Cervical Spine Clearance Research Articles

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.

Application of the Canadian C-Spine rule and nexus low criteria and results of cervical spine radiography in emergency condition.

IntroductionThe Canadian C Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (Nexus) low criteria are well accepted as guide to help physician in case of cervical blunt trauma.MethodsWe aimed to evaluate retrospectively the application of these recommendations in our emergency department. Secondly we analyzed the quality of cervical spine radiography (CSR) in an emergency setting.Results281 patients with cervical blunt trauma were analyzed retrospectively. The CCR and the NEXUS rules were respected in 91.2% and 96.8% of cases respectively. No lesions were found in 96.4% of patient. A lesion was present in 1.1% of patient and suspected in 2.5% of patient. The quality of CSR was adequate in only 37.7% of patient. The poor quality of CSR was due either to the lack of C7 vertebrae visualization in 64.6% or other lower vertebrae in 28%. Other causes included the absence of open mouth view (8%), the absence C1 vertebrae visualization (3.4%), artifact in 2.3% and the absence of lateral view in 0.6% of patient.ConclusionCCR and NEXUS are widely used in our emergency department. The high rate of inadequate CSR reinforces the debate about it’s utility in emergency condition.

Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project.

Quality improvement project. Reduce the amount of radiation exposure in the pediatric trauma population 5 years of age and older in relation to cervical spine clearance. The evaluation of pediatric cervical spine injuries must be accurate and timely to avoid missed injuries. The difficult clinical examination in pediatric trauma patients necessitates the use of radiologic examinations to avoid missing catastrophic injuries. However, exposure to radiation at an early age increases the pediatric patients' risk of developing cancer (R. A. ). A retrospective chart review was conducted to assess radiation exposure in pediatric patients requiring evaluation for cervical spine clearance. Surgical staff and emergency department physicians received education on the risks related to pediatric radiation exposure and information related to the institution's diagnostic trends for cervical spine clearance. An algorithm was then developed to assist with determining the necessary imaging study for cervical spine clearance. Radiation exposure was monitored following initial education and use of the algorithm to determine its effect on radiation exposure. The retrospective chart review identified cervical spine computed tomography (CT) in 34%, with an average radiation exposure of 3.5 mSv. Following education and introduction of an algorithm, 18% of patients underwent CT for cervical spine clearance with an average radiation exposure of 3.2 mSv, representing a 47% decrease in the use of CT. Staff education and the use of an algorithm show promise in the reduction of radiation exposure and provide safe, effective clearance of the cervical spine in pediatric trauma.

Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project.

Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project.

Diagnostic imaging for cervical spine clearance in multiple trauma patients - a comprehensive review

Diagnostic imaging for cervical spine clearance in multiple trauma patients - a comprehensive review

Cervical spine clearance in adults following blunt trauma: a national survey across major trauma centres in England

To assess current practice in cervical spine clearance across major trauma centres in England and review current guidelines. An electronic survey was sent to lead trauma clinicians at 22 major trauma centres in England. This assessed the clinical decision tools used, the choice of initial imaging technique, and the methods used to clear the cervical spine in alert and obtunded patients without focal neurology, and where initial imaging was normal. British Orthopaedic Association Standards for Trauma (BOAST) 2 and Eastern Association for Surgery for Trauma (EAST) guidelines were used as standards. Eighteen out of the 22 (82%) centres responded by completing the survey. Most (71%) centres used the Canadian C-Spine Rule for clearing the cervical spine clinically. Seventy-two percent of centres preferred computed tomography (CT) as the first-line imaging technique, the choice based on age of patient and mechanism of injury. If the initial CT imaging was normal, magnetic resonance imaging (MRI) was performed in 52% of centres to clear the cervical spine, with half of these centres stating that they would discuss further imaging with a radiologist first. The practice across centres was highly variable for the obtunded patient, with most centres preferring continuing immobilisation or MRI to clear the cervical spine, with a small minority removing spinal precautions when a high-quality multidetector CT was normal. Multidetector CT is the preferred initial imaging technique across most major trauma centres in England when blunt cervical spine trauma is suspected. There is widespread reliance on MRI to clear the cervical spine in both alert and obtunded patients, if initial CT imaging is normal and there is no focal neurology on clinical assessment. This calls for greater awareness of the reliability of a high-quality normal multidetector CT examination in clearing the cervical spine in the absence of focal neurology.

Triage tools for detecting cervical spine injury in pediatric trauma patients.

