1. C-Spine Evaluation: Who do you image? Steven A. Godwin MD, FACEP Assistant Professor and Program Director Department of Emergency Medicine University of Florida HSC/Jacksonville

2. Flexion Teardrop Fracture

3. Case Presentation 30 yo helmeted motorcyclist presents to the ED fully immobilized with c-spine precautions following an accident. He states he was ejected approximately 25-30 feet from the vehicle. He recalls most of the accident but believes he may have lost consciousness briefly. Physical exam is normal with a non-tender c- spine. GSC 15

4. Case: Questions Does he need neuroimaging of the c-spine prior to “clearing the c-collar”? What if he were intoxicated or he had an altered mental status? What if he had a “distracting injury”?

5. Background Prevalence of Disease Findings of NEXUS: –818 patients identified (2.4%) of 34,069 patients with blunt trauma 1,496 distinct cervical spine injuries to 1,285 different spine structures 27 (.08%) identified via MRI with SCIWORA 2 1 Goldberg W, Mueller C, Panacek E, Tigges S et al. for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17-21. 2 Hendley G, Wolfson A, William R et al.; for the NEXUS Group. Spinal cord injury without radiographic abnormality: Results of the national emergency x-radiography utilization study in blunt cervical trauma. J Trauma. 2002;53:1-4.

6. Distribution and patterns of injury –Most common level of injury- C2 vertebra- 286 (24%) fractures including 92 odontoid fractures C6 and C7 vertebra- 235 (39.3%) fractures –Most common site of fracture - Vertebral body 1 Goldberg W, Mueller C, Panacek E, Tigges S et al. for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17-21 (I)

7. Lowery et al. (NEXUS) Demographics of c-spine trauma –818/33,922 patients Age > 65 yo- RR 2.09; 95% CI 1.77-2.59 “Other” ethnicity- RR 1.79, 95% CI 1.46-2.19 Male sex - RR 1.72, 95% CI 1.48-2.00 White ethnicity- RR 1.50, 95% CI 1.32-1.52 3 Lowery D, Wald M, Browne B et al.,for the NEXUS Group. Epidemiology of cervical spine injury victims, Ann Emer Med. 2001;38:12-16 (I)

8. “Truth grows and evolves over time. ” Harvey and His Discovery, In An Alabama Student, 296.

9. Previous Recommendations Who should we image? ATLS 1997 –Indications: Every patient with multiple trauma All patients with trauma above the clavicle 4 American College of Surgeons. Advanced Trauma Life Support for Doctors Provider Manual. 6 th ed. Chicago, IL: American College of Surgeons; 1997

10. Previous Recommendations Frohna 1999: an evidence based review –Neuroimaging- 1.Neurologic deficits c/w cord lesion 2.Altered mental status from head injury or intoxication 3.Patients complaining of neck pain or tenderness 4.Low threshold for imaging in trauma pt’s with painful, distracting injuries 5 Frohna WJ. Emergency department evaluation and treatment of the neck and cervical spine injuries. Em Med Clin North Am, 1999;17(4):739-91(Review)

11. Most Recent Recommendations Clinical Decision Rules 1.NEXUS (N Engl J Med, 2000) 6 2.Canadian C-Spine Rule (JAMA, 2001) 7 6 Hoffman JR, Mower WR, Wolfson AB, et al., for the NEXUS Group. 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;343:94-99. 7 Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for Radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.

12. NEXUS Prospective observational study at 21 centers across the US (n= 34,069) Validation of a clinical criteria for indications for c-spine imaging –A “decision instrument” –The ‘instrument’ identified all but 8/818 patients with cervical spine injury

13. NEXUS So what does 8/818 patients mean? Sensitivity= 99% (95% CI, 98-99.6%) NPV= 99.8% (95% CI, 99.6-100%) Specificity= 12.9%

14. NEXUS Were any of the 8 missed injuries clinically significant? 2 patients met preset definitions of clinically significant injuries (n=576) –An asymptomatic 54 yo s/p motorcycle accident Fracture of anteroinferior C2 w/no soft tissue swelling –? Extensor tear drop fracture –57 yo s/p head on MVC w/ transient LOC; pain in R shoulder w/ tenderness at paraspinous muscles, R clavicle and scapula Fracture of R lamina of C6 –developed R arm parasthesias and required laminectomy/fusion

15. NEXUS Decision Instrument- 5 criteria 1.Absence of posterior midline cervical tenderness 2.Absence of focal neurologic deficit 3.A normal level of alertness 4.No evidence of intoxication 5.Absence of clinically apparent distracting injury

16. NEXUS Conclusions Application of the decision instrument would have decreased overall imaging by 12.6% A simple decision rule can reliably predict patients who need neuroimaging following blunt trauma with very high sensitivity There may still be compelling reasons to order c- spine images outside of the criteria in individual cases

