HWN Suggests

Unstable Cervical Spine Fractures

Recommendations for imaging the cervical spine for trauma has changed quit a lot over the last several years. The National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-Spine Rule (CCR) have been validated and have allowed our practice to advance such that we can effectively practice clinical medicine. However, a word of caution on using these criteria with patients who could be impaired. Sometimes the mild dementia, delirium or subtle drug, alcohol intoxication can lead us astray when we rely solely on these criteria. The cross table lateral films and specifically flexion/extension views have fallen out of favor. Most patients without focal neurological complaint…

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 Backboard and Collar Nightmares from Emergency Medicine Update Conference

The idea that backboards and c-spine collars prevent spinal cord injuries came from level 3 evidence in the 1960’s and there has never been an RCT to prove this theory. In fact a Cochrane review on the topic in 2007 concluded that “the effect of pre-hospital spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain” and that “the possibility that immobilisation may increase mortality and morbidity cannot be excluded”. There have subsequently been several observational studies that describe increased morbidity and mortality associated with backboard and collars in a subset of patients.

 C-Spine Clearance in the ED: When to ditch the collar

For any patient with a possible cervical spine injury, it is still standard of practice to initiate spinal immobilization. The conservative approach is to assume the possibility of a cervical spine injury in any patient; however spinal immobilization has its own risks and adverse effects long term. We get it. We personally aren’t the biggest fans of cervical collars in awake and alert patients, but the boards want you to be conservative! In unstable trauma patients requiring immediate surgery, cervical collar should be maintained and cleared later after life-threatening injuries have been dealt with. In those with major trauma undergoing CT imaging of the head, chest, abdomen or pelvis, CT cervical spine should be obtained as well.

Articles of Interest

Canadian C-Spine Rule

The CCR is only intended for use with alert and stable trauma patients with neck pain; therefore, patients over the age of 65 with neck pain do not necessarily require imaging.

NEXUS Criteria for C-Spine Imaging

The notion that tenderness is quantifiable on a score without trusting the patient is crazy. Let’s go back and remember what this is about: our goal was never to get rid of negative c-spine films, our goal was to get rid of an extra percentage of those. 98% of them were already negative. We wanted to see if there was a way to avoid doing a film in somebody that everyone in the world knows is okay, and we’re only doing it because we’re all scared.

C-Spine Injuries + CT Interpretation

Cervicocranial injuries (C1-C2) can be distinguished from lower cervical spine injuries (C3-C7). Cervicocranial injuries are classified by their anatomical location whereas lower cervical spine injuries are classified by their mechanism of injury (Schwartz 2008).

Cervical Spine Imaging in Trauma

Consider if if your patient is a candidate for plain radiographs instead of CT, particularly if their pain is mild, their traumatic mechanism was low risk, and they are young.

Emergency Department Management of Cervical Spine Injuries

A systematic approach to the diagnosis and management of the spine-injured patient is outlined in this review, with a focus on recent updates and management of emergent complications.

Emergency Department Management of Cervical Spine Injuries

NEXUS and the Canadian c-spine rule: using clinical decision rules to determine who is safe to discharge without imaging. Using the Denver criteria to determine when further imaging for blunt cerebrovascular injury is needed.

Geriatric Trauma Part 1: The Under-Triaging Problem, Resuscitation, Airway, Head and C-spine Imaging, Clearing the C-spine

There are significant patient harms associated with delayed c-spine clearance including pressure ulcers, dysphagia, aspiration pneumonia, respiratory failure, agitation, and delirium. The goal at each center should be to have processes in place to quickly evaluate and clear the c-spine.

Pediatric Cervical Spine Injury

With adults it is relatively straight forward; apply your favorite validated screening tool and if your patient needs imaging, obtain a CT. With children, it isn’t as “simple.” Fortunately, my friend and colleague, Dr. Emily MacNeill has spent some time pondering this and can help us decipher the issue of Pediatric Cervical Spine Injury:

Spine Injuries

Evaluate the exclusion criteria if the patient is conscious and has no posterior midline tenderness on examination. Nexus and Canadian C-spine rules are the main rule-out criteria of a cervical spine injury.

The Management of Unstable Cervical Spine Injuries

Injuries to the cervical spine can cause potentially devastating morbidity and even mortality. In this review we discuss the anatomy and biomechanics of the cervical spine. The evaluation and treatment of cervical spine injuries begins with the prompt immobilization of suspected injuries in the field. Once an assessment of the patient's neurological status is made, imaging studies are obtained, which can include X-rays, CT, and MRI.

We Have Your Back: ED Presentations, Evaluation, and Management of Spinal Cord Injuries

SCI can have devastating consequences contributing to high morbidity in patients and consideration of these pathologies with appropriate neurological exam and imaging... Although CT should be considered initially for patients with concern for traumatic SCI, MRI is the gold standard for those with neurological deficits localizing to the spinal cord.