1. Evaluation of Cervical Spine Injury Teresa Siefke, RN, BSN Wright State University AG-ACNP Student

2. Objectives Define high risk mechanisms for cervical spine injury Identify barriers to an accurate physical exam of the cervical spine Select appropriate method of examination of patients at risk for cervical spine injury Identify the need of cervical spine immobilization

3. Prevalence of Cervical Spine Injury (CSI) (Milby, Halpern, Guo, & Stein, 2008) Meta Analysis Pooled Data: 1985-2008

4. Prevalence Cervical Spine injury (CSI) 1-14% of trauma patients Co-existence of head injury increases risk Glascow Coma Scale (GCS) ≤8 has 6-fold increased risk 4-8% have missed or delayed diagnosis Of those with missed or delayed diagnosis, 70% had altered LOC Importance to maintain a high index of suspicion in those who are unable to have full physical exam evaluation at the time of presentation (Ackland, Cooper, Fitzgerald, Malham, & Varma, 2009; Milby, Halpern, Guo, & Stein, 2008)

5. Incidence of CSI Frequency of males to females 4:1 Annually in the United States: 6000 deaths 5000 new quadriplegia Fractures: 2 nd vertebra 24% 6 th & 7 th vertebra 39% Over age 65 relative risk increases two- times that of younger trauma victims Mortality rate 24% for this age group (Pimentel & Diegelmann, 2010)

6. Key Anatomy First cervical-atlas provides support to the head. Articulate with the occipital condyles and form atlanto-occipital joint. Allows 50% of neck flexion and extension Second cervical-axis forms the surface for the atlas to pivot and allows rotation of the head laterally. Atlantoaxial joint allows half of the neck rotation Neither the C1-C2 joints or atlanto- occipital joint has intervetebral discs and is predisposed to inflammatory arthritis (Pimentel & Diegelmann, 2010)

7. Google.com Images

8. Seventh vertebra is the highest spinous process, the length extends beyond the other cervical vertebrae predisposing to fracture Three important ligaments: Anterior longitudinal ligament: Resists hyperextension Posterior longitudinalligament Limits hyperflexion Ligamentum flavum Connects the laminae of adjacent vertebrae Forms the posterior surface of the spinal canal (Pimentel & Diegelmann, 2010) Anatomy cont…

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10. Definitions

11. Head Injury Any trauma to the head excluding superficial facial injuries According to NICE, approximately 200,000 people are admitted for head injury Outcomes related to impaired level of consciousness 95% that present to ED with head injury have Glascow Coma Scale >12 Fatal outcomes most common in GCS 9-12 GCS <8 (NICE: National Institute for Health and Care Excellence, 2014)

12. High-Energy Head Injury Pedestrian struck Diving Fall from more than 5 stairs or >1 meter Ejection from vehicle High-speed MVC or rollover Motorized recreation vehicle Bicycle collision Any other high-energy mechanism (NICE: National Institute for Health and Care Excellence, 2014)

13. Dangerous Mechanism of Injury (MOI) Fall from elevation ≥3 ft or 5 stairs Axial load to head (e.g. diving) High speed MVC (≥100 km/h, 62 mph) Rollover or ejection Motorized recreational vehicle (ATV) Bicycle collision Any death on scene (Gumm, et al., 2011; NICE: National Institute for Health and Care Excellence, 2014)

14. Focal Neurological Deficits Restriction or deficit of a particular part of the body or activity Speaking Reading Sensation Balance Weakness Abnormal reflexes, etc. (NICE: National Institute for Health and Care Excellence, 2014)

15. Immobilization Any significant trauma to the head or torso Suspect cervical spine injury until proven otherwise Immobilization with hard collar until injury is ruled-out or c-spine “clearance” Penetrating neck injury Immobilization and imaging not typically necessary Unless injury has direct path traversing the neck or associated direct spinal destruction (Ackland, Cooper, Fitzgerald, Malham, & Varma, 2009; Department of Surgical Education, Orlando Regional Medical Center, 2009; Gumm, et al., 2011; NICE: National Institute for Health and Care Excellence, 2014; Stassen, Williams, Gestring, Cheng, & Bankey, 2006)

16. Risk Stratify

17. National Emergency X-Radiography Utilization Study (NEXUS) Tenderness at the posterior midline of the cervical spine Focal neurologic deficit Decreased level of alertness (GCS <15) Evidence of intoxication Clinically apparent pain that might distract the patient from the pain of the cervical spine (Ackland, Cooper, Fitzgerald, Malham, & Varma, 2009; Department of Surgical Education, Orlando Regional Medical Center, 2009; Eyre, 2006; Gumm, et al., 2014; Michaleff, Maher, Verhagen, Rebbeck, & Lin, 2006)

18. (Eyre, 2006, p. 13)

19. Canadian Cervical-Spine Rule (CCR) High Risk Age 65 or over Dangerous mechanism Fall from elevation ≥3 ft / 5 stairs, axial load to head (e.g. diving), high speed MVC (≥100 km/h, 62 mph), rollover, ejection, motorized recreational vehicle (ATV), bicycle collision Paresthesia in any or all extremities Any YES=scan (Department of Surgical Education, Orlando Regional Medical Center, 2009; Eyre, 2006; The College of Emergency Medicine, 2010)

