1. Trauma Conference Evaluation and Clearance of Cervical Spine Injuries: An Update

2. Facts and Figures 12,000 spinal cord injuries annually in US 12,000 spinal cord injuries annually in US 250,000 Americans living with spinal cord injuries 250,000 Americans living with spinal cord injuries Annual cost of $4 billion Annual cost of $4 billion >50% occur between age 16 and 30 years old >50% occur between age 16 and 30 years old >80% male >80% male Assault MVA Accidents / falls National Spinal Cord Statistics Center, 2001

3. History 1700 BC: first reported by Egyptians on papyrus describing 2 neck injuries causing paralysis that were “not to be treated.” 1700 BC: first reported by Egyptians on papyrus describing 2 neck injuries causing paralysis that were “not to be treated.” 460-377 BC: Hippocrates employed rudimentary traction devises 460-377 BC: Hippocrates employed rudimentary traction devises 1543 – Vesalius published complete anatomy of spinal cord and consequences of injury at each level (coined terms cervical, thoracic, lumbar and sacral) 1543 – Vesalius published complete anatomy of spinal cord and consequences of injury at each level (coined terms cervical, thoracic, lumbar and sacral) 1920 – X-ray enables surgeons to better localize fracture 1920 – X-ray enables surgeons to better localize fracture 1990’s – methylprednisolone added to early treatment 1990’s – methylprednisolone added to early treatment National Spinal Cord Statistics Center, 2001

4. Types of C-spine Fractures Atlas Fractures (C1): 5% Atlas Fractures (C1): 5% - Jefferson fracture: burst fx caused by axial loading causing disruption of anterior and posterior rings of C1 w/ lateral of C1 w/ lateral displacement. Unstable. ATLS Student Course Manual, 2008

5. Types of C-spine Fractures Axis (C2) Fractures Axis (C2) Fractures Odontoid fx: 60% of C2 fx. Type I involves tip of odontoid (uncommon), Type II involves base of dens (most common), Type III extends obliquely through body of axis Odontoid fx: 60% of C2 fx. Type I involves tip of odontoid (uncommon), Type II involves base of dens (most common), Type III extends obliquely through body of axis “Hangman’s fx:” Posterior elements of C2 (pars interarticularis). Extension injury. Unstable. “Hangman’s fx:” Posterior elements of C2 (pars interarticularis). Extension injury. Unstable.

6. Types of C-spine Fractures C3-C7 C3-C7 C3 fx: very uncommon C3 fx: very uncommon C5/C6: Most common level of fx and subluxation (site of greatest flexion/extension) C5/C6: Most common level of fx and subluxation (site of greatest flexion/extension) Most common injuries: vertebral body, laminae, spinous processes or pedicle fractures Most common injuries: vertebral body, laminae, spinous processes or pedicle fractures

7. Role of Trauma Team Properly identify those who warrant C-spine precautions and evaluation Properly identify those who warrant C-spine precautions and evaluation Obtain prompt spinal surgery consultation if an injury is diagnosed Obtain prompt spinal surgery consultation if an injury is diagnosed Clear and remove C-collar ASAP to minimize harmful effects of prolonged C-collar use Clear and remove C-collar ASAP to minimize harmful effects of prolonged C-collar use

8. Effects of Prolonged C-Collar (CC) Use Length of CC use directly proportional to risk of CC decubitus ulcers Length of CC use directly proportional to risk of CC decubitus ulcers 7-38% overall risk of decubitus ulcers in SICU patients in CC who survived >24 hours 7-38% overall risk of decubitus ulcers in SICU patients in CC who survived >24 hours CC use increases ICP CC use increases ICP 90% of TBI patients have been shown to have documented elevations in ICP after application of CC 90% of TBI patients have been shown to have documented elevations in ICP after application of CC Early CC removal associated with decreased ventilator days, SICU LOS, hospital LOC, health-care associated pneumonia, and delirium Early CC removal associated with decreased ventilator days, SICU LOS, hospital LOC, health-care associated pneumonia, and delirium Chendrasekhar, Am Surg, 1998 Powers, J Trauma Nurse, 2006 Mobbs, ANZ J Surg, 2002