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population. To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma. We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility. We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards. Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy. Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity. There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

The Use of Clinical Cervical Spine Clearance in Trauma Patients: A Literature Review

IntroductionFive million patients in America are placed in spinal immobilization annually, with only 1% to 2% of these patients suffering from an unstable cervical spine injury. Prehospital agencies are employing selective and limited immobilization practices, but there is concern that this practice misses cervical spine injuries and therefore possibly predisposes patients to worsening injuries. MethodsA systematic review was conducted that examined literature from the last 5 years that reviewed cervical spine immobilization application and/or clearance in alert trauma patients. ResultsPrehospital selective immobilization protocols and bedside clinical clearance examinations are becoming more commonplace, with few missed injuries or poor outcomes. Prehospital providers can evaluate patients in the field safely to assess who needs or does not need cervical collars; similar criteria can be used in the emergency department. Harm from cervical collars is increasingly documented, with concerns that risks exceed possible benefits. DiscussionThe literature suggests that alert trauma patients can be cleared from cervical spine immobilization safely through a structured algorithm in either the prehospital or ED setting. The evidence is primarily observational. Thus, many providers who fear missing cervical injuries may be reluctant to follow the recommendations despite few or no published cases of sudden deterioration from missed cervical spine injuries.Image 1

GLASS Clinical Decision Rule Applied to Thoracolumbar Spinal Fractures in Patients Involved in Motor Vehicle Crashes.

IntroductionThere are established and validated clinical decision tools for cervical spine clearance. Almost all the rules include spinal tenderness on exam as an indication for imaging. Our goal was to apply GLASS, a previously derived clinical decision tool for cervical spine clearance, to thoracolumbar injuries. GLass intact Assures Safe Spine (GLASS) is a simple, objective method to evaluate those patients involved in motor vehicle collisions and determine which are at low risk for thoracolumbar injuries.MethodsWe performed a retrospective cohort study using the National Accident Sampling System-Crashworthiness Data System (NASS-CDS) over an 11-year period (1998–2008). Sampled occupant cases selected in this study included patients age 16–60 who were belt-restrained, front- seat occupants involved in a crash with no airbag deployment, and no glass damage prior to the crash.ResultsWe evaluated 14,191 occupants involved in motor vehicle collisions in this analysis. GLASS had a sensitivity of 94.4% (95% CI [86.3–98.4%]), specificity of 54.1% (95% CI [53.2–54.9%]), and negative predictive value of 99.9% (95% CI [99.8–99.9%]) for thoracic injuries, and a sensitivity of 90.3% (95% CI [82.8–95.2%]), specificity of 54.2% (95% CI [53.3–54.9%]), and negative predictive value of 99.9% (95% CI [99.7–99.9%]) for lumbar injuries.ConclusionThe GLASS rule represents the possibility of a novel, more-objective thoracolumbar spine clearance tool. Prospective evaluation would be required to further evaluate the validity of this clinical decision rule.

Validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk patients with blunt trauma to the neck: part 2. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration.

To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) on the validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk adult patients with blunt trauma to the neck. We searched four databases from 2005 to 2015. Pairs of independent reviewers critically appraised eligible studies using the modified QUADAS-2 and QAREL criteria. We synthesized low risk of bias studies following best evidence synthesis principles. We screened 679 citations; five had a low risk of bias and were included in our synthesis. The sensitivity of the Canadian C-spine rule ranged from 0.90 to 1.00 with negative predictive values ranging from 99 to 100%. Inter-rater reliability of the Canadian C-spine rule varied from k=0.60 between nurses and physicians to k=0.93 among paramedics. The inter-rater reliability of the Nexus Low-Risk Criteria was k=0.53 between resident physicians and faculty physicians. Our review adds new evidence to the Neck Pain Task Force and supports the use of clinical prediction rules in emergency care settings to screen for cervical spine injury in alert low-risk adult patients with blunt trauma to the neck. The Canadian C-spine rule consistently demonstrated excellent sensitivity and negative predictive values. Our review, however, suggests that the reproducibility of the clinical predictions rules varies depending on the examiners level of training and experience.

317 Cost-Effectiveness of a Novel Cervical Spine Clearance Protocol

Abstract INTRODUCTION Cervical spine injury (CSI) occurs in 2–4% of trauma patients in the USA causing significant decrements in quality of life and even death. Treatment of CSI is estimated to cost $9.7 billion annually. Computed tomography (CT) has an almost 100% negative predictive value (NPV) for cervical spine (c-spine) clearance, in both alert and obtunded patients. However, MRI can depict occult discoligamentous injury in some patients with negative CT scans. It remains unclear whether MRI findings should preclude c-spine clearance and prolong hospital stay. This review intends to critically assess CT-missed CSI patients and derive a safe, economically sustainable protocol for c-spine clearance. METHODS A retrospective review of prospectively collected CSI data from two, level-1 trauma centers, was conducted from 2015–2016. Primary outcome measures include: NPV and the incremental cost-effectiveness ratio (ICER) of a novel c-spine clearance protocol compared with standard of care. The protocol included thin-cut CT scans with either weight-bearing or flexion-extension films. The ICER was calculated using standard cost-utility analysis techniques in US dollars ($) per quality-adjusted-life-year (QALY), assuming a willingness-to-pay threshold of 50,000$/QALY. RESULTS >A total of 614 patients were reviewed. Mean age was 38.3 years (SD 18.6), 147 (23.9%) had altered mentation, and 12 (2%) had clinically meaningful CT-missed acute discoligamentous disruption. Our c-spine clearance protocol had a NPV of 99.8% (CI 96.5-100%). There was no statistically significant difference between awake and obtunded patients (P = 0.74). Mean time to c-spine clearance improved by 1.3 days (SD 0.9). Duration of c-spine immobilization was reduced by 930 person-days. Mean cost savings was $1230 (SD $242) per patient. Mean change in QALY was 0.02 (SD 0.01). The ICER was 61,500$/QALY. CONCLUSION Our novel CSI clearance protocol is both safe and highly cost-effective. It improves outcomes at less cost, making it a dominant strategy that centers should consider implementing.

Cervical Spine Collar Removal by Emergency Room Nurses: A Quality Improvement Project

IntroductionThe Canadian C-Spine Rule (CCR) is a clinical decision aid to facilitate the safe removal of cervical collars in the alert, orientated, low-risk adult trauma patient. Few health care settings have assessed initiatives to train charge nurses to use the CCR. This practice improvement project conducted in a secondary trauma center in Canada aimed to (1) train charge nurses of the emergency room to use the CCR, (2) monitor its use throughout the project period, and (3) compare the assessments of the charge nurses with those of emergency physicians. MethodsThe project began with the creation of an interdisciplinary team. Clinical guidelines were established by the interdisciplinary project team. Nine charge nurses of the emergency room were then trained to use the CCR (3 on each 8-hour shift). The use of the CCR was monitored throughout the project period, from June 1 to October 5, 2016. ResultsThe 3 aims of this practice improvement project were attained successfully. Over a 5-month period, 114 patients were assessed with the CCR. Charge nurses removed the cervical collars for 54 of 114 patients (47%). A perfect agreement rate (114 of 114 patients, 100%) was attained between the assessments of the nurses and those of physicians. DiscussionThis project shows that the charge nurses of a secondary trauma center can use the CCR safely on alert, orientated, and low-risk adult trauma patients as demonstrated by the agreement in the assessments of emergency room nurses and physicians.Image 1

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma

Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies. The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.

Pediatric Trauma

Children have unique anatomy and physiologic responses to trauma that create different challenges for their management. It is important to follow the Advanced Trauma Life Support (ATLS) algorithm for assessing and treating a pediatric trauma patient, paying close attention to the primary survey. Once the primary survey is accomplished with adequate stabilization, the secondary survey proceeds with a focus on specific injuries. Head trauma is the leading cause of morbidity and mortality (M+M) in children. Early identification and prevention of secondary injury are important to optimize outcomes. The head and neck anatomic differences in a child cause a higher fulcrum of their cervical spine, leading to higher cervical spine injuries (CSIs). CSI is rare but carries a higher M+M due to higher spinal cord injuries. The National Emergency X-radiography Utilization Study (NEXUS) and Canadian C-spine Rule (CCR) are useful decision rules to clear cervical spines in adults but have limited strength in young children. PECARN has derived a pediatric cervical spine clearance rule, but this has yet to be prospectively validated. Similar to CSIs, thoracic injuries in children are rare but carry a higher M+M due to anatomic differences in children. A child’s chest anatomy and increased compliance cause more difficulty in injury identification. Abdominal trauma is common in children and can also be difficult to identify. Unlike adults, children can compensate for blood loss much longer while maintaining their blood pressure. Serial abdominal examinations are useful when imaging is negative and a patient has persistent symptoms. This review contains 5 highly rendered figures, 18 tables, and 92 references. Key words: abdominal trauma, Advanced Trauma Life Support (ATLS), cervical spine injury, head trauma, National Emergency X-radiography Utilization Study (NEXUS), Pediatric Emergency Care Applied Research Network (PECARN), thoracic trauma, traumatic brain injury

Effect of cervical collars on intracranial pressure in patients with head neurotrauma

Trauma patients are at high risk of cervical and associated injuries. The standard protocol includes immobilization of the cervical spine in a polytrauma as it will help to prevent spinal injuries in the prehospital settings. Hard cervical collar (or alternatives) is routinely used until the cervical spine clearance is obtained . In patients with traumatic brain injury avoiding any kind of maneuver may lead to increased intracranial pressure.

PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.

LO83: Effectiveness of implementing evidence based interventions to reduce C-spine imaging in the emergency department: a systematic review

Introduction: Unnecessary imaging of adult cervical spine (C-spine) injury patients in the Emergency Department (ED) is a concern. Guidance for C-spine image ordering exists; however, the effectiveness and safety of their implementation in the ED is not well studied. This review examines their implementation and effectiveness at reducing C-spine imaging in adults presenting to the ED with stable neck trauma. Methods: Six electronic databases and the grey literature were searched. Comparative studies examining interventions to reduce C-spine imaging were eligible for inclusion. Two independent reviewers screened for study eligibility, assessed study quality, and extracted data. Data were analyzed using RevMan (Version 5.3) to explore the effectiveness of these interventions in safely reducing C-Spine radiography. Results: A total of 848 unique citations were screened of which six before-after studies and one randomized controlled trial were included. The study population varied with respect to injury severity (i.e., stability status). None of the studies were assessed as high quality. The interventions employed included locally developed guidelines and clinical decision rules, specifically the National X-radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR). Various implementation strategies, such as teaching sessions, pocket reminder cards, posters and computerized decision support were used. Several studies used multi-faceted interventions. Overall, of the five study groups that examined change in x-ray ordering, three groups reported a significant reduction in c-spine radiography. The remaining two showed no change in imaging. A pooled estimate of the effectiveness of the interventions was prohibited by significant heterogeneity. Conclusion: The evidence regarding the effectiveness of interventions to reduce C-spine imaging in adult ED patients with stable neck trauma is inconclusive. Given the national and international focus on improving appropriateness and reducing unnecessary imaging through campaigns such as Choosing Wisely®, additional interventional research in this field is warranted.

Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol.

Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol. A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol. Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a combination of x-ray and computed tomographic imaging. Only 46% of institutions utilize a written, standardized pediatric cervical spine clearance protocol. This study demonstrates a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is our opinion that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries. Level 4-economic and decision analyses.

64-Slice CT compared to MRI to clear cervical spine injury in high-risk GCS < 14 blunt trauma patients admitted to the ICU

Objective Clearance of cervical spine injury including ligamentous injury is of paramount importance as results of missed injury may have serious consequences. In obtunded patients, cervical spine clearance is challenging. This study sought to determine whether a negative 64-slice CT scan alone is sufficient to clear cervical spine injury. Patients and methods All consecutive blunt trauma patients admitted to a regional (level 1) trauma center from 1 April 2008 to 31 March 2012 were screened for inclusion in this study. High-risk, GCS < 14, blunt trauma patients were included if they were admitted to the intensive care unit, had a negative 64-slice CT, and MRI of diagnostic quality. GCS was measured at the time of CT scan. Patients with a positive finding on CT scan were excluded. All images were re-interpreted by a trauma radiologist blinded to clinical outcome. Details of missed injuries and clinical impact were reported. The primary outcome was missed clinically significant injury, defined as any injury requiring an additional intervention including continued immobilization or surgery. Results There were 5891 blunt trauma patients admitted to the ICU, 44 of whom met inclusion criteria. Patients had a median injury severity score of 35 and MRI three (2–9) days after CT. Eight of 44 (18%) patients had a positive finding on MRI and five of the findings were clinically insignificant. Three patients (7%) with focal neurologic findings on clinical exam had missed injuries requiring immobilization with a collar. Two of these patients had spine disease, which may have increased their injury risk. Conclusions In high-risk obtunded blunt trauma patients admitted to the ICU, a negative 64-slice CT scan alone is insufficient to clear clinically significant cervical spine injury, with a missed clinically significant injury rate of 7%. When considered with symmetric motor function, a negative 64-slice CT scan may be sufficient. A prospective study is required to confirm these findings.