20. CCR Low risk Simple rear-end MVC exclusion: pushed into oncoming traffic, hit by bus/large truck, rollover, hit by high speed vehicle (≥100 km/h, 62 mph) Ambulatory at any time at scene No neck pain at scene (delay in pain) Absence of midline c-spine tenderness Any NO=scan (Department of Surgical Education, Orlando Regional Medical Center, 2009; Eyre, 2006; The College of Emergency Medicine, 2010)

21. CCR Pass all of the above (high risk and low risk criteria) then: Voluntarily able to actively rotate neck 45° left and right when requested, regardless of pain NO=scan (Department of Surgical Education, Orlando Regional Medical Center, 2009; Eyre, 2006; The College of Emergency Medicine, 2010)

22. (Eyre, 2006, p. 14)

23. NEXUS - vs - CCR Direct comparison study concluded: CCR: 99.4% sensitive and 45.1% specific NEXUS: 90.7% sensitive and 36.8% specific Other sources reported sensitivity of both criteria approaching near 100% (Department of Surgical Education, Orlando Regional Medical Center, 2009; Eyre, 2006; Stiell, et al., 2003; Michaleff, Maher, Verhagen, Rebbeck, & Lin, 2006; The College of Emergency Medicine, 2010)

24. Comparison Data (Stiell, et al., 2003, p. 15)

25. NEXUS - vs - CCR CCR has a slight advantage with higher reported sensitivity and specificity Clearer defined criteria to rule-in or rule- out those who need imaging Physicians expressed reluctance to evaluate the ROM and sent patients for imaging Physicians failed to complete the range of motion exam in 10.2% (845 out of 8,283) They had a higher rate of imaging (98.8%) but not a higher incidence of injury (0.8%) (Department of Surgical Education, Orlando Regional Medical Center, 2009; Eyre, 2006; Stiell, et al., 2003; Michaleff, Maher, Verhagen, Rebbeck, & Lin, 2006; The College of Emergency Medicine, 2010

26. Imaging

27. Imaging: Bone CT and Plain films for bony structures Plain films 52% sensitive according to meta-analysis Plain films of 3 views: Anteroposterior, lateral, and odontoid Plain films are technically difficult to obtain adequate views in the trauma patient CT is preferred over plain films Obtain axial CT from occiput to T1 with sagittal and coronal reconstructions Plain films are not needed and add no additional value (Como, et al., 2009; Department of Surgical Education, Orlando Regional Medical Center, 2009; Pimentel & Diegelmann, 2010; The College of Emergency Medicine, 2010)

28. Imaging: Soft Tissue MRI or dynamic (fluoroscopic) flexion- extension (F/E) films Evaluate soft tissue injury Spinal cord involvement Ligamentous injury F/E in obtunded patient poses unnecessary safety risks and questionable sensitivity MRI highly sensitive and does not require spine mobilization that could cause further injury (Como, et al., 2009; Department of Surgical Education, Orlando Regional Medical Center, 2009; Stassen, Williams, Gestring, Cheng, & Bankey, 2006)

29. Guidelines

30. Obtain CT Imaging Perform head CT scan within one hour of identification of the risk factor GCS <13 on initial assessment to ED GCS < 15 at 2 hours after injury Suspected open or depressed skull fracture Signs of basal skull fracture Racoon eyes Battle’s sign Cerebrospinal fluid leak from ears or nose Post-traumatic seizure Focal neurologic deficit More than 1 episode of vomiting (NICE: National Institute for Health and Care Excellence, 2014) NICE Guidelines

31. Obtain CT Imaging CT to r/o c-spine injury if ANY of the following GCS <13 on initial assessment Intubation Plain x-rays inadequate (i.e. desired view unobtainable) Plain x-rays are abnormal or suspicious Urgent need for definitive diagnosis of cervical injury (i.e. prior to surgery) Other body areas being scanned for head injury or multi-region trauma (you’re in the scanner, get the cervical spine) (NICE: National Institute for Health and Care Excellence, 2014)

32. Obtain CT Imaging Patient is alert and stable with clinical suspicion and ANY of the following apply: ≥ 65 years old Dangerous MOI (see prior definition) Focal peripheral neurological deficit Paresthesia in the limbs (upper or lower) (NICE: National Institute for Health and Care Excellence, 2014)

33. CT Imaging Not Indicated Assess cervical spine without imaging, ONLY if no high-risk factors Simple rear-end MVC Seated position in ER, comfortably Ambulatory since time of injury Absence of midline cervical spine tenderness Presents with delayed onset of neck pain (NICE: National Institute for Health and Care Excellence, 2014)

34. High Risk GCS <15 on assessment (Level of evidence (LOE): 1) Neurological deficits: focal, paralysis, or paresthesia (LOE: 1) Abnormal vitals (SBP 24) (LOE: 5) Urgent need (e.g. surgery) (LOE: 5) Severe neck pain (≥7/10) (LOE: 4) (The College of Emergency Medicine, 2010) The College of Emergency Medicine

