c Spine Trauma

8/6/2019 c Spine Trauma

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Cervical Spine TraumaCervical Spine TraumaDr. Martin Leahy PGYDr. Martin Leahy PGY--11

Dr.Norah DugganDr.Norah Duggan -- FacultyFaculty

Cervical Spine Trauma

Dr. Martin Leahy PGY-1

Dr. Norah Duggan


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IntroductionIntroduction

The diagnosis of an unstable spinal injuryThe diagnosis of an unstable spinal injury

and its subsequent management can beand its subsequent management can be

difficultdifficult

A missed spinal injury can have devastatingA missed spinal injury can have devastating

long term consequenceslong term consequences

As such, spinal column injury mustAs such, spinal column injury must

therefore be presumed until it is excludedtherefore be presumed until it is excluded


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Missed or delayed diagnosis most oftenMissed or delayed diagnosis most often

attributed to failure to suspect cervicalattributed to failure to suspect cervicalinjury, inadequate radiology, or incorrectinjury, inadequate radiology, or incorrect

interpretation of radiographsinterpretation of radiographs

As such, guidelines are needed to maximizeAs such, guidelines are needed to maximize

sensitivity and efficiency for the evaluationsensitivity and efficiency for the evaluation

of potentially unstable spine injuriesof potentially unstable spine injuries


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Primary concerns with cervical spinePrimary concerns with cervical spine

trauma include safe and effective clinicaltrauma include safe and effective clinicalclearance, the appropriate use of plain films,clearance, the appropriate use of plain films,

and when additional imaging such as CT orand when additional imaging such as CT or

MRI

should be used.MRI

should be used.


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Spinal stabilization andSpinal stabilization and

managementmanagement All patients with sufficient mechanism ofAll patients with sufficient mechanism of

injury to lead to a spinal injury should beinjury to lead to a spinal injury should be

considered to have a spinal injury untilconsidered to have a spinal injury untilproven otherwiseproven otherwise

What exactly constitutes sufficientWhat exactly constitutes sufficient

mechanism is undefinedmechanism is undefined


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Techniques of immobilisation andTechniques of immobilisation and

patient handlingpatient handling

Protect spine at all times during the managementProtect spine at all times during the managementof the multiply injured patient.of the multiply injured patient.

Up to 5% of spinal injuries have a second,Up to 5% of spinal injuries have a second,

possibly non adjacent, fracture elsewhere in thepossibly non adjacent, fracture elsewhere in thespinespine

Ideally, whole spine immobilised in neutralIdeally, whole spine immobilised in neutralposition on firm surface.position on firm surface.

Can be done manually or with a combination ofCan be done manually or with a combination ofsemisemi--rigid cervical collar, side head supports andrigid cervical collar, side head supports andstrappingstrapping


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Immobilisation in the pre hospital settingImmobilisation in the pre hospital setting

Application of definitiveApplication of definitiveimmobilisation devicesimmobilisation devicesshouldshould notnot taketake

precedence over lifeprecedence over life

saving proceduressaving procedures If neck not in the neutralIf neck not in the neutral

position, attempt shouldposition, attempt shouldbe made to achievebe made to achievealignment.alignment.

If the patient awake andIf the patient awake andcooperative, encourage tocooperative, encourage toactively move their neckactively move their neckinto lineinto line


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Abandon procedure ifAbandon procedure if

pain neurologicalpain neurological

deterioration ordeterioration or

resistance toresistance tomovementmovement

Long spine boards areLong spine boards are

valuable primarily forvaluable primarily for

extrication fromextrication from

vehicles.vehicles.


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Immobilisation in hospitalImmobilisation in hospital

Remove spine board as soon as possibleRemove spine board as soon as possible

once patient is on a firm stretcheronce patient is on a firm stretcher

Full immobilisation, however, should beFull immobilisation, however, should bemaintained and manual protection should bemaintained and manual protection should be

reinstated if restraints have to be removedreinstated if restraints have to be removed

for examination or procedures (eg.for examination or procedures (eg.

intubation)intubation)


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Log roll is standard manoeuver to allowLog roll is standard manoeuver to allow

examination of the back and patient transferexamination of the back and patient transfer

Optimally, four people are required, forOptimally, four people are required, for

head chest pelvis and limbshead chest pelvis and limbs

Rigid transfer slides are useful forRigid transfer slides are useful fortransferring the patient from one surface totransferring the patient from one surface to

another (eg. to CT scanner)another (eg. to CT scanner)


