Cervical Spine Clearance Research Articles

Evaluating the Cervical Spine in the Blunt Trauma Patient.

Following a blunt trauma, the goal of the cervical spine evaluation is to identify any injuries that might require active management: either through continued use of a collar or surgical stabilization. This is achieved through a step-wise approach that considers the nature of the patient's trauma, presenting complaints, distracting injuries and capacity to cooperate with the examination. In the last 15 to 20 years, technological advances in radiographic imaging have improved clinicians' abilities to certify the cervical spine as free of injury following blunt trauma. Within the last decade, the use of CT has supplanted plain radiograph imaging as the standard screening modality. Although MRI is more sensitive than CT in identifying occult cervical injury, particularly ligamentous or soft-tissue trauma, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries.

Implementation of a pediatric trauma cervical spine clearance pathway.

Pediatric cervical spine injuries are rare events. Missed injuries must be weighed against radiation exposure and excess resource utilization in a young population. A universal pediatric cervical spine clearance algorithm does not exist. The study objective is to determine if care improved after the implementation of a standardized cervical spine clearance pathway by evaluating imaging rates, length of stay, speciality consultation, and injury detection. A multidisciplinary group reviewed relevant literature to develop an algorithm for cervical spine clearance in pediatric trauma patients. We reviewed patient charts 15months before and after implementation. Categorical comparisons were tested with Chi-square. A p value less than 0.05 was considered statistically significant. The pre- and post-implementation groups were homogenous when comparing demographics, mechanism and severity of injury. Using the cervical spine clearance pathway, patients received fewer plain cervical spine radiographs (34% vs 16%), fewer spine speciality consults (28% vs 13%), and more patients were cleared clinically (44% vs 62%) (p < 0.05). There were 2 (1.7%) documented injuries in the pre-implementation group and 3 (3%) documented injuries in the post-implementation group. There were no missed injuries. Use of a standardized pathway allows more patients' cervical spines to be cleared clinically and better utilizes resources without compromising patient care. Level III. Care Management Study.

Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group

BACKGROUND: One recent survey of Level One Pediatric Trauma Centers shows only 46% of institutions utilize a standardized, written pediatric cervical spine clearance protocol. This study aims to create an expert, multi-disciplinary consensus statement and algorithm for pediatric cervical spine clearance by employing a modified Delphi method. METHODS: The Pediatric Cervical Spine Working Group is comprised of pediatric orthopaedic surgeons (n=15), pediatric emergency medicine physicians (n=3), pediatric trauma …

Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group

Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group

Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost

BackgroundFor years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar...

LO71: Evaluating the application of the prehospital Canadian C-Spine Rule by paramedics in sport-related injuries

Introduction: The Canadian C-Spine rule (CCR) was validated for use by paramedics to selectively immobilize stable trauma patients. However, the CCR “Dangerous Mechanism” is highly prevalent in sports. Our objective was to compare the CCR performance in sport-related vs. non-sport-related injuries and describe sport-related mechanisms of injury. Methods: We reviewed data from the prospective paramedic CCR validation and implementation studies in 7 Canadian cities, which already included identification of sport-related injuries. A single trained reviewer further categorized mechanisms of injury using a pilot-tested standardized form, with the aid of a sport medicine physician in 15 ambiguous cases. We compared the CCR's recommendation to immobilize sport-injured versus non-sport-injured patients using chi-square and relative risk statistics with 95% confidence intervals. Results: There were 201 amateur sport-injuries among the 5,978 patients. Sport-injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs 46.8%) than non-sport-injured patients. Paramedics did not miss any c-spine injuries when using the CCR. Although cervical spine injury rates were similar between sport (2/201; 1.0%) and non-sport injured patients (47/5,777; 0.8%), the absolute number of sport-related injuries was very small. Although CCR recommended immobilization equally between the two groups (46.4% vs 42.5% p = 0.29; RR 1.17 95%CI 0.87-1.57), the reason for immobilization was more likely to be a dangerous mechanism in sport injuries (68.6% vs 54.5%, p = 0.012). Although we observed a wide range of mechanisms, the most common dangerous mechanism responsible for immobilization in sport was axial load. Conclusion: The CCR identified all significant c-spine injuries in a cohort of patients assessed and transported by paramedics. Although an equal proportion of sport and non-sports related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the CCR to evaluate all sport-related injuries in collegiate or pro athletes evaluated by sport medicine therapists and physicians, as these patients are rarely assessed by paramedics or transported to a hospital. It does support the safety and benefit of using the CCR in sport-injured patients for which paramedics are called.

