OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• CT spine - cervical (Cx), thoracic (Tx) or lumbar (Lx)
• trauma
• head injury in the adult patient
• paediatric head injury
• Spinal cord syndromes and lesions
• orthopaedics in the ED
• RCH guideline - paediatric cervical spine injury
• Western health cervical spine injury guideline (pdf) - WH intranet only
• NHMRC Clinical guidelines for Mx of whiplash associated disorders (2008 1.4Mb pdf)
• 2013: the tide may be turning against cervical collars
• 2016: no compelling reasons left to use cervical collars

• 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.

• 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⁾.

• image everyone with trauma and potential neck injury (eg. initial sore neck or clinical suspicion) and either:
  • aged 65 or more
    • imaging modality of choice in the elderly is CT Cx spine as plain films can be more difficult to interpret.
    • NB. age criteria is not included in the Nexus algorithm and this will lead to missed unstable odontoid fractures in the frail elderly who just trip over. Odontoid fractures account for 20% of Cx spine fractures in the elderly compared with 5% in non-geriatric patients. Elderly have twice the risk of non-geriatrics of having a Cx spine fracture but only 45% have neck tenderness.²⁾
    • In patients 65 years and over, there is a greater risk of cervical spine fractures with low-moderate energy trauma compared to the general population, and a higher incidence of fractures without associated clinical factors that are predictive of cervical spine injury.³⁾
  • 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:
  • Canadian C spine rule for adults
    • 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
      • a low risk feature that would allow assessing range of movement is EITHER:
        • simple rear end MVA ie. NOT pushed into oncoming traffic, not hit by a bus or truck, not by a high speed vehicle, and no rollover
        • sitting in ED
        • ambulated post accident
        • neck pain onset was delayed
        • no midline c-spine tenderness
  • Nexus Cx spine imaging rule
    • 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:
      • focal neurologic deficit
      • midline spinal tenderness
      • altered level of consciousness such as:
        • GCS < 15
        • disorientation to time, place, person or events
        • inability to remember 3 objects at 5 minutes - if you don't do this test you are not following the rule!
        • a delayed or inappropriate response to external stimuli
        • or “other findings”
      • intoxication
      • distracting injury
  • WA Govt article on Cx spine imaging rules with emphasis on those over aged 65 years

• ~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.

• as a general rule, clearance of the cervical spine should be reserved for senior registrars or consultants only.
• clinical clearance without imaging may be possible in many patients using the Canadian C spine rule
• 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.

• 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
  • at Western Health, most of these patients may be discharged with Philadelphia collar with appointment for MRI scan then review in neurosurgery OP at Western Hospital in a week.

• those with neurology should be referred for MRI scan
• those without neurology and a high quality CT scan reported by a radiologist (or perhaps emergency physician or trauma surgeon) experienced in trauma scans probably do not need MRI scan as it is extremely unlikely an unstable injury will be present although up to 9% of MRI scans in these patients would detect stable injuries missed by CT scan
  • it is now increasingly accepted that it is safe to remove the collar in these patients and manage as per below under low risk patients after Cx spine clearance
  • see https://www.nuemblog.com/blog/cspine-clearance-ct

• 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 indicators⁵⁾ such as:
    • high initial disability (restricted movement, etc)
    • high initial pain
    • lower education levels
    • low self-efficacy
    • cold sensitivity
• should be given simple analgesics +/- non-steroidal anti-inflammatory drugs (NSAIDs), and advised to do early gentle neck range of motion exercises as prolonged restricted neck movement in itself will lead to secondary neck pain.
• collars should NOT be used, and if used, should not be in place for more than 48 hours⁶⁾
• 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 months⁷⁾.