9. Patient do NOT need CS imaging if… Low-risk mechanism of injury Low-risk mechanism of injury Neurologically intact Neurologically intact No distracting injuries No distracting injuries No midline tenderness or pain on full ROM No midline tenderness or pain on full ROM Penetrating neck trauma (unless trajectory suggest possible direct injury to CS) Penetrating neck trauma (unless trajectory suggest possible direct injury to CS) Eastern Association for the Surgery of Trauma, 2009

10. Who Needs CS Imaging?  The National emergency X-radiography Utilization Study (NEXUS) Prospective, observational study of 21 US centers evaluating 34,069 stable patients with blunt trauma Prospective, observational study of 21 US centers evaluating 34,069 stable patients with blunt trauma Identified 5 findings that indicated increased risk for CS injury requiring radiographic evaluation Identified 5 findings that indicated increased risk for CS injury requiring radiographic evaluation 1. Tenderness at the posterior midline of the CS 2. Focal neurologic deficit 3. Decreased level of alertness 4. Evidence of intoxication 5. Distracting injury Hoffman et al, N Engl J Med, 2000

11. Radiological Evaluation Axial CT from occiput to T1 with coronal and sagittal reconstruction Axial CT from occiput to T1 with coronal and sagittal reconstruction Plain radiographs of C-spine are no longer standard Plain radiographs of C-spine are no longer standard MRI recommended to evaluate any neurologic deficits attributable to a C-spine injury regardless of CT findings MRI recommended to evaluate any neurologic deficits attributable to a C-spine injury regardless of CT findings

12. If C-spine CT demonstrates an injury… Prompt spinal surgery consultation Prompt spinal surgery consultation C-spine MRI (if associated neuro deficits) C-spine MRI (if associated neuro deficits)

13. Clearance of C-spine after negative CS imaging C-collar may be removed if: C-collar may be removed if: 1. Neurologically intact (no organic or toxic alterations) 2. No distracting injuries 3. No vertebral tenderness 4. No pain on full ROM Eastern Association for the Surgery of Trauma, 2009

14. Clearance of C-spine after negative CS imaging If neurologically intact but fails clinical clearance exam (ie, midline tenderness) If neurologically intact but fails clinical clearance exam (ie, midline tenderness) Continue C-collar, or Continue C-collar, or Obtain flexion/extension X-ray (Level 3), or Obtain flexion/extension X-ray (Level 3), or Obtain MRI (Level 3) Obtain MRI (Level 3) If flex/ex or MRI are negative, CC may be removed and a soft collar may be provided for comfort (Level 2) If flex/ex or MRI are negative, CC may be removed and a soft collar may be provided for comfort (Level 2) Eastern Association for the Surgery of Trauma, 2009

15. Clearance of C-spine after negative CS imaging If not neurologically intact or has distracting injuries: If not neurologically intact or has distracting injuries: If deficits are transient (EtOH, post-ictal, other fx s/p reduction, ect.), wait for them to resolve then clear C-spine clinically If deficits are transient (EtOH, post-ictal, other fx s/p reduction, ect.), wait for them to resolve then clear C-spine clinically But what if they are unlikely to resolve soon? But what if they are unlikely to resolve soon?

16. C-spine Clearance in Obtunded Patient Previous guidelines mandated MRI for all obtunded patients prior to C-collar removal to r/o ligamentous/soft tissue injury Previous guidelines mandated MRI for all obtunded patients prior to C-collar removal to r/o ligamentous/soft tissue injury Flexion/extension fluoroscopy studies? Flexion/extension fluoroscopy studies? Is a negative CT alone sufficient? Is a negative CT alone sufficient?

17. Flex/Ex Fluoroscopy No longer recommended for obtunded pt No longer recommended for obtunded pt Only 4% are adequate studies due to logistical aspects of proper positioning Only 4% are adequate studies due to logistical aspects of proper positioning Incidence of ligamentous injury found on flex/ex is only 0.4% and of those, none were found to have any neurological sequelae Incidence of ligamentous injury found on flex/ex is only 0.4% and of those, none were found to have any neurological sequelae Bolinger, Trauma, 2004 David, J Trauma, 2001

18. MRI If negative, CC may be removed If negative, CC may be removed Risk/benefit of MRI’s in all obtunded patient has been questioned Risk/benefit of MRI’s in all obtunded patient has been questioned $$$ $$$ Risk associated with laying flat for the length of the study (elevations in ICP, aspiration, ect) Risk associated with laying flat for the length of the study (elevations in ICP, aspiration, ect) MRI is most sensitive within 48-72 hrs of injury when the obtunded patient may not be stable enough to be out of the ICU for length of study MRI is most sensitive within 48-72 hrs of injury when the obtunded patient may not be stable enough to be out of the ICU for length of study

19. Is MRI needed after negative CT? 366 prospectively enrolled obtunded pt’s had a normal CT then received MRI 366 prospectively enrolled obtunded pt’s had a normal CT then received MRI 354 (96.7%) MRIs were negative 354 (96.7%) MRIs were negative 7 (1.9%) showed cervical cord contusion; 4 (1.1%) showed ligamentous injury; 3 (0.8%) showed intervertebral disk edema; 1 (0.3% had all 3 types of soft-tissue injuries. 7 (1.9%) showed cervical cord contusion; 4 (1.1%) showed ligamentous injury; 3 (0.8%) showed intervertebral disk edema; 1 (0.3% had all 3 types of soft-tissue injuries. CT had NPV of 98.9% for ligamentous injury CT had NPV of 98.9% for ligamentous injury CT had NPV of 100% for unstable CS injury CT had NPV of 100% for unstable CS injury Hogan et al, Radiology, 2005

20. Is MRI needed after negative CT? Several additional similar but smaller series (N = 47-60) showed similar results Several additional similar but smaller series (N = 47-60) showed similar results While additional ligamentous and soft tissue injuries are occasionally found (5-11%), no operative or otherwise unstable injuries were missed on CT and later found on MRI While additional ligamentous and soft tissue injuries are occasionally found (5-11%), no operative or otherwise unstable injuries were missed on CT and later found on MRI Sarani, et al. J Trauma, 2007 Adams, et al. Am Surg, 2007

21. Is MRI needed after negative CT? Prospective randomized clinical trial of 215 consecutive obtunded trauma patients Prospective randomized clinical trial of 215 consecutive obtunded trauma patients 140 required negative CT and MRI for CC removal 140 required negative CT and MRI for CC removal 75 received only a CT prior to CC removal 75 received only a CT prior to CC removal Stelfox, et al. J Trauma, 2007

22. - Shorter ICU LOS (6 vs. 4, p = 0.028), and shorter hosptial LOS (16 vs. 4, p = 0.043). Stelfox, et al. J Trauma, 2007

23. Retrospective 5-year review of all MVC or fall victims (14,755 patients) 2% of all patients had a CS injury 2% of all patients had a CS injury 0.2% of all blunt trauma patients and 11% of all CS injury patients had subluxation without fracture 0.2% of all blunt trauma patients and 11% of all CS injury patients had subluxation without fracture 100% of all subluxations were diagnosed or highly suspected by plain radiograph and CS imaging alone. 100% of all subluxations were diagnosed or highly suspected by plain radiograph and CS imaging alone. Demetriades et al. Trauma, 2000

24. EAST Recommendations Cannot make a definitive recommend on need for MRI following a negative CT in an obtunded trauma patient Cannot make a definitive recommend on need for MRI following a negative CT in an obtunded trauma patient Left at discretion of each institution Left at discretion of each institution Eastern Association for the Surgery of Trauma, 2009

25. SurgicalCriticalCare.net Recommendations Level 1: Level 1: Awake and alert patients may be cleared by H&P alone Awake and alert patients may be cleared by H&P alone Level 2: Level 2: CT from occiput to T1 including axial, sagittal, ad coronal images should be used for CC clearance CT from occiput to T1 including axial, sagittal, ad coronal images should be used for CC clearance CC clearance should be performed w/in 72 hrs of injury CC clearance should be performed w/in 72 hrs of injury Level 3: Level 3: In the obtunded patient, CT is sufficient to allow clearance of the CS In the obtunded patient, CT is sufficient to allow clearance of the CS

26. References Spinal Cord Injury Information Center: http://www.spinalcord.uab.edu/ Spinal Cord Injury Information Center: http://www.spinalcord.uab.edu/ Chendrasekhar A, Moorman DW, Timberlake GA. An evaluation of the effects of semirigid cervical collars in patients with severe closed head injury. Am Surg 1998; 64:604-606. Chendrasekhar A, Moorman DW, Timberlake GA. An evaluation of the effects of semirigid cervical collars in patients with severe closed head injury. Am Surg 1998; 64:604-606. Powers J, Daniels D, McGuire C, et al. The incidence of skin breakdown associated with the use of cervical collars. J Trauma Nurs 2006; 13:198-200. Powers J, Daniels D, McGuire C, et al. The incidence of skin breakdown associated with the use of cervical collars. J Trauma Nurs 2006; 13:198-200. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial injury after head injury. ANZ J Surg 2002; 72:389- 391. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial injury after head injury. ANZ J Surg 2002; 72:389- 391. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma - update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee http://www.east.org/tpg.asp Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma - update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee http://www.east.org/tpg.asp Hoffman, JR. Validity of a Set of Clinical Criteria to Rule Out Injury to the CervicalSpine in Patients with Blunt Trauma N Engl J Med 2000; 343: 94-9 Advanced Trauma Life Support for Doctors. ATLS Student Course Manual, 8 th Ed. American College of Surgeons Committee on Trauma, 2008 Advanced Trauma Life Support for Doctors. ATLS Student Course Manual, 8 th Ed. American College of Surgeons Committee on Trauma, 2008 Bolinger B, Shartz M, Marion D. Bedside fluoroscopic flexion and extension cervical spine radiographs for clearance of the cervical spine in comatose trauma patients. J Trauma 2004; 56:132-136. Bolinger B, Shartz M, Marion D. Bedside fluoroscopic flexion and extension cervical spine radiographs for clearance of the cervical spine in comatose trauma patients. J Trauma 2004; 56:132-136. Demetriades D, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma 2000; 48:724-727. Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma 2001; 50:1044- 1047. Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma 2001; 50:1044- 1047. Hogan GJ, Mirvis SE, Shanmuganathan K, et al. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multidetector row CT findings are normal? Radiology 2005; 237:106-113. Hogan GJ, Mirvis SE, Shanmuganathan K, et al. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multidetector row CT findings are normal? Radiology 2005; 237:106-113. Sarani B, Waring S, Sonnad S, et al. Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients. J Trauma 2007; 63:637-640. Sarani B, Waring S, Sonnad S, et al. Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients. J Trauma 2007; 63:637-640. Adams JM, Cockburn MIE, Difazio LT, et al. Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine. Am Surg 2006; 72:101-105. Adams JM, Cockburn MIE, Difazio LT, et al. Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine. Am Surg 2006; 72:101-105. Stelfox HT, Velmahos GC, Gettings E, et al. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J Trauma 2007; 63:630-636. Stelfox HT, Velmahos GC, Gettings E, et al. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J Trauma 2007; 63:630-636.