"Next Day" Examination Reduces Radiation Exposure in Cervical Spine Clearance at a Level 1 Pediatric Trauma Center: Preliminary Findings.

Safe and effective clearance of the pediatric cervical spine presents a challenging problem due to a myriad of reasons, which has often led to further imaging studies such as computed tomographic (CT) scans being performed, exposing the pediatric patient to significant radiation with a potential increased cancer risk. The goal of this study is to develop an effective algorithm for cervical spine clearance that minimizes radiation exposure. A cervical spine clearance protocol had been utilized in our institution from 2002 to 2011. In October 2012, the protocol was revised to provide indications for appropriate imaging by utilizing repeat "next day" physical examination. In 2014, the protocol was again revised with the desired goal of decreasing the use of CT scans through increased involvement of the Spine Service. A retrospective review was commenced using information from the Trauma Database from 2011 to 2014. Three groups were analyzed according to which protocol the patients were evaluated under: 2011, 2012, and 2014 protocols. During the study period, 762 patients underwent cervical spine clearance; 259 (2011 protocol), 360 (2012 protocol), and 143 (2014 protocol). The average age of all patients was 8.8 years, with 28% of patients younger than 5 years of age. There were no missed or delayed diagnoses of cervical spine injury. The use of CT scans decreased during the study period from 90% (2011 protocol) to 42% (2012 protocol) to 28.7% (2014 protocol). There was an increase in time to removal of the cervical collar at 13 to 24 hours from 8% (2011 protocol) to 22% (2012 protocol) to 19% (2014 protocol). This was not associated with an increase in hospital length of stay, which averaged 2.51 days (2011 protocol), 2.45 days (2012 protocol), and 2.27 days (2014 protocol). Repeat "next day" clinical examinations and increased involvement of the Spine Service decreased radiation exposure without compromising the diagnosis of cervical spine injury or increasing the length of stay at a Level One Pediatric Trauma Center in this pilot study. Level 4-case series.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Cervical spine clearance in adult trauma patients.

Up to 4% of adults with blunt trauma suffer cervical spine injury. Clinicians who evaluate trauma patients can use validated clinical decision tools to assess whether patients are at risk for these injuries. Beyond these tools, imaging (most often CT) remains the mainstay of evaluation. Further challenges exist when patients have persistent pain or cannot be evaluated clinically. This article reviews the evidence available to assist clinicians in evaluating adults for significant cervical spine injury after blunt trauma.

Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

Study Design:Expert consensus.Objectives:To establish treatment recommendations for subaxial cervical spine injuries based on current literature and the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma.Methods:This recommendation summarizes the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma.Results:Therapeutic goals are a stable, painless cervical spine and protection against secondary neurologic damage while retaining maximum possible motion and spinal profile. The AOSpine classification for subaxial cervical injuries is recommended. The Canadian C-Spine Rule is recommended to decide on the need for imaging. Computed tomography is the favoured modality. Conventional x-ray is preserved for cases lacking a “dangerous mechanism of injury.” Magnetic resonance imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and to exclude disco-ligamentous injuries. Computed tomography angiography is recommended in high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are operated in the majority of cases. A4- and B- and C-type injuries are treated surgically. Most injuries can be treated with anterior plate stabilization and interbody support; A4 fractures need vertebral body replacement. In certain cases, additive or pure posterior instrumentation is needed. Usually, lateral mass screws suffice. A navigation system is advised for pedicle screws from C3 to C6.Conclusions:These recommendations provide a framework for the treatment of subaxial cervical spine Injuries. They give advice about diagnostic measures and the therapeutic strategy.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis.

In a consensus process with four sessions in 2017, the working group "upper cervical spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures", taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

Triage Nurses Can Implement the Canadian C-Spine Rule Safely

Prehospital personnel are rightly compulsive about applying cervical collars, but the collars are uncomfortable for patients and may nudge providers

Acceptability of a Mobile Clinical Decision Tool Among Emergency Department Clinicians: Development and Evaluation of The Ottawa Rules App.