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Agitation, shock, restlessness, orAgitation, shock, restlessness, or

intoxication may make adequateintoxication may make adequateimmobolization impossibleimmobolization impossible

In these situatuions, forced restraints orIn these situatuions, forced restraints or

manual fixation of the head may risk furthermanual fixation of the head may risk furtherinjury to the spineinjury to the spine

Consider removing immobilisation devicesConsider removing immobilisation devices

allowing the patient to move unhinderedallowing the patient to move unhindered


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Clinical Clearance of CervicalClinical Clearance of Cervical

SpineInjurySpineInjury

Key PointsKey Points

1. Spinal immobilisation is a priority in multiple1. Spinal immobilisation is a priority in multipletrauma, spinal clearance is nottrauma, spinal clearance is not

2. The spine should be assessed and cleared when2. The spine should be assessed and cleared whenappropriate, given the injury characteristics andappropriate, given the injury characteristics andphysiological statephysiological state

3. Imaging the spine does not take precedence3. Imaging the spine does not take precedenceover life saving diagnostic and therapeuticover life saving diagnostic and therapeuticproceduresprocedures


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Numerous large prospectiveNumerous large prospectivestudies have described the largestudies have described the large

cost and low yield of thecost and low yield of the

indiscriminate use of cindiscriminate use of c--spinespine

radiology in trauma patientsradiology in trauma patients


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Two recent papers haveTwo recent papers have

attempted to address this questionattempted to address this question

NEXUSNEXUS --The National Emergency XThe National Emergency X--

Radiograph Utilization StudyRadiograph Utilization Study

This was a prospective study put forth toThis was a prospective study put forth to

validate a rule for the decision whether to xvalidate a rule for the decision whether to x--ray in low risk patientsray in low risk patients


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Criteria were as follows..Criteria were as follows..

1. Absence of tenderness in the posterior1. Absence of tenderness in the posterior

midlinemidline

2. Absence of a neurological deficit2. Absence of a neurological deficit 3. Normal level of alertness (GCS15)3. Normal level of alertness (GCS15)

4. No evidence of intoxication4. No evidence of intoxication

5. No distracting pain elsewhere5. No distracting pain elsewhere


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Any patient who fulfilled all 5 of theAny patient who fulfilled all 5 of the

aforementioned criteria were consideredaforementioned criteria were considered

low risk for Clow risk for C--spine injury and as such didspine injury and as such didnot receive Cnot receive C--spine radiographyspine radiography

For patients who had any of the 5 criteria,For patients who had any of the 5 criteria,

radiographic imaging was deemed indicatedradiographic imaging was deemed indicated

in the form of AP, lateral, and odontoid Cin the form of AP, lateral, and odontoid C--

spine viewsspine views


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Results of NEXUS studyResults of NEXUS study

34069 patients were enrolled34069 patients were enrolled

818 had significant C818 had significant C--spine injuryspine injury

810 were identified as potential spinal810 were identified as potential spinalinjury patients by the decision ruleinjury patients by the decision rule

8 patients were identified as low risk but in8 patients were identified as low risk but in

fact had radiographic injuryfact had radiographic injury


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Sensitivity 99%Sensitivity 99%Negative predictive value 99.8%Negative predictive value 99.8%

Specificity 12.9%Specificity 12.9%

Positive predictive value 2.7%Positive predictive value 2.7%

Study was well receivedStudy was well received

But..some felt criteria to be tooBut..some felt criteria to be too

ambiguous and open to interpretationambiguous and open to interpretation


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Canadian CCanadian C--Spine RulesSpine Rules

Prospective study whereby patients wereProspective study whereby patients were

evaluated for 20 standardized clinicalevaluated for 20 standardized clinical

findings as a basis for formulating afindings as a basis for formulating a

decision as to the need for subsequentdecision as to the need for subsequent

radiographyradiography


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Rules were as follows..Rules were as follows..

1. Was there any high risk factor that1. Was there any high risk factor that

mandates radiography?mandates radiography?

Includes age>65, dangerous mechanism ofIncludes age>65, dangerous mechanism ofinjury, and presence of paraesthesiasinjury, and presence of paraesthesias

If yes, XIf yes, X--rayray


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2. Were there any low risk factors that2. Were there any low risk factors that

allow some assessment of range ofallow some assessment of range ofmotion?motion?

Included simple rear end MVC, sittingIncluded simple rear end MVC, sitting

position in ER, ambulatory at any time,position in ER, ambulatory at any time,delayed onset of neck pain, and absence ofdelayed onset of neck pain, and absence of

midline cmidline c--spine tendernessspine tenderness

I

f none, need XI

f none, need X--rayray


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3. Was the patient actively able to move3. Was the patient actively able to move

their neck?their neck?

If yes, then no xIf yes, then no x--rayray


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Results of Canadian CResults of Canadian C--SpineSpine

StudyStudy 8924 patients enrolled8924 patients enrolled

100 % sensitivity for identifying 151100 % sensitivity for identifying 151clinically important Cclinically important C--spine injuriesspine injuries

42.5 % specificity42.5 % specificity

deemed a highly sensitive decision rule fordeemed a highly sensitive decision rule foruse of Cuse of C--spine radiography in alert andspine radiography in alert and

stable trauma patientsstable trauma patients


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Clearance of Cervical SpineClearance of Cervical Spine

Injury in Conscious,Injury in Conscious,Symptomatic PatientsSymptomatic Patients

Key PointsKey Points

1. Radiological evaluation of the cervical1. Radiological evaluation of the cervicalspine is indicated for all patients who do notspine is indicated for all patients who do notmeet the criteria for clinical clearance asmeet the criteria for clinical clearance asdescribed abovedescribed above

2. Imaging studies should be technically2. Imaging studies should be technicallyadequate and interpreted by experiencedadequate and interpreted by experiencedcliniciansclinicians


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Plain Film RadiologyPlain Film Radiology

The standard 3 view plain film series is theThe standard 3 view plain film series is thelateral, anterolateral, antero--posterior, and openposterior, and open--mouthmouthviewview

The lateral cervical spine film must includeThe lateral cervical spine film must includethe base of the occiput and the top of thethe base of the occiput and the top of thefirst thoracic vertebrafirst thoracic vertebra

The lateral view alone is inadequate andThe lateral view alone is inadequate andwill miss up to 15% of cervical spinewill miss up to 15% of cervical spineinjuries.injuries.


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If lower cervical spine difficult to see,If lower cervical spine difficult to see,

caudal traction on the arms may be usedcaudal traction on the arms may be used

to improve visualisationto improve visualisation

Repeated attempts at plain radiographyRepeated attempts at plain radiography

are usually unsuccessfulare usually unsuccessful

If the lower cervical spine is not visible,If the lower cervical spine is not visible,

a CT scan of the region is then indicateda CT scan of the region is then indicated


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How to read the Lateral CervicalHow to read the Lateral Cervical

Spine XSpine X--RayRay Lateral cervical spineLateral cervical spine

xx--ray must visualiseray must visualise

entire cervical spine .entire cervical spine .

A film that does notA film that does not

show the upper bordershow the upper border

of T1 is inadequateof T1 is inadequate

Caudal traction on theCaudal traction on the

arms may helparms may help


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The anterior vertebral line ,The anterior vertebral line ,

posterior vertebral line, andposterior vertebral line, and

spinolaminar line should havespinolaminar line should have

a smooth curve with no stepsa smooth curve with no steps

or discontinuitiesor discontinuities

Malalignment of the posteriorMalalignment of the posterior

vertebral bodies is morevertebral bodies is more

significant than that anteriorly,significant than that anteriorly,

which may be due to rotationwhich may be due to rotation

A step of >3.5mm isA step of >3.5mm is

significant anywheresignificant anywhere


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Anterior subluxation of oneAnterior subluxation of one

vertebra on another indicatesvertebra on another indicatesfacet dislocationfacet dislocation

Less than 50% of the widthLess than 50% of the width

of a vertebral body impliesof a vertebral body implies

unifacet dislocationunifacet dislocation

Greater than 50% impliesGreater than 50% implies

bilateral facet dislocationbilateral facet dislocation

This is usually accompaniedThis is usually accompanied

by widening of theby widening of the

interspinous and interlaminarinterspinous and interlaminar

spacesspaces


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Vertebral body andVertebral body andintervertebral discintervertebral disc

examination revealexamination revealcompression and burstcompression and bursttype injuriestype injuries

Bodies normally regularBodies normally regularcuboids similar in size andcuboids similar in size and

shape to the vertebraeshape to the vertebraeimmediately above andimmediately above and

below (not C1/C2)below (not C1/C2)

Anterior wedging ofAnterior wedging ofvertebral body or teardropvertebral body or teardrop

fractures of anterofractures of antero--inferiorinferiorportion of body impliesportion of body impliescompression fracturecompression fracture


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Anterior compression of greater than 40%Anterior compression of greater than 40%of normal vertebral body height indicates aof normal vertebral body height indicates a

burst fracture with retropulsion of fragmentsburst fracture with retropulsion of fragments

of the vertebral body into the spinal canalof the vertebral body into the spinal canal


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Loss of height of anLoss of height of anintervertebral discintervertebral discspace may indicatespace may indicatedisc herniationdisc herniation

Analysis ofAnalysis of

prevertebral softprevertebral softtissues may allow thetissues may allow thediagnosis of cervicaldiagnosis of cervicalinjuriesinjuries

Soft tissue shadow isSoft tissue shadow iscreated by pharyngealcreated by pharyngealand prevertebraland prevertebraltissuestissues


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AtlantoAtlanto occipital dissociationoccipital dissociation

AtlantoAtlanto--occipital dissociation can beoccipital dissociation can be

very difficult to diagnose and is easilyvery difficult to diagnose and is easily

missed.missed.

The distance from the occiput to theThe distance from the occiput to the

atlas should not exceed 5mm anywhereatlas should not exceed 5mm anywhere

on the filmon the film


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Odontoid peg must also beOdontoid peg must also be

examined for fracturesexamined for fractures Soft tissue swellingSoft tissue swelling

anterior to arch of C1anterior to arch of C1suggests fracture at thissuggests fracture at thislevel.level.

AtlantoAtlanto--Dens IntervalDens Interval(ADI) in adults should be(ADI) in adults should be 3.5mm impliesinjury to transverseinjury to transverse

ligament, and > 5mmligament, and > 5mmindicates complete ruptureindicates complete ruptureand instabilityand instability

C1C1--C2 interspinous spaceC2 interspinous spaceshould not be >10mmshould not be >10mm

widewide


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The AnteroThe Antero--Posterior ViewPosterior View

AnteroAntero--posteriorposterior

view must includeview must include

spinous processes ofspinous processes ofall cervical vertebraeall cervical vertebrae

from C2 to T1from C2 to T1


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The Open Mouth ViewThe Open Mouth View

The open mouth viewThe open mouth view

should visualise the lateralshould visualise the lateral

masses of C1 and themasses of C1 and the

entire odontoid peg.entire odontoid peg.

Bite blocks may improveBite blocks may improve

viewingviewing

In the unconscious,In the unconscious,

intubated patient the openintubated patient the open

mouth view is inadequatemouth view is inadequate

and occiput to C2 CTand occiput to C2 CT

scan recommendedscan recommended


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The addition of two oblique views toThe addition of two oblique views tothe standard 3 view series does notthe standard 3 view series does not

increase the sensitivity of plain filmincrease the sensitivity of plain film

evaluationevaluation


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CT ScanningCT Scanning

Thin cut CT scanningThin cut CT scanning

should be used to evaluateshould be used to evaluate

abnormal, suspicious orabnormal, suspicious or

poorly visualised areas onpoorly visualised areas on

plain radiologyplain radiology

The combination of plainThe combination of plain

radiology and directed CTradiology and directed CT

scanning provides a falsescanning provides a false

negative rate of less thannegative rate of less than0.1%0.1%


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MRIMRI

Ideally (ie. U.S.) all patients with anIdeally (ie. U.S.) all patients with anabnormal neurological examinationabnormal neurological examination

should be evaluated in a specialist unitshould be evaluated in a specialist unit

and have an MRI scan of the spineand have an MRI scan of the spine Patients who report transientPatients who report transient

neurological symptoms but who have aneurological symptoms but who have a

normal exam should also undergo annormal exam should also undergo anMRI assessment of their spinal cordMRI assessment of their spinal cord


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Radiographic Examination andRadiographic Examination and

Clearance of Cervical SpineInjuryClearance of Cervical SpineInjury --

Unconscious, Intubated PatientsUnconscious, Intubated Patients

K

ey PointsK

ey Points1. The odontoid view is unreliable in intubated1. The odontoid view is unreliable in intubated

patientspatients

2. Clinical examination is impossible in the2. Clinical examination is impossible in the

unconscious patientunconscious patient3. Plain film radiology cannot exclude3. Plain film radiology cannot exclude

ligamentous instabilityligamentous instability


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Standard radiological examination ofStandard radiological examination of

cervical spine in unconscious,cervical spine in unconscious,intubated patients isintubated patients is

1. Lateral cervical spine film1. Lateral cervical spine film

2. Antero2. Antero--posterior cervical spine filmposterior cervical spine film3. CT scan of occiput3. CT scan of occiput -- C3C3

The open mouth odontoid radiographThe open mouth odontoid radiographis inadequate in intubated patients andis inadequate in intubated patients andwill miss up to 17%of injuries to thewill miss up to 17%of injuries to the

upper cervical spineupper cervical spine


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Clearance of the spine in unconsciousClearance of the spine in unconscious

patients is limited by the lack ofpatients is limited by the lack ofclinical informationclinical information

Incidence of unstable spinal injury inIncidence of unstable spinal injury in

adult, intubated trauma patients isadult, intubated trauma patients is

about 10.2%about 10.2%

Incidence of unstable, occult spinalIncidence of unstable, occult spinal

trauma (not visible on plain films) istrauma (not visible on plain films) is

about 2.5%about 2.5%


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Unconscious patient .Unconscious patient .

Continue spinal precautions until fullyContinue spinal precautions until fullyconsciousconscious

If patient is expected to regain fullIf patient is expected to regain full

consciousness within 24consciousness within 24--48 hrs, patient48 hrs, patientcan be nursed with full spinalcan be nursed with full spinalprecautionsprecautions

Collar not necessary in adequatelyCollar not necessary in adequatelysedated, ventilated patient, and maysedated, ventilated patient, and mayincrease intracranial pressure inincrease intracranial pressure inpatients with traumatic brain injurypatients with traumatic brain injury


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Magnetic Resonance Imaging inMagnetic Resonance Imaging in

Unconscious CUnconscious C--Spine TraumaSpine Trauma Extremely sensitive at detecting soft tissueExtremely sensitive at detecting soft tissue

injuries without stressing cervical spineinjuries without stressing cervical spine--

SIGNIFICANCE??SIGNIFICANCE?? High false positive rateHigh false positive rate

Few good studies on the use of MRI inFew good studies on the use of MRI inclearing the cervical spine in unconsciousclearing the cervical spine in unconsciouspatientspatients


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CT ScanCT Scan Whole CWhole C--SpineSpine

Recent concept of full cervical spine CT forRecent concept of full cervical spine CT forassessment of spinal injury has emerged.assessment of spinal injury has emerged.

Several studies have demonstrated robustness ofSeveral studies have demonstrated robustness of

full CT scan for exclusion of significant spinalfull CT scan for exclusion of significant spinalinjuryinjury

When whole cervical spine CT scanning isWhen whole cervical spine CT scanning isperformed, anteroperformed, antero--posterior plain film becomesposterior plain film becomes

redundantredundant


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In any case, regardless of theIn any case, regardless of theinjury suspected, protectinjury suspected, protect

yourselfyourself


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Four Basic Reasons WhyFour Basic Reasons Why

Cervical Spine Fractures AreCervical Spine Fractures Are

Missed By ER PhysiciansMissed By ER Physicians

1. Failure to obtain indicated films1. Failure to obtain indicated films

2. Inadequate films2. Inadequate films

3. Misinterpretation of the films3. Misinterpretation of the films

4. Films fail to adequately visualize the4. Films fail to adequately visualize theinjuriesinjuries


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Excuses That Wont WorkInExcuses That Wont WorkIn

CourtCourt I felt the xI felt the x--ray wasray was

adequate even thoughadequate even thoughI couldnt see the C7I couldnt see the C7--

T1 areaT1 area Never settleNever settlefor inadequate films!for inadequate films!

I didnt immobilizeI didnt immobilize

his neck because hehis neck because hewas drunk andwas drunk anduncooperativeuncooperative


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I didnt think an openI didnt think an openfemur fracture wouldfemur fracture would

distract him fromdistract him fromreporting tenderness onreporting tenderness onhis neck examhis neck exam AnyAnydoubts of a distractingdoubts of a distractinginjury, order a Cinjury, order a C--spinespine

filmfilm

I wanted to get a lateral I wanted to get a lateralCC--spine film beforespine film beforeintubationI had no wayintubationI had no way

of knowing he wouldof knowing he wouldaspirate!aspirate! Dont hesitateDont hesitateto use oral endotrachealto use oral endotrachealintubation with cervicalintubation with cervicalimmobilization as it hasimmobilization as it has

been proven safebeen proven safe


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References

Mower W., Hoffman J., Pollock C, et al. Use of plain

radiography to screen for cervical spine injuries.Annals of

Emergency Medicine. 2001;38(1)

Brohi K. Initial assessment of spinal trauma. Trauma.

Org.2002;7 (4)

Steill I, Wells G, VandemheenK, et al. The Canadian C-

spine rule for radiography in alert and stable trauma

patients. JAMA. 2001 Oct 17; 286 (15): 1841-8.

Tintinalli J, Krome R, Ruiz R. Emergency Medicine. A

comprehensive study guide. 1992


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