Risk Of Cervical Spine Injury Research Articles

Radiating Upper Limb Pain in the Contact Sport Athlete

Participation in contact sports exposes the athlete to a risk of cervical spine injury. Temporary neurological injuries manifesting as radiating arm pain or paresthesias, such as transient quadriparesis and stingers, present unique challenges for the sports medicine physician and will be reviewed in detail. The initial management of these conditions must recognize signs and symptoms of spinal cord injury and prevent further neurological sequelae. Evaluation will often include advanced imaging of the cervical spine in addition to serial neurological examinations. This review concludes with rational return-to-play guidelines for contact sport athletes.

Use of GlideScope in airway management of a patient with osteogenesis imperfecta

To the Editor: Patients with osteogenesis imperfecta (OI) have multiple factors that impact airway management, including megalocephaly, macroglossia, and a short neck, which may be complicated by the potential risk of cervical spine injury during neck extension. We present the first reported case of the use of the GlideScope for endotracheal intubation in a patient with severe OI. A 65-year-old woman (86 cm tall, 18.6 kg) with OI congenita was admitted for umbilical hernia repair. She had a history of multiple extremity fractures and contractures, fractures with coughing, and scoliosis (Fig. 1). Airway examination showed mild macroglossia, Mallampati grade II, 3-cm mouth opening, and neck fixed in 20 extension. Planned anesthetic management included local anesthesia and sedation with midazolam 2 mg and fentanyl 125 lg IV. The incision site was infiltrated with local anesthetic. The patient tolerated the procedure until intraperitoneal stimulation caused herniation of abdominal contents, so general anesthesia was induced with propofol 2 mg/kg and rocuronium 1 mg/kg IV. A mask airway was easily obtained. Succinylcholine was avoided because of the risk of fasciculation-induced fractures. Placement of a #3 laryngeal mask airway (LMA) was attempted, but the distorted oral anatomy would not allow it to advance into the hypopharynx. The patient was easily intubated using a GlideScope #3 and cuffed endotracheal tube size 5.5 with in-line stabilization. Direct laryngoscopy was avoided to prevent facial, dental, or spinal trauma. Anesthesia was maintained with O2 and propofol, avoiding volatile triggers for malignant hyperthermia [1]. Blood pressure was measured with a pediatric cuff, set at child inflation limits, every 15 min. The patient was extubated after reversal of muscle relaxation with no coughing. Postoperatively, the patient had a mild sore throat, but no injuries or nausea. She was discharged home on postoperative day 3. Osteogenesis imperfecta is an autosomal dominant disorder characterized by defective synthesis of collagen type I (abnormal mineralization) and a triad of skeletal fragility, blue sclera, and conductive hearing loss [2]. Preoperative evaluation should include an echocardiogram, pulmonary function tests, and assessment of platelet function. Airway management can be complicated by macroglossia, cervical spine problems, micrognathia, and dental fractures with minimal manipulation. The GlideScope uses less force as compared to conventional laryngoscopy. It has an antifogging mechanism and unique angulation permitting a better view of the anterior glottis and can be used with inline stabilization. The distortion of anterior airway anatomy is reduced with use of GlideScope as compared to a Macintosh blade. Cervical extension between the occiput and C4 as well as anterior deviations of the vertebral bodies from baseline are significantly less with the GlideScope [3]. Previous reports illustrate the use of nasal fiberoptic intubation in patients with OI and dental anomalies presenting for maxillary surgery. LMA and intubating LMA F. A. Khan (&) S. Shah S. Shah V. Mandoff W. Brooks Gentry Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, # 515, Little Rock, AR 72205, USA e-mail: fakhan@uams.edu

Evolving role of video laryngoscopy for airway management in the emergency department

Evolving role of video laryngoscopy for airway management in the emergency department

Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review

Background The objective of this study was to characterize the incidence, risk factors, and patterns of cervical spine injury (CSI) in different pediatric developmental ages. Methods A retrospective review of the National Trauma Data Bank was conducted for the period of January 2002 through December 2006 to identify pediatric patients admitted following blunt trauma. Patients were stratified into 4 developmental age groups: infants/toddlers (age 0-3 years), preschool/young children (age 4-9 years), preadolescents (age 10-13 years), and adolescents (age 14-17 years). Patients with a CSI were identified by the International Classification of Diseases, Ninth Revision codes. Demographics, clinical injury data, level of CSI, and outcomes were abstracted and analyzed. Results A total of 240,647 patients met the inclusion criteria. Of these, 1.3% (n = 3,035) sustained a CSI. The incidence of CSI in the stratified age groups was 0.4% in infants/toddlers, 0.4% in preschool/young children, 0.8% in preadolescents, and 2.6% in adolescents. The level of CSI (upper [C1-C4] vs lower [C5-C7]) according to the age groups was as follows: infants and toddlers, 70% vs 25%; preschool/young children, 74% vs 17%; preadolescents, 52% vs 37%; and adolescents, 40% vs 45%, respectively. The adjusted risk for CSI increased 2-fold in preadolescents and 5-fold in adolescents. Conclusion The incidence of pediatric CSI increases in a stepwise fashion after 9 years of age. We noted an increase in lower CSI and a decrease in upper CSI after the age of 9 years. The incidence of upper CSI compared with lower CSI was higher in preadolescents (52% vs 37%) and almost equal in adolescents (40% vs 45%).

Risk factors for cervical spine injury

IntroductionThe early recognition of cervical spine injury remains a top priority of acute trauma care. Missed diagnoses can lead to exacerbation of an existing injury and potentially devastating consequences. We sought to identify predictors of cervical spine injury. MethodsTrauma registry records for blunt trauma patients cared for at a Level I Trauma Centre from 1997 to 2002 were examined. Cervical spine injury included all cervical dislocations, fractures, fractures with spinal cord injury, and isolated spinal cord injuries. Univariate and adjusted odds ratios (ORs) were calculated to identify potential risk factors. Variables and two-way interaction terms were subjected to multivariate analysis using backward conditional stepwise logistic regression. ResultsData from 18,644 patients, with 55,609 injuries, were examined. A total of 1255 individuals (6.7%) had cervical spine injuries. Motor Vehicle Collision (MVC) (odds ratio (OR) of 1.61 (1.26, 2.06)), fall (OR of 2.14 (1.63, 2.79)), age <40 (OR of 1.75 (1.38–2.17)), pelvic fracture (OR of 9.18 (6.96, 12.11)), Injury Severity Score (ISS) >15 (OR of 7.55 (6.16–9.25)), were all significant individual predictors of cervical spine injury. Neither facial fracture nor head injury alone were associated with an increased risk of cervical spine injury. Significant interactions between pelvic fracture and fall and pelvic fracture and head injury were associated with a markedly increased risk of cervical spine (OR 19.6 (13.1, 28.8)) and (OR 27.2 (10.0–51.3)). ConclusionsMVC and falls were independently associated with cervical spine injury. Pelvic fracture and fall and pelvic fracture and head injury, had a greater than multiplicative interaction and high risk for cervical spine injury, warranting increased vigilance in the evaluation of patients with this combination of injuries.

Occupant and Crash Characteristics for Case Occupants With Cervical Spine Injuries Sustained in Motor Vehicle Collisions