BackgroundThe Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule—together known as The Ottawa Rules—are a set of internationally validated clinical decision rules developed to decrease unnecessary diagnostic imaging in the emergency department. In this study, we sought to develop and evaluate the use of a mobile app version of The Ottawa Rules.ObjectiveThe primary objective of this study was to determine acceptability of The Ottawa Rules app among emergency department clinicians. The secondary objective was to evaluate the effect of publicity efforts on uptake of The Ottawa Rules app.MethodsThe Ottawa Rules app was developed and publicly released for free on iOS and Android operating systems in April 2016. Local and national news and academic media coverage coincided with app release. This study was conducted at a large tertiary trauma care center in Ottawa, Canada. The study was advertised through posters and electronically by email. Emergency department clinicians were approached in person to enroll via in-app consent for a 1-month study during which time they were encouraged to use the app when evaluating patients with suspected knee, foot, or neck injuries. A 23-question survey was administered at the end of the study period via email to determine self-reported frequency, perceived ease of use of the app, and participant Technology Readiness Index scores.ResultsA total of 108 emergency department clinicians completed the study including 42 nurses, 33 residents, 20 attending physicians, and 13 medical students completing emergency department rotations. The median Technology Readiness Index for this group was 3.56, indicating a moderate degree of openness for technological adoption. The majority of survey respondents indicated favorable receptivity to the app including finding it helpful to applying the rules (73/108, 67.6%), that they would recommend the app to colleagues (81/108, 75.0%), and that they would continue using the app (73/108, 67.6%). Feedback from study participants highlighted a desire for access to more clinical decision rules and a higher degree of interactivity of the app. Between April 21, 2016, and June 1, 2017, The Ottawa Rules app was downloaded approximately 4000 times across 89 countries.ConclusionsWe have found The Ottawa Rules app to be an effective means to disseminate the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule among all levels of emergency department clinicians. We have been successful in monitoring uptake and access of the rules in the app as a result of our publicity efforts. Mobile technology can be leveraged to improve the accessibility of clinical decision tools to health professionals.

A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses

The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization. We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to "clear" the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries). In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule. We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.

Safe management of acute cervical spine injuries.

Cervical spine injuries are frequent and often caused by a blunt trauma mechanism. They can have severe consequences, with a high mortality rate and a high rate of neurological lesions.Diagnosis is a three-step process: 1) risk assessment according to the history and clinical features, guided by a clinical decision rule such as the Canadian C-Spine rule; 2) imaging if needed; 3) classification of the injury according to different classification systems in the different regions of the cervical spine.The urgency of treatment is dependent on the presence of a neurological lesion and/or instability. The treatment strategy depends on the morphological criteria as defined by the classification.Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170076

Routine cervical spine immobilisation is unnecessary in patients with isolated cerebral gunshot wounds: A South African experience.

Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs). A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs. During the 5 year study period, 102 patients were included. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-eight per cent of the injuries were secondary to low velocity GSWs. Twenty-seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty-five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted. Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs.

Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) for detecting clinically important cervical spine injury following blunt trauma

Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) for detecting clinically important cervical spine injury following blunt trauma

Erratum: This Article Corrects: "GLASS Clinical Decision Rule Applied to Thoracolumbar Spinal Fractures in Patients Involved in Motor Vehicle Crashes".

[This corrects the article on p. 1108 in vol. 18, PMID: 29085544.].

Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT.

To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT. A review of medical records identified all adult patients with blunt trauma who underwent CT cervical spine followed by MRI within 48 h over a 33-month period. Utility of subsequent MRI was assessed in terms of findings and impact on outcome. A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management. MRI for blunt trauma evaluation remains not infrequent at our institution. MRI may have utility only in certain patients with persistent abnormal neurological examination. • MRI has limited utility after negative cervical CT in blunt trauma. • MRI is frequently positive for non-specific soft-tissue injury. • Unstable injury missed on CT is infrequent.

Effectiveness of Implementing Evidence-based Interventions to Reduce C-spine Image Ordering in the Emergency Department: A Systematic Review.

Appropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma. Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects. A total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR=0.69, 95% CI= 0.51-0.93); however, heterogeneity was high (I2 =82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p=0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p=0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported. There is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted.