Clearing the cervical spine Jules Blackham Speciality Registrar Emergency Medicine BASICS Avon Great Western Air Ambulance

Clinically clearing Cervical Spine 2 major studies

Reviews of “current” practice Number of authors noted the patients with [Neifield 1988 , Saddison 1991, Hoffman 1992, Zabel 1997] : Normal level of consciousness, no focal neurological deficit, no intoxication, no distracting injury and no neck pain/tenderness Did not have a c-spine injury Most studies were not very large (up to 1000 patients), and only had relatively few c-spine fractures(3%).

NEXUS GROUP Hoffman JR, et al. “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma.” N Engl J Med 2000;343:94-9 21 centres across US 34,069 patient underwent C-spine radiography after blunt trauma. All patient with blunt trauma undergoing cervical radiography were included

5 low risk criteria No midline cervical tenderness No focal neurological deficit Normal alertness No intoxication No painful distracting injury

Results Identified all but 8 of the 818 patients with C-spine injury Sensitivity 99%[98-99.6%] Sensitivity 12.9%

Paediatric Subgroup analysis of NEXUS [Viccellio and colleagues 2001] 3,065 patients under 18 88 under 2 years 817 aged 2-8 years 2,160 aged 8-17 yrs 30 (0.98%) had cervical spine injuries Lower incidence than in adult population ?due to lower threshold to x-ray children

No cases of CSI who were negative to all 5 nexus criteria No cases of SCIOWRA 45.9% of injuries occurred in lower cervical spine (C5-7) However – No CSI in under 2s, and only 4 in under 8s

NEXUS should be used with caution in under 8s Case report of 3 year old child with a PEG fracture, who was low risk, but high mechanism of injury (RTC, fatality in same vehicle) Recommended that consider mechanism of injury in young children and advised to return if child becomes reluctant to move head.

Canadian C-Spine rules Stiell IG, et al. “The Canadian C-spine rule for radiography in alert and stable trauma patients.” JAMA. 2001 Oct 17;286(15):1841-8. Prospective cohort study in 10 large EDs 20 standardized clinical findings were noted prior to radiography 8,924 patients, including 151 (1.7%) clinically significant CSI. Excluded children <16 and all patients with GCS <15

Resultant model asks 3 questions: Is there any high risk factor present which mandates radiography Is there any low risk factor that allows safe assessment of range of motion Is the patient able to actively rotate neck 45⁰ to left and right By cross validation Sensitivity = 100% [98-100%] Specificity 42.5% [40-44%]

High risk factors yes to any mandates x-ray Age >65 years OR Dangerous Mechanism Fall from ≥ 1 metre/5 stairs Axial load to head e.g. diving MVC High speed (>100km/hr), rollover, ejection Motorized recreational vehicles Bicycle collision Paraesthesia in Extremities

low risk factor that allows safe assessment of range of motion Simple read-end MVC Excludes Pushed into oncoming traffic Hit by bus/large truck Rollover Hit by high-speed vehicle Or Sitting position in ED Ambulatory at any time Delayed onset of neck pain Absence of midline c-spine tenderness

Able to actively rotate neck 45º to left and right If able to do above then no radiograph is required.

Independent judgement or CCR [Bandiera et al. 2003] Prospective cohort study (10 EDs) Compared physician’s judgement with CCR in 6,265 patients Physicians asked to estimate probability of unstable c-spine # from 0-100% Judgement – sensitivity = 93% CCR = 100% Poor correlation between physicians for “zero probability of injury” Kappa=0.46 [0.28-0.65] METHODS: This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck.. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. RESULTS: During 18 months, 6265 patients were enrolled. Sixty-four (1%) patients had a clinically important injury. The physicians' kappa for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule (P <.05). With a threshold of 0% predicted probability of injury, the respective indices of accuracy for physicians and the Canadian C-Spine rule were sensitivity 92.2% versus 100% (P <.001) and specificity 53.9% versus 44.0% (P <.001).

2 studies comparing NEXUS with CCR Dickenson et al [2004] applied retrospectively the NLC to the original CCR data. Did not accurately apply the rules as differences in definitions e.g. “no evidence of intoxication “ and “unreliable findings due to alcohol or drugs” Sensitivity of 92%

Stiell et al 2003 Prospective cohort study in 9 Canadian Eds. patient’s were examined with both guidelines 10% did not have range of movement applied CCR was more sensitive than the NLC (99.4% cf. 90.7%) CCR missed 1 clinically significant C-spine injury, while NLC missed 16. Problems Definition of distracting injury is difficult and is not defined in study (or original NLC) Study performed in Canada by CCR investigators - ?bias

2 studies comparing NEXUS with CCR Dickenson et al [2004] applied retrospectively the NLC to the original CCR data. Did not accurately apply the rules as differences in definitions e.g. “no evidence of intoxication “ and “unreliable findings due to alcohol or drugs” Sensitivity of 92%

Stiell et al 2003 Prospective cohort study in 9 Canadian Eds. patient’s were examined with both guidelines 10% did not have range of movement applied CCR was more sensitive than the NLC (99.4% cf. 90.7%) CCR missed 1 clinically significant C-spine injury, while NLC missed 16. Problems Definition of distracting injury is difficult and is not defined in study (or original NLC) Study performed in Canada by CCR investigators - ?bias

Nurses - NEXUS Pitt et al. 2006 Hsieh 2000 More conservative than doctors 59/112 removed by triage nurses, further 7 removed by Drs. Reduced duration of immobilisation by a mean of 23 mins (p<0.005) Hsieh 2000 211 patients. Good agreement between nurses and doctors (k=0.65) Poor agreement on what was a distracting injury (k=0.35)

Nurses - CCR Kelly et al 2004 Stiell et al 2006 Miller et al 2006 Good agreement between doctors and nurses (K=0.55) Nurses less likely to clear spine (P=<0.001), reporting more tenderness test range of movement – also noted in original study where 10% of patients did not have ROM tested. Stiell et al 2006 Trained 112 nurses in 6 EDs to use CCR 47.5% of pts could safely have c-spine cleared Inter-observer agreement Excellent (second = nurse/physician) K=0.81 Miller et al 2006 Good agreement between doctors and nurses K=0.6

Pre-hospital Guidelines EAST [Como et al 2009] Based on NEXUS guidelines NICE Head Injury guidelines Sept 2007 – section 5 Based on NEXUS JRCALC [Fisher et al. 2006] EAST = Eastern Association of the Surgery of Trauma

Pre-hospital Studies – NEXUS Brown 1998 EMS staff and Emergency Physicians completed a questionnaire on NEXUS findings for 451 patients Reasonable agreement – kappa=0.48 44 (9.8%) of patients EMS would have removed c-spine protection, EM physicians wouldn’t. No comments whether any had injuries Sahni et al 1997 10 standardised patients examined by 10 paramedics and 10 EPs Good agreement –Kappa=0.62-0.77 for each criteria 1 pt where 2 groups disagreed, EPs would have cleared, paramedics not

One UK based study [Armstrong et al. 2007] Based on NEXUS 103 patients, of whom 67% would have had the c-spine cleared on scene with no cases of missed CSI

Stroh and Braude 2001 Retrospective chart review over 6 years. Spinal immobilisation protocol of Fresno county EMS implemented at beginning of study period by by Ferno/Kings/ Madera (FKM) EMS service 861 patients discharged diagnosis of cervical spine injuries 357 eliminated as inter-hospital transfers or not transferred by FKM EMS service 504 transported by EMS 495 immobilised Spinal pain or tenderness, inc. Any neck pain with a history of trauma Significant multisystem trauma Severe head or facial trauma Numbness or weakness in any extremity after truam Loss of consciousness caused by trauma If altered mental state and No history available Found in setting of possible trauma Near drowning with a history or probability of diving Distracting injury subsequently added to protocol

9 not immobilised: 2 refused 1 combatitive 1 severe kyphosis 2 protocol violations C6 # (stable) Odontoid # (post chiropractor treatment) 3 protocol misses Sensitivity of immobilisation protocol for confirmed c-spine injury=99% (97.7-99.7%)

Canadian prospective study Vaillancourt et al. 2007 Study of 2,397 patients using CCR over 50 months in 10 Ontario cities Patients examined by paramedics using CCR and then immobilised and transferred to hospital for assessment clinically important c-spine injury 12 patients (0.5%), Sensitivity =100%[74-100] specificity 38.2% [36-40]. Kappa = 0.94 Comfortable in applying in 81.5% of patients Would have cleared 916 (38%) of spine pre-hospitally Sensitivity is for clinically important injuries.

Examples Can you Clear the Spine?

Example 1 An 85 yr old woman reportedly unconscious after she fell over in her bathroom banging her forehead on the bath before falling to the ground, landing flat on her face. On your arrival she is conscious and talking complaining about the blood from her forehead making a mess on her bathroom floor and apologising profusely for wasting your time. She has a 3cm vertical laceration in the centre of her forehead, and appears to have no other injuries. She is tender in the midline over the upper portion of her neck, but has no pain in her neck at rest.

Example 2 You are called to a 25 yr old seat belted male driver who was involved in a rear ended shunt at traffic lights in the centre of Gloucester. His car was hit from behind by another car who had failed to spot that the car in front had stopped. The driver has got out of the car and is complaining of pain in the centre of his neck. He has no complaints of altered sensation or weakness in his limbs.

Example 3 A 30 yr old man has had a “couple of drinks” this evening and has been involved in a fight. He has been punched in the face a number of times. He has not been knocked out, but has a black eye, bleeding nose and fractured right cheek. He has not neck tenderness and no distracting injuries. A private ambulance RRV has arrived on scene before you and the paramedic is applying a collar to the patient. He says as the patient has been drinking it is drunk it is not possible to clear his cervical spine and he has injuries above the clavicle so needs a collar applying.

Example 4 You are called to a 20 yr old girl who has been thrown from a horse, landing on her back. She is complaining of severe pain in her lower back and pins and needles in the front of her thighs. She is unwilling to move as the pain is so severe.

Example 5 A 14 yr old boy has been pulled out of a swimming pool after diving in and hitting the bottom, by life guards. You find him lying on the side of the pool in the recovery position. He is conscious and complaining of a head ache. He is tender in his upper cervical spine, but has no neurology in his upper limbs.

Summary C-spine injuries are rare C-spine immobilisation in a common procedure Majority of c-spines can be cleared clinically.

Any Questions?