Motor vehicle collisions (MVCs) are the leading cause of spine and spinal cord injuries in the United States. Traumatic cervical spine injuries (CSIs) result in significant morbidity and mortality. This study was designed to evaluate both the epidemiologic and biomechanical risk factors associated with CSI in MVCs by using a population-based database and to describe occupant and crashes characteristics for a subset of severe crashes in which a CSI was sustained as represented by the Crash Injury Research Engineering Network (CIREN) database. Prospectively collected CIREN data from the eight centers were used to identify all case occupants between 1996 and November 2009. Case occupants older than 14 years and case vehicles of the four most common vehicle types were included. The National Automotive Sampling System's Crashworthiness Data System, a probability sample of all police-reported MVCs in the United States, was queried using the same inclusion criteria between 1997 and 2008. Cervical spinal cord and spinal column injuries were identified using Abbreviated Injury Scale (AIS) score codes. Data were abstracted on all case occupants, biomechanical crash characteristics, and injuries sustained. Univariate analysis was performed using a χ analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. CSIs were identified in 11.5% of CIREN case occupants. Case occupants aged 65 years or older and those occupants involved in rollover crashes were more likely to sustain a CSI. In univariate analysis of the subset of severe crashes represented by CIREN, the use of airbag and seat belt together (reference) were more protective than seat belt alone (odds ratio [OR]=1.73, 95% confidence interval [CI]=1.32-2.27) or the use of neither restraint system (OR=1.45, 95% CI=1.02-2.07). The most frequent injury sources in CIREN crashes were roof and its components (24.8%) and noncontact sources (15.5%). In multivariate analysis, age, rollover impact, and airbag-only restraint systems were associated with an increased odds of CSI. Using the population-based National Automotive Sampling System's Crashworthiness Data System data, 0.35% of occupants sustained a CSI. In univariate analysis, older age was noted to be a significant risk factor for CSI. Airbag-only restraint systems and both rollover and lateral crashes were also identified as risk factors for CSI. In addition, increasing delta v was highly associated with CSIs. In multivariate analysis, similar risk factors were noted. Of all the restraint systems, seat belt use without airbag deployment was found to be the most protective restraint system (OR=0.29, 95% CI=0.16-0.50), whereas airbag-only restraint was associated with the highest risk of CSI (OR=3.54, 95% CI=2.29-5.46). Despite advances in automotive safety, CSIs sustained in MVC continue to occur too often. Older case occupants are at an increased risk of CSI. Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs. Seat belt use is very effective in preventing CSI, whereas airbag deployment may increase the risk of occupants sustaining a CSI. More protection for older occupants is needed and protection in both rollover and lateral crashes should remain a focus of the automotive industry. The design of airbag restraint systems should be evaluated so that they are not causative of serious injury. In addition, engineers should continue to focus on improving automotive design to minimize the risk of spinal injury to occupants in high severity crashes.

Motorcycle Helmets Associated with Lower Risk of Cervical Spine Injury: Debunking the Myth

There has been a repeal of the universal helmet law in several states despite definitive evidence that helmets reduce mortality, traumatic brain injury, and hospital expenditures. Opponents of the universal helmet law have successfully claimed that helmets should not be required because of greater torque on the neck, which is thought to increase the likelihood of a cervical spine injury. There is currently insufficient evidence to counter claims that helmets do not increase the risk of cervical spine injury after a motorcycle collision. The objective of this study was to determine the impact of motorcycle helmets on the likelihood of developing a cervical spine injury after a motorcycle collision. We reviewed cases in the National Trauma Databank (NTDB) v7.0 involving motorcycle collisions. Multiple logistic regression was used to analyze the independent effect of helmets on cervical spine injury. Cases were adjusted for age, race, sex, insurance status, anatomic (Injury Severity Score) and physiologic injury severity (systolic blood pressure < 90 mmHg), and head injury (Abbreviated Injury Score > 3). Between 2002 and 2006, 62,840 cases of motorcycle collision were entered into the NTDB; 40,588 had complete data and were included in the adjusted analysis. Helmeted riders had a lower adjusted odds (0.80 [CI 0.72 to 0.90]) and a lower proportion of cervical spine injury (3.5% vs 4.4%, p < 0.05) compared with nonhelmeted riders. Helmeted motorcyclists are less likely to suffer a cervical spine injury after a motorcycle collision. This finding challenges a long-standing objection to mandatory helmet use that claims helmets are associated with cervical spine injury. Re-enactment of the universal helmet law should be considered in states where it has been repealed.

Cervical Spine Injuries in American Football

American football is a high-energy contact sport that places players at risk for cervical spine injuries with potential neurological deficits. Advances in tackling and blocking techniques, rules of the game and medical care of the athlete have been made throughout the past few decades to minimize the risk of cervical injury and improve the management of injuries that do occur. Nonetheless, cervical spine injuries remain a serious concern in the game of American football. Injuries have a wide spectrum of severity. The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury. Less common and more serious an injury, cervical cord neuropraxia is the clinical manifestation of neuropraxia of the cervical spinal cord due to hyperextension, hyperflexion or axial loading. Recent data on American football suggest that approximately 0.2 per 100,000 participants at the high school level and 2 per 100,000 participants at the collegiate level are diagnosed with cervical cord neuropraxia. Characterized by temporary pain, paraesthesias and/or motor weakness in more than one extremity, there is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury. Stenosis of the spinal canal, whether congenital or acquired, is thought to predispose the athlete to cervical cord neuropraxia. Although quite rare, catastrophic neurological injury is a devastating entity referring to permanent neurological injury or death. The mechanism is most often a forced hyperflexion injury, as occurs when 'spear tackling'. The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100,000 participants at high school level and 1.5 per 100,000 at the collegiate level. This incidence has decreased significantly when compared with the incidence in the early 1970s. This decrease in the incidence of catastrophic injury is felt to be the result of changes in the rules in the mid-1970s that prohibited the use of the head as the initial contact point when blocking and tackling. Evaluation of patients with suspected cervical spine injury includes a complete neurological examination while on the field or the sidelines. Immobilization on a hard board may also be necessary. The decision to obtain radiographs can be made on the basis of the history and physical examination. Treatment depends on severity of diagnosed injury and can range from an individualized cervical spine rehabilitation programme for a 'stinger' to cervical spine decompression and fusion for more serious bony or ligamentous injury. Still under constant debate is the decision to return to play for the athlete.

CT Should Replace Three-View Radiographs as the Initial Screening Test in Patients at High, Moderate, and Low Risk for Blunt Cervical Spine Injury: A Prospective Comparison

An estimated 10,000 Americans suffer cervical spine injuries each year. More than 800,000 cervical spine radiographs (CSR) are ordered annually. The human and healthcare costs associated with these injuries are enormous especially when diagnosis is delayed. Controversy exists in the literature concerning the diagnostic accuracy of CSR, with reported sensitivity ranging from 32% to 89%. We sought to compare prospectively the sensitivity of cervical CT (CCT) to CSR in the initial diagnosis of blunt cervical spine injury for patients meeting one or more of the NEXUS criteria. The study prospectively compared the diagnostic accuracy of CSR to CCT in consecutive patients evaluated for blunt trauma during 23 months at an urban, public teaching hospital and Level I Trauma Center. Inclusion criteria were adult patient, evaluated for blunt cervical spine injury, meeting one or more of the NEXUS criteria. All patients received both three-view CSR and CCT as part of a standard diagnostic protocol. Each CSR and CCT study was interpreted independently by a different radiology attending who was blinded to the results of the other study. Clinically significant injuries were defined as those requiring one or more of the following interventions: operative procedure, halo application, and/or rigid cervical collar. Of 1,583 consecutive patients evaluated for blunt cervical spine trauma, 78 (4.9%) patients received only CCT or CSR and were excluded from the study. Of the remaining 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by CSR or CCT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. CCT detected all patients with clinically significant injuries (100% sensitive), whereas CSR detected only 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for cervical spine injury according to previously published risk stratification. CSR detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive). Our results demonstrate the superiority of CCT compared with CSR for the detection of clinically significant cervical spine injury. The improved ability to exclude injury rapidly provides further evidence that CCT should replace CSR for the initial evaluation of blunt cervical spine injury in patients at any risk for injury.

Association of injury mechanism with the risk of cervical spine fractures

A full understanding of an injury event and the mechanical forces involved should be important for predicting specific anatomical patterns of injury. Yet, information on the mechanism of injury is often overlooked as a predictor for specific anatomical injury in clinical decision-making. We measured the relationship between mechanism of injury and risk for cervical spine fracture. Our case-control study is a secondary analysis of data collected from the Canadian C-Spine Rule (CCR) study. Data were collected from 1996 to 2002 and included patients presenting to the emergency departments of 9 tertiary care centres after sustaining acute blunt trauma to the head or neck. Cases are defined as patients who were categorized in the CCR study with a clinically important cervical spine fracture. Controls had no radiologic evidence of cervical spine injury. Bivariate and multivariate unconditional logistic regression models were used. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Among the 17,208 patients in the CCR study, 320 (2%)received a diagnosis of a cervical spine fracture. Axial loads, falls, diving incidents and nontraffic motorized vehicle collisions (e.g., collisions involving snowmobiles or all-terrain vehicles) were injury mechanisms that were significantly related to a higher risk of fracture. For motor vehicle collisions, the risk of cervical spine injury increased with the posted speed, being involved in a head-on collision or a rollover, or not wearing a seat belt (p < 0.05). The occurrence of cervical spine fracture was negligible in simple rear-end collisions (1 in 3694 cases; OR 0.015, 95% CI 0.002-0.104]). Our study quantitatively demonstrates the relationship between specific mechanisms of injury and the risk of a cervical spine fracture. A full understanding of the injury mechanism would assist providers of emergency health care in assessing risk for injury in trauma patients.

