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Paucis Verbis card: Cervical spine imaging rules

Many emergency physicians go straight to CT imaging for patients with neck tenderness and moderate/high risk findings. I personally rarely use the CCR algorithm because I can rarely remember all of the criteria. NEXUS is nice because of its simplicity. Where the CCR algorithm IS helpful is in clinical clearance of the low-risk patient with neck pain. I’ve cleared many patients who self-present with a whiplash mechanism (simple rear-end motor vehicle crash) and diffuse neck pain. By NEXUS criteria, you’d have to image them because they have neck tenderness. By CCR criteria, if they can actively rotate their neck 45 degrees left and right, they don’t have a clinically significant c-spine injury.…

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Featured

 A Pain in the Neck – C-Spine Imaging and Clearance

I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, it should be with a 3-view reconstructed CT scan. And even after that is done, you still need a clearance exam before removing the collar.

 Cervical spine clearance in the intoxicated patient

The most commonly used c spine clearance rules exclude or mandate imaging in the case of the “intoxicated” patient, and there is debate as to whether a normal CT C spine is adequate to clear the neck of the intoxicated patient in blunt trauma.

 Diagnostics: C-Spine Rules

Prior to the creation of clinical decision rules for cervical spine imaging, management was based primarily on physician gestalt and an overall “play it safe” mentality. This essentially amounted to nearly every patient with blunt trauma undergoing some type of cervical spine imaging, especially in the setting of a presumed head injury. In the United States, >13 million patients are evaluated each year for possible cervical spine injuries after trauma. However, only about 0.3% of these patients are found to have significant injury. It’s hard to blame people for being trigger happy on cervical spine imaging though – the tests in isolation are relatively quick and cheap, and the consequence for missing occult injury can be catastrophic. But when all those tests get added together, it’s estimated that over $180 million dollars gets spent each year.

 The Cervical Spine: The Iconoclasm Continues

We are improving our tools for assessment of the C-spine of blunt trauma patients all the time. I am convinced that the clinical examination in conjunction with sensible CT scan use is the key to this and the days of mindless CT scanning of asymptomatic c-spine patients are numbered. We just need a better tool and the ability to use that tool. Perhaps we need to adjust our examination and do away with the distracting injury clause. The evidence is mounting, it is not conclusive yet, but is certainly something to think about.

Articles of Interest

A New PECARN Clinical Decision Rule Minimizes Unnecessary Imaging for Pediatric Cervical Spine Injuries

Figuring out which children need cervical spine imaging after blunt trauma can be a real challenge for even the most seasoned EMS and ED clinicians. We often end up extrapolating rules derived mainly in adults or using pediatric rules based on small retrospective analyses. Thanks to Dr. Leonard’s work, we now have a validated clinical prediction rule based on a large prospective pediatric study. It is exciting that this prediction rule, when used in clinical algorithms, could reduce the number of children receiving unnecessary radiographic testing and radiation exposure.

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

The National Emergency X‐Radiography Utilization Study (NEXUS) criteria and the Canadian C‐spine rule are two clinical decision rules developed to help clinicians risk‐stratify patients with cervical spine trauma to determine if they need imaging to rule out clinically important CSI. These clinical decision rules have been externally validated internationally and their use in routine clinical practice is recommended by international guidelines

Cervical spine Assessment following trauma

One of the two widely adopted and evidence based decision rules is used in the initial evaluation of the cervical spine following trauma: the National Emergency X-Radiography Utilisation Study (NEXUS) criteria or the Canadian C-spine rule. The sensitivity, specificity and negative predictive value of the NEXUS criteria to clinically significant cervical spine injury was reported as 99.6%, 12.9% and 99.9% respectively, while the Canadian C-spine rule was reported as 100% sensitive and 42.5% specific to clinically important injury, with the negative predictive value not reported.

Cervical Spine Imaging in Trauma

When evaluating a patient with any traumatic injury, one of two validated, widely used, and accepted clinical decision instruments can be applied to assist in determining which patients require imaging of their cervical spine: the NEXUS (National Emergency X-Radiography Utilization Study) criteria and the Canadian Cervical Spine Rule (CCR). While both tools are validated and accepted, it is important to know their test characteristics in considering which to apply to the patient in question.

Neck Trauma: Diagnosis and Management in the Emergency Department

The NEXUS criteria for C-spine imaging clear patients from cervical spine fracture clinically, without imaging. The Canadian C-Spine Rule clinically clears cervical spine fracture without imaging. The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems.

Overview and Comparison of NEXUS and Canadian C-Spine Rules

While the literature has consistently demonstrated the CCR to be both more sensitive and specific than the NEXUS Low-Risk Criteria for detecting cervical spine injuries, one must question how good the instruments must be before they are widely accepted by practitioners.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study

Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury.

Which C-Spine Rule Works Best in Trauma Patients?

The authors conclude that the CCR decision rule is more sensitive than the NLC rule for identification of clinically important C-spine injuries and also is more specific, thereby decreasing the number of unnecessary C-spine radiographs. editor’s note: The results of any study where almost 30 percent of eligible patients are not enrolled should be viewed with some skepticism. Yealy and Auble note in an accompanying editorial1 that the NLC rule was initially studied in over 34,000 patients, and a sensitivity of 99.6 percent was reported. He also notes that the CCR rule was developed at the same Canadian medical centers where this study was conducted.

Resources

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.