17. Anterior Occipitoaltlantal Subluxation

18. Canadian C-Spine Rule 7 Prospective cohort study at 10 community and university hospitals Convenience sample of 8924 adults Objective- To derive a clinical decision rule to detect C-spine injury and allow more selective use of radiography in alert and stable blunt trauma patients

19. Canadian C-Spine Rule 151/8924 (1.7%) patients identified with clinically significant injury Decision rule results –Sensitivity- 100% (95% CI, 98-100%) –Specificity- 42% (95% CI, 40-44%) –Ordering rate utilizing criteria- 58%

20. Canadian C-Spine Rule 7 Decision rule results Clinically insignificant injury –28/8924 patients (0.3%) –1/28 missed 63 yo with unidentified C3 osteophyte avulsion fx

21. Canadian C-Spine Rule Decision Rule- 3 questions 1. Is there a high risk factor present mandating radiography ? Defined as: age > 65y, dangerous mechanism*, or parasthesias in extremities

22. Canadian C-Spine Rule Decision Rule- 2. Is there low-risk factor present that allows for safe assessment of ROM? Defined as: simple rear-end MVC, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness

23. Canadian C-Spine Rule Decision Rule- 3. Is the patient able to actively rotate neck 45 o to R and L

24. Canadian C-Spine Rule *Dangerous Mechanisms 1. Fall > 1 meter/ 5 stairs 2. Axial load 3. MVC high speed (>100 km/hr), rollover, ejection 4. Motorized recreational vehicles 5. Bicycle collision

25. Canadian C-Spine Rule Conclusions 1. Potential sensitive rule for identifying patients requiring c-spine radiography following blunt trauma 2. Potential c-spine radiography rate of 58.2% Relative reduction of 15.5% from 68.9%

26. Recommendations Both the Canadian and Nexus clinical decision rules provide sensitive and reliable indicators for identification of patients at risk for cervical injury following blunt trauma Use of clinical decision rules may reduce the number of imaging test performed

27. Summary Which study to use? Does it really matter? Don’t get caught up in the hype! –Might be as simple as finding the one you can best remember and follow it!

28. Evolving Literature Prospective study of 1,757 patients to develop decision rule (1,449 received plain films) With decision rule implementation 537 (30.6%) studies were felt to be redundant Failure of C-spine to document injury –129 patients underwent CT with 33 positive findings –9/38 (23.7%) fractures were not identified with plain films 8 Edwards M, Frankema S, Kruit M, et al. Routine cervical spine radiography for trauma victims: Does everybody need it. J Trauma 2001; 50:529-534.

29. Evolving Literature: Griffen et al. 2003 Cervical Spine Radiographs (CSR) vs CT Retrospective query of prospectively collected trauma database –CSR and CT performed on all patients with posterior midline neck tenderness, altered mental status, or neurologic deficit (3,018 patients) –116 patients (9.5%) identified with cervical spine injury (fracture or subluxation) 9 Griffen M, Frykberg E, Kerwin A, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55(2):222-6.

30. Griffen et al. 2003 C-spine injury was identified on both CSR and CT in 75/116 (65%) patients Injury missed 41/116 (35%) patients with CSR –All these injuries required some form of treatment –No identifiable factors predicted false negative CSR 9 Griffen M, Frykberg E, Kerwin A, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55(2):222-6.

31. ? Nexus/Canadian Rules Does the new literature cloud the results of the previous decision rules?

32. “ General acceptance of truth takes time.” On The Study of Tuberculosis, Phila Med J 1900;6:1029-30

33. Questions?

34. Gracias

35. References 1 Goldberg W, Mueller C, Panacek E, Tigges S et al. for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17-21.(I) 2 Hendley G, Wolfson A, William R et al.; for the NEXUS Group. Spinal cord injury without radiographic abnormality: Results of the national emergency x-radiography utilization study in blunt cervical trauma. J Trauma. 2002;53:1-4.(I) 3 Lowery D, Wald M, Browne B et al.,for the NEXUS Group. Epidemiology of cervical spine injury victims, Ann Emer Med. 2001;38:12-16 (I) 4 American College of Surgeons. Advanced Trauma Life Support for Doctors Provider Manual. 6 th ed. Chicago, IL: American College of Surgeons; 1997 (III) 5 Frohna WJ. Emergency department evaluation and treatment of the neck and cervical spine injuries. Em Med Clin North Am, 1999;17(4):739-91(Review) 6 Hoffman JR, Mower WR, Wolfson AB, et al., for the NEXUS Group. 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;343:94-99. 7 Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for Radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.

36. References 8 Edwards M, Frankema S, Kruit M, et al. Routine cervical spine radiography for trauma victims: Does everybody need it. J Trauma 2001; 50:529-534. 9 Griffen M, Frykberg E, Kerwin A, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55(2):222-6.