336: What is the Impact of Obesity on the Relative Risk of Cervical Spine Injury in Blunt Trauma Patients?

The incidence of obesity has reached epidemic proportions in the United States. The impact of this comorbid condition on the likelihood of injury in the trauma patient is unknown. In this study, the relative risk of cervical spine injury was determined for a population of obese blunt trauma patients as compared to a nonobese cohort.

Risk of Cervical Spine Injury and Other Complications Seen with Skull Fractures in the Setting of Mild Closed Head Injury in Young Children: A Retrospective Study

We have reviewed records for patients under 2 years of age who presented at our hospital with mild closed head injuries and nondisplaced skull fractures, specifically to examine methods utilized for spine clearance, associated cervical injuries, involvement and findings of child protective services and delayed complications. Of 42 patients included in the series, none were found to have cervical spine injuries. Child protective services were involved in 12 cases with confirmatory findings and subsequent placement occurring in 2 cases. There were no serious delayed complications in this series of patients. AP and lateral plain films of the cervical spine are nonetheless recommended until larger prospective studies suggest otherwise.

Pedestrians Injured by Automobiles: Risk Factors for Cervical Spine Injuries

Diagnosis of cervical spine injuries (CSI) in multitrauma patients, especially in the presence of head trauma, can be difficult. Identification of risk factors associated with CSI can help avoid missed or delayed diagnosis. Trauma registry study of pedestrian injuries caused by being hit by an automobile. Data abstracted for each patient included age, gender, Glasgow Coma Score on admission, Injury Severity Score, Abbreviated Injury Scale (AIS) for each body area, level of cervical spine injuries, and associated injuries. The incidence of spine injuries was derived for 4 age groups (14 years and younger, 15 to 55 years, 56 to 65 years, and older than 65 years). Logistic regression analysis was performed to identify risk factors associated with CSI. There were 8,401 pedestrian injuries caused by automobiles, and 178 patients (2.1%) had CSI. Incidence of CSI increased with age (0.3% in the age group 14 years and younger, 2.2% in the group 15 to 55 years, 3.7% in the group 56 to 65 years, and 4.4% in the group older than 65 years). Using the youngest age group (14 years and younger) as reference, relative risk of CSI in the other groups was 7.0, 12.1, and 14.2, respectively (p < 0.0001). Patients with severe head trauma (AIS > 3) were significantly more likely to have CSI than patients with less severe head injuries (AIS <or= 3) (1.3% versus 9.0%, p < 0.0001). In the group of 5,040 injuries with no head trauma, there was not even a single case of CSI. Stepwise logistic regression analysis identified age, severe head injury (AIS > 3), severe chest trauma (AIS > 3), pelvic fracture, and femur fracture as independent risk factors for CSI. Incidence of CSI after injuries to pedestrians hit by automobiles increases with age and severity of head trauma. Age, severe head trauma, severe chest trauma, pelvic fracture, and femur fractures are independent predictors of CSI.

