.

Cervical Spine Clearance in Pediatric Trauma: A Review of Current Literature

Cervical spine injury in children is rare, representing 1 to 2% of pediatric trauma patients, and less than 10% of total spinal trauma cases.1–6 However, 60 to 80% of vertebral injuries in children are in the cervical spine, compared with 30 to 40% in adults.2,5,7 In addition, there are indications