35. Neck pain and ANY of following risk factors: (LOE: 1) Fall > 1 meter or 5 stairs Axial load (e.g. diving) High speed MVC (combined speed >60 mph) Rollover MVC Ejection from vehicle Involving motorized recreation vehicle Bicycle collision ≥65 years old Injury >48 hours earlier (LOE: 5) Re-visit with same injury (LOE: 5) Known vertebral disease (e.g. ankylosing spondylitis, RA, spinal stenosis, prior cervical surgery) ( LOE: 4) Patients with dangerous MOI AND visible injury above clavicles or thoracic injury with severe pain ≥7/10 even with no neck tenderness or pain (LOE: 4) (The College of Emergency Medicine, 2010)

36. Low Risk Simple rear-end MVC, but NOT if pushed into another vehicle or hit at high speed by large vehicle Sitting position in ED Ambulatory at any time following injury Delayed onset of pain Absence of midline cervical spine tenderness If ONLY low risk, remove collar and perform physical assessment Actively rotate neck 45 degrees right & left If unable to rotate in both directions or pain ≥7/10 should have imaging (The College of Emergency Medicine, 2010)

37. CT Recommended Dementia or chronic disability impairing adequate and accurate assessment (LOE: 5) Neurological signs or symptoms referable to c-spine (LOE: 3) Severe neck pain ≥7/10 (LOE: 4) Significantly reduced ROM (active in both directions 45 degrees) (LOE: 4) Known vertebral disease ankylosing spondylitis, RA, spinal stenosis, or previous cervical surgery (LOE: 4) (The College of Emergency Medicine, 2010)

38. Sample Algorithms

39. (Department of Surgical Education, Orlando Regional Medical Center, 2009)

40. (Gumm, et al., 2014)

41. (Ackland, Cooper, Fitzgerald, Malham, & Varma, 2009)

42. (Stassen, Williams, Gestring, Cheng, & Bankey, 2006)

43. References Ackland, H., Cooper, J., Fitzgerald, M., Malham, G., & Varma, D. (2009, November). The Alfred spinal clearnace management protocol. Retrieved from Alfred Health: http://www.alfred.org.au/Assets/Files/SpinalClearanceManagem entProtocol_External.pdf Como, J. J., Diaz, J. J., Dunham, C. M., Chiu, W. C., Duane, T. M., Capella, J. M.,... Winston, E. S. (2009). 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. The Journal of Trauma Injury, Infection, and Critical Care, 67(3), 651-659. doi:10.1097/TA.0b013e3181ae583b Department of Surgical Education, Orlando Regional Medical Center. (2009, 10 24). Cervical spine clearance. Orlando, Florida. Retrieved from http://www.surgicalcriticalcare.net/Guidelines/cervical_spine_cle arance_2009.pdf

44. Eyre, A. (2006). Overview and comparison of NEXUS and Canadian c-spine rules. American Journal of Clinical Medicine, 3(4), 12- 15. Retrieved from http://www.wildmedcenter.com/uploads/5/9/8/2/5982510/nexus_ _ccr.pdf Gumm, K., Judson, R., Liersch, K., Walsh, M., Pascoe, D., & Cunningham, J. (2014, November). Cervical spine guideline. The Royal Melbourne Hospital: Trauma Service Guidelines. Parkville, Vic, Australia. Retrieved from http://clinicalguidelines.mh.org.au/brochures/TRM03.01.pdf Gumm, K., Judson, R., Walsh, M., Truesdale, M., Thomson, B., Mcgurgan, C.,... Pascoe, D. (2011, May). Cervical spine guideline. Trauma Service Guidelines. Parkville, Australia. Retrieved from http://clinicalguidelines.mh.org.au/brochures/TRM03.01.pdf Michaleff, Z. A., Maher, C. G., Verhagen, A. P., Rebbeck, T., & Lin, C.-W. C. (2006). Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. Canadian Medical Association Journal, 184(16), E867-E876. doi:10.1503/cmaj.120675

45. Milby, A. H., Halpern, C. H., Guo, W., & Stein, S. C. (2008). Prevalence of cervical spine injury in trauma. Neurosurgical Focus, 25(5), E10: 1-9. doi:10.3171/FOC.2008.25.11.E10 NICE: National Institute for Health and Care Excellence. (2014, January). Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults. NICE clinical guideline 176. London. Retrieved from http://www.nice.org.uk/guidance/cg176/resources/guidance- head-injury-pdf Pimentel, L., & Diegelmann, L. (2010). Evaluation and management of acute cervical spine trauma. Emergency Medicine Clinics of North America, 28(4), 719-738. doi:10.1016/j.emc.2010.07.003 Stassen, N. A., Williams, V. A., Gestring, M. L., Cheng, J. D., & Bankey, P. E. (2006). Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient. The Journal of Trauma Injury, Infection, and Critical Care, 60(1), 171-177. doi:10.1097/01.ta.0000197647.44202.de