Risk of injury of the cervical spine in sled tests in female volunteers

The description of cervical spine motion and the risk to sustain a cervical spine injury is mainly based on cadaver studies. As the active influence of soft tissue is neglected in cadaver studies, our understanding of the kinematic model for whiplash is limited. Therefore the objective of this study was, to describe the in vivo cervical spine motion and acceleration during rear-end sled collisions to identify sequences of motion in which the risk of injury to the cervical spine is increased. A rear-end collision with a speed change (DeltaV) of 6.3 km/h was simulated in a sled test with eight female subjects with no history of prior injury or pain of the cervical spine. A high-speed camera was used to document motion data. Acceleration data were recorded using accelerometers. Acceleration input to the cervical spine was assessed by the simultaneous analysis of the head angle and angular head acceleration as well as the simultaneous analysis of the relative motion and the relative acceleration between the head and T1 to define intervals of increased risk of cervical spine injuries during rear-end collision. The motion sequence is characterized by the same phases that have already been described for male volunteers. Increasing angular head acceleration can explain facet joint injuries during the extension movement (100-120 ms) and hence occur about 50 ms later than shown in cadaver models. In the late rebound the combination of maximal ventral head acceleration and head movement is underestimated and can be responsible for soft tissue injuries. The study shows that during the extension phase and the late rebound phase, acceleration and movement pattern occur that could lead to cervical spine injuries.

The Effect of Protective Equipment on Cervical Spine Alignment in Collegiate Lacrosse Players

Background Contact sports place athletes at risk for cervical spine injury. Protective helmets and shoulder pads worn by football and ice hockey athletes alter cervical spine alignment. The effect of helmet and shoulder pads on neck alignment in lacrosse athletes is not known. Hypothesis Helmets and shoulder pads worn by lacrosse athletes alter cervical spine alignment. Study Design Controlled laboratory study. Methods Sagittal plane cervical spine alignment was evaluated in 16 uninjured male collegiate lacrosse players using computed tomography. Patients were immobilized in the supine position on a standard spine board. Testing was performed without equipment, with both helmet and shoulder pads in place, and with the helmet removed. Angular measurements of the cervical spine were made and analyzed. Results The presence of both the helmet and shoulder pads caused an increase in overall cervical extension (mean, 6°) compared with the absence of both pieces of equipment (P =. 002). Helmet removal alone resulted in a mean increase in cervical flexion of 4.7° in the upper cervical spine compared with the presence of both pieces of equipment (P =. 011). Compared with the absence of equipment, shoulder pads caused increased cervical flexion in the lower cervical spine (mean, 4.4°; P =. 036). Conclusion Protective equipment worn by lacrosse athletes causes statistically significant increases in cervical extension, and its removal causes statistically significant increases in cervical flexion. This alteration is different from that previously reported for protective equipment in football and ice hockey. Clinical Relevance The authors’ recommendation is that both lacrosse helmets and shoulder pads be left in place until they can be completely removed in a controlled fashion. The effect of external equipment on neck position is different for lacrosse compared with football and ice hockey.

Detected and overlooked cervical spine injury in comatose victims of trauma: report from the Pennsylvania Trauma Outcomes Study

This study was undertaken to determine whether a clinically useful rule could be formulated for identifying the presence of traumatic brain injury (TBI) in patients who are at exceptionally low risk of cervical spine injury. The Pennsylvania Trauma Outcomes Study database was searched for cases of TBI in which the admission Glasgow Coma Scale (GCS) score was less than or equal to 8. Cases of cervical injury were identified based on diagnostic codes. Associations between cervical injury and various clinical variables were tested using chi-square analysis. The probability of cervical injury was modeled using logistic regression. Decision tree models were constructed. Statistical determinants of overlooked cervical injury were examined. The prevalence of cervical injury among 41,142 cases of TBI was 8%. Mechanism of injury, thoracolumbosacral (TLS) fracture, age, limb fracture, admission GCS score, hypotension, and facial fracture were associated with cervical injury and were incorporated into the following logistic regression model: probability = 1/(1 + exp[4.248 - 0.417 X mechanism -0.264 X age - 0.678 X TLS - 0.299 X limb - 0.218 X GCS - 0.231 X hypotension - 0.157 X facial]). The results of applying this model provided a rule for cervical spine clearance applicable to 28% of the cases with a negative predictive value (NPV) of 97.0%. Decision tree analysis yielded a rule applicable to 24% of the cases with an NPV of 98.2%. The prevalence of overlooked cervical injury in all individuals with severe TBI was 0.3%; the prevalence of overlooked cervical injury in patients with cervical injury was 3.9%. Overlooked cervical injury was less common in patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245-0.837). This analysis identified no acceptable rule to justify relaxing vigilance in the search for cervical injury in patients with severe TBI. Provider vigilance and consequent rates of overlooked cervical injury can be affected by environmental cues and presumably by other behavioral and organizational factors.

Instructions for Obtaining Journal CME Credit

Anesthesiology's journal-based CME program is open to all readers. Members of the American Society of Anesthesiologists participate at a preferred rate, but you need not be an ASA member or a journal subscriber to take part in this CME activity. Please complete the following steps:The American Society of Anesthesiologists is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education programs for physicians.The American Society of Anesthesiologists designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.Purpose: The focus of the journal-based CME program, and the articles chosen for the program, is to educate readers on current developments in the science and clinical practice of the specialty of Anesthesiology.Target Audience: Physicians and other medical professionals whose medical specialty is the practice of anesthesia.Learning Objectives: After reading this article, participants should have a better understanding of the pathophysiology and management of adults who have sustained blunt trauma and are at risk for cervical spine injury.Author –Edward T. Crosby, M.D., F.R.C.P.C.Grants or research support: None Consultantships or honoraria: None The article authored by Dr. Crosby was supported solely from institutional and/or departmental sources.Question Writer –Peter L. Bailey, M.D.Dr. Bailey has no grants, research support, or consultant positions, nor does he receive any honoraria from outside sources, which may create conflicts of interest concerning this CME program.Based on the article by Crosby entitled “Airway management in adults after cervical spine trauma”http://content.wkhealth.com/linkback/openurl/trusted?issn=0003-3022&amp;volume=104&amp;issue=6&amp;spage=1293&amp;part=fulltextin the June issue of Anesthesiology, choose the one correct answer for each question:1. In patients who have sustained blunt trauma and may be at risk for cervical spine injury, fractures to which one of the following are most likely to be clinically significant?A. Vertebral bodyB. Spinous processC. Transverse processD. Osteophyte2. Which one of the following statements concerning approaches to decompression of the cervical spinal cord to restore neurological function after blunt trauma is most likely true?A. Surgical decompression can lead to further neurological deterioration.B. Complete recovery can only be achieved if decompression occurs within 30 minutes after injury.C. Complete recovery can only be achieved if decompression occurs within 180 minutes after injury.D. Conservative (nonsurgical) approaches are rarely an acceptable alternative.3. Which one of the following statements concerning cervical spine injury after blunt trauma is most likely true?A. The majority of injuries occur in the mid- (C3 to C5) cervical spine.B. The majority of injuries include either C2 or C6/C7.C. The vertebral body is rarely involved in cervical spine injuries.D. The incidence of cervical spine injury in victims of blunt trauma is greater than 10%.4. Which one of the following statements concerning the decision instrument used in the National Emergency X-Radiography Utilization Study to identify blunt trauma victims at low risk for cervical spine injury is most likely true?A. Its positive predictive value is greater than 90%.B. Its negative predictive value is greater than 90%.C. Its application reduces the need for imaging in the majority of trauma patients.D. The likelihood of significant injury is low in the absence of all five described clinical risk factors.5. Which one of the following statements concerning cervical spine immobilization in victims of blunt trauma is most likely true?A. It should be instituted immediately after radiographic documentation of the potential for injury.B. Cervical collars can increase cerebral spinal fluid pressure.C. Soft foam collars effectively limit spinal motion.D. A rigid cervical collar will produce the best limitation of spinal motion.6. Which one of the following statements concerning manual in-line immobilization (MILI) and airway management in patients with suspected cervical spine injury after blunt trauma is most likely true?A. Cervical collars are more effective than MILI at preventing cervical spine movement during laryngoscopy.B. Traction should be routinely applied during MILI.C. MILI impairs the laryngoscopic view as much as other forms of immobilization.D. There is little difference in spinal motion relative to the type of laryngoscopic blade used.7. Which one of the following statements concerning approaches to tracheal intubation in blunt trauma victims with suspected cervical spine injury is most likely true?A. Awake nasal intubation is never appropriate.B. Fiberoptic intubation is the best way to avoid causing secondary injury.C. Rapid sequence induction with manual in-line immobilization should not be used.D. A range of options should be considered.

