spine_injury_cx
cervical spine injury
introduction
it is prudent care that all patients from a trauma who have neck pain or potential neck injury, particularly if they are either elderly, have a high risk mechanism, decreased conscious state, or distracting pain, should be managed with
spinal precautions from the outset and until the Cx spine is clinically “cleared” of mechanically unstable injuries which may threaten the spinal cord
by a senior registrar or consultant - see
Western Health cervical spine injury guideline (pdf) for details on spinal precautions - WH intranet only
at Western Health, spinal injuries are managed by neurosurgery (either WH or RMH neurosurg reg), NOT by orthopaedics
hard collars should be replaced by fitted Philadelphia collars ASAP if clearance is likely to be delayed, and definetly within 5 hours.
HOWEVER, forcing Cx spine immobilisation upon a combative person is likely to do more harm than good in terms of spinal cord injury and thus common sense judgement needs to prevail as to how to best manage such persons.
the first aim in such cases is to try to get the person calm so that they are unnecessarily moving the neck, particularly in a forceful manner.
those with serious head injury and GCS < 9 should be considered for early intubation with Cx spine precautions to take control of airways, breathing and Cx spine stabilisation.
incidence
in patients with brain injury after trauma, 7-20% will have Cx spine injury
in alert, stable patients under age 65 years with no neurology who have suspected neck injury, only 3% will have clinically significant injury on imaging.
children under age 8 years have a different pattern of Cx spine injury than adults with relatively higher incidence of atlanto-occipital injuries than lower cervical injuries (80% of injuries in children < 2 years involve upper Cx spine), and the possibility of SCIWORA.
incidence of significant Cx spine injury in children under 3 years is even lower at 0.7%, and even lower if you look at the under 2 year group
1).
who should have Cx spine imaging after trauma?
image everyone with trauma and potential neck injury (eg. initial sore neck or clinical suspicion) and either:
aged 65 or more
high risk mechanism of injury such as:
fall from > 1m or 5 stairs
axial load to head eg. diving
high speed MVA (eg. > 100kph)
roll-over in MVA
ejection from vehicle in MVA
motorised recreation vehicles
bicycle crash
paraesthesiae in the extremities
unstable trauma patient
severely painful distracting injuries
altered level of consciousness or intoxicated
midline Cx tenderness
vertebral disease or past cervical spine surgery - eg. Down's syndrome, ankylosing spondylitis
if none of the above apply, then follow an algorithm to see if imaging can be avoided:
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this algorithm may reduce ordering of Xrays by 25% or more and thus potentially reduce time in hard collar, whilst still detecting 99% of significant injuries.
if CT not indicated from the above and there is at least one low risk feature to which allows assessing range of movement, then CT scan only if patient not able to actively rotate neck 45deg to each side
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only 90% sensitive in a later validation study
4)
does not consider the elderly nor mechanism of injury, but many use this simple rule to manage patients aged 9 years and older.
no need to image if NONE of the following are present - BUT be warned, don't be fooled by it's apparent simplicity as the devil is in the detail and much is left to clinicial interpretation:
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plain films or initial CT scan
~30% of injured patients having plain Xrays will have inadequate films to adequately clear the Cx spine.
sensitivity of plain Xray for detecting significant injury is 30-60% (most commonly missed fractures are at C2, C6 and C7) whereas CT scan is close to 100%
patients with a positive finding on any of the NEXUS criteria should have imaging
CT scans should be strongly considered if any of the following:
age > 65 yrs old as plain films are often difficult to interpret due to degenerative changes.
high risk patients such as presence of neurologic symptoms or dangerous mechanism of injury
patient having a CT brain or other CT following trauma
clinician or radiographer not confident that plain C spine xray will be adequate. Eg due to body habitus - in reality, all adults with indication for Cx spine imaging should have CT scan rather than plain Xray
all other patients should have a 3 view C spine Xray, and if these are abnormal, a Cx spine CT scan should be then ordered from skull base to mid-T4
avoid CT scans in children under 8 years of age in particular - consider MRI if persistent symptoms despite normal plain films.
clearing the C-spine
as a general rule, clearance of the cervical spine should be reserved for senior registrars or consultants only.
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those who require imaging, and the imaging is appropriate, adequate and appears normal as assessed by an experienced clinician, require further clinical correlation and a risk analysis performed by the attending clinician based on symptoms and signs, and mechanism of injury to adequately clear the Cx spine.
NB. Most patients lying in a hard collar for an hour or more WILL develop neck pain!
patients with normal imaging and moderate persisting midline tenderness but no neurology may be considered for Mx in a Philadelphia collar , preferably for no more than 48 hours, and reassessment as an outpatient (by GP or neurosurgical team pending local processes) to determine need for further imaging such as MRI or flexion/extension plain film views.
patients with neurologic symptoms should be discussed with the neurosurgical team and an urgent MRI may be indicated.
most will remove a hard collar on an intubated patient once a CT Cx spine is regarded as normal even though there is a small risk of instability due to undiagnosed ligamentous injury.
Mx of probable cervical spine injury based on plain Xray or CT scan
spinal precautions (but with a Philadelphia collar) should be continued until specialist consultation
at Western Health, adults with cervical spine injuries are referred to neurosurgery at RMH as orthopaedics at Western do not manage these patients
at RMH, these injuries are generally managed by orthopaedic unit
patients with possible ligamentous injury only with minimal symptoms should be discussed with specialist unit
Mx of low risk patients after Cx spine clearance
low risk patients are those in whom their neck soreness is presumed to be due to muscle or ligamentous strain only with no instability.
these patients historically have been given the term whiplash injury if due to a MVA
50% of these patients will have ongoing symptoms after 4 weeks and thus early physiotherapy referral shuld be considered, particularly for those with poor prognostic indicators
5) such as:
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collars should NOT be used, and if used, should not be in place for more than 48 hours
6)
most people recover from the acute emotional shock of an event such as a motor vehicle accident with the support of family and friends. A small minority may continue to experience high levels of acute stress, or trauma-specific psychological reactions, and this is associated with poor emotional recovery post injury.
where symptoms such as intrusive recollections of the event (e.g. nightmares), avoidance and emotional numbing, (e.g. avoiding reminders of the event, loss of interest in normal activities) or hyperarousal (e.g. difficulty sleeping or irritability) persist beyond one to two weeks and interfere with the patients daily activities, work or relationships, early referral to a psychologist or psychiatrist is recommended.
primary care practitioners should review patients at least at 7 days, 3 weeks, 6 weeks and 3 months
7).
spine_injury_cx.txt · Last modified: 2018/07/27 12:28 (external edit)