Risk Factors for Water Sports???Related Cervical Spine Injuries

To examine risk factors associated with water sports-related cervical spine injuries (WSCSI). A retrospective analysis of all patients admitted for WSCSI from 1993 to 1997 was performed. The severity of cervical spine injury was assessed by review of medical records and imaging studies. Mechanisms of injury and activities at the time of injury were noted to determine risk factors for cervical spine injuries caused by wave forced impacts (WFI) from activities such as bodysurfing and body boarding. These risks were compared with injuries incurred by shallow water dives (SWD). One hundred patients were analyzed (mean age, 36 years old); 89% were male, 62% were nonresidents of Hawaii, and 75% had a large build. Patients without radiographic evidence of fractures, subluxations, and/or dislocations (n = 26) were significantly older (48 versus 32 years old, p < 0.0001) with a higher rate of pre-existing cervical spine abnormalities (65% versus 15%, p < 0.0001) compared with the remainder of patients (n = 74). Seventy-seven percent of WFI involved nonresidents. The mean age of WFI patients was significantly older than patients involved in SWD (42 versus 25 years). Ninety-six percent of wave-related accidents occurred at moderately to severely rated shorebreak beaches. Wave forced impacts of the head with the ocean bottom typically occurred at moderate to severe shorebreaks, and involved inexperienced, large-build males in their 40s. Spinal stenosis and degenerative spondylosis may increase the risk of cervical spine injury associated with WFI due to the increased risk of neck hyperextension and hyperflexion impacts inherent to this activity.

Cervical spine injuries in patients with head injuries

It is generally believed that significant head injury after a traffic accident or fall is associated with a high incidence of concurrent cervical spine injury. This study prospectively examined 260 victims of traffic accidents or falls with significant head injury. The incidence of associated cervical spinal injury was only 3.5 per cent. There was no association between the severity of head injury and the incidence of cervical spine injury. The risk of concurrent spinal injury in head injury patients is not higher than the reported risk in patients without head injury. Although care should be taken to protect the cervical spine in patients with head injury, the results of the present investigation show that the risk of cervical spine injury is much less than previously reported.

Detected and overlooked cervical spine injury among comatose trauma patients: from the Pennsylvania trauma outcomes study

A rule for identifying patients with traumatic brain injury (TBI) who are at exceptionally low risk of cervical spine injury might be clinically useful. The goal in this study was to research case records to determine whether such a rule would be practicable. The Pennsylvania Trauma Outcomes Study database was used to find patients with TBI in whom Glasgow Coma Scale (GCS) scores at admission were 8 or less. Cases of cervical spine injury were identified from diagnostic codes. Associations between these injuries and a variety of clinical variables were tested using chi-square analysis. The probability of a cervical spine injury in these patients was modeled by logistic regression. Decision tree models were constructed and statistical determinants of overlooked cervical spine injury were examined. The prevalence of cervical spine injury among 41,142 cases of TBI was 8%. The mechanism of injury, presence of thoracolumbosacral (TLS) spinal, limb and/or facial fracture, patient age, GCS score at admission, and the presence of hypotension were all factors associated with cervical spine injury. These were incorporated into the following logistic regression model: probability of cervical spine injury = 1/(1 + exp[4.030 - 0.417*mechanism - 0.264*age - 0.678*TLS - 0.299*limb + 0.218*GCS score - 0.231*hypotension - 0.157*facial]). This model yielded a rule for clearance of 28% of cases, with a negative predictive value (NPV) of 97%. Decision tree analysis yielded an easily stated rule for clearance of 24% of cases, with an NPV of 98.2%. The prevalence of overlooked cervical spine injury among all patients with severe TBI was 0.3%; the prevalence of overlooked cervical spine injury among patients in whom it was later diagnosed was 3.9%. Overlooked cervical spine injury was less common among patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245-0.837). No acceptable rule for relaxation of vigilance in the search for cervical spine injury among patients with severe TBI has been identified. Levels of provider vigilance and consequent rates of overlooked cervical spine injury can be affected by environmental cues and presumably by other behavioral and organizational factors.