Cervical injury in head trauma

Criteria for excluding cervical spine injury in patients who have sustained blunt head or neck trauma were prospectively studied at four hospitals in the Chicago area. The authors attempted to define a subset of these adult patients who, based on clinical criteria, could reliably be excluded from cervical spine radiography, thus avoiding unnecessary radiation and saving considerable time and money in their evaluation. Patients fell into four groups: (1) patients who were awake, alert, and had no complaint of neck pain or tenderness on physical examination; (2) patients who were awake, alert, but had complaint of neck pain or tenderness on physical examination laterally over the trapezius muscle only; (3) patients who were awake, alert, but had complaint of central neck pain or tenderness on physical examination over the cervical spine or center of the neck; and (4) patients who were not fully awake or alert, were clinically intoxicated, had other painful or distracting injuries, or had focal neurologic findings. Patients in group 4 had significantly more fractures (21/387) when compared with all other patients (7/478). Patients with central neck pain or tenderness (group 3) had significantly more fractures (7/237) than patients without pain or tenderness or with these findings limited to the trapezius area (0/236). It is clear that patients who have altered mental status, abnormal examination findings, distracting injury, or pain or tenderness over the cervical spine must have cervical spine radiographs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical Clearance of Cervical Spinal Injuries by Emergency Nurses

OBJECTIVES: To determine the interrater reliability between emergency nurses and emergency physicians on defined criteria for clinically clearing the cervical spine in blunt trauma patients. METHODS: Blunt trauma patients, 12 years or older, arriving with cervical spinal precautions were prospectively enrolled as a convenience sample. Each member of the emergency physician-nurse pair completed a questionnaire with regard to five criteria for clinically clearing the cervical spine for each patient. Interrater reliability was determined by calculating the kappa statistics for the individual and combined criteria. RESULTS: Physicians and nurses agreed on the presence or absence of the combined criteria in 175 of 211 patients (82.9%; kappa, 0.65). Agreements on individual criteria were as follows: 1) intoxication--203 patients (96.2%; kappa, 0.82); 2) altered consciousness--197 patients (93.4%; kappa, 0.60); 3) neck pain--185 patients (87.7%; kappa, 0.75); 4) distracting injury--160 patients (75.8%; kappa, 0.36); and 5) neurologic deficit--198 patients (93.8%; kappa, 0.45). If disagreements in which the physician would clinically clear the patient but the nurse would not were considered as agreements, then overall agreement would be 198 of 211 patients (93.8%; kappa, 0.88). On the assumption that nurses would assess patients prior to physicians, they would have cleared 35% of the patients before the physicians. However, they would have ordered 12% more radiographs and unsafely clinically cleared 5% of the patients. CONCLUSIONS: The interrater reliability for the combined cervical spinal injury criteria between emergency nurses and physicians was good to excellent. However, with the training given in this study, nurses would order more radiographs than physicians and would unsafely clinically clear cervical spines in some patients.     

Cervical spine injury and radiography in alert, high-risk patients

Controversy exists over the need for cervical spine radiographs in alert, nonintoxicated victims of blunt trauma. We identified 286 patients admitted to a Level II trauma center over a 14-month period who were alert (Glasgow Coma Scale [GCS] greater than 13) and considered at high risk for cervical spine injury by published criteria. All 5 (1.7%) fractures or ligament disruptions occurred in the group with neck pain or tenderness. Of the study group, 141 (49%) were asymptomatic for cervical injury and nonintoxicated (blood alcohol concentration (BAC) less than 100 mg/dL). Mandatory cervical spine radiography in this group would have resulted in an additional cost of $33,699. Routine cervical spine radiography in alert, nonintoxicated asymptomatic victims of blunt trauma is a costly practice that warrants further examination.     

Clearance of the cervical spine in multitrauma patients: The role of advanced imaging

The cervical spine is injured in 3% of major trauma patients. Radiographic clearance for injury must be provided efficiently and accurately. There are numerous choices for clearance that are now in clinical practice: lateral radiograph only, 3-view or 5-view cervical-spine (c-spine) series, flexion-extension radiographs, computed tomography (CT) with multiplanar reformations, and magnetic resonance imaging (MRI). This article reviews the literature on methods of c-spine clearance, and emphasizes the pitfalls of each modality. Although lateral radiographs detect 60% to 80% of c-spine fractures, a significant number of fractures are not visible, even when three views of the spine are obtained. The sensitivity of plain radiographs can be improved by attention to several subtle features, which are discussed. Flexion-extension radiographs in the acute setting have an unacceptably high false-negative and false-positive rate. CT detects 97% to 100% of fractures, but its accuracy in detection of purely ligamentous injuries has not been documented. Furthermore, CT is limited in patients with severe degenerative disease. MRI is highly sensitive in the detection of ligamentous injury, but not all cases of injury may cause instability. MRI is also much less sensitive than CT to fractures of the posterior elements of the spine, and to injuries of the craniocervical junction. The causes of missed cervical spine injury and delayed instability are discussed and shown in this article. An algorithm for the use of advanced imaging is proposed.     

Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients

This study examined if use of clinical screening criteria for selective radiography of blunt trauma patients can identify all patients with thoracolumbar (TL) spine injuries. The study was a prospective cohort of patients undergoing TL spine radiographs following blunt trauma. Patients were considered at risk for TL spine injury if they had any of the following clinical criteria: 1) complaints of TL spine pain, 2) TL spine tenderness, 3) a decreased level of consciousness, 4) intoxication with ethanol or drugs, 5) a neurologic deficit, or 6) a painful distracting injury. Patients without any of these findings were considered at low risk for TL spine injury. Severity of mechanism of injury was also recorded. Data sheets were completed prior to TL radiography. Injury status was determined by the final faculty radiologist interpretation of all radiographic studies. A total of 2404 patients were enrolled. TL spine injuries were identified in 152 patients. Of these 152 patients with spine injuries, all 152 (100%, 95% confidence interval 98-100%) were considered high risk by having at least one of the high-risk criteria. These criteria have a specificity of 3.9%, a positive predictive value of 6.6%, and a negative predictive value of 100%. All of the high-risk criteria but intoxication with ethanol or drugs were important as sole predictors of TL spine injury. The use of high-risk clinical screening criteria identified virtually all blunt trauma patients with acute TL spine injuries. These criteria, however, have poor specificity and positive predictive value.     

Does the National Emergency X-ray Utilization Study make a difference?

OBJECTIVE: To assess whether the introduction of the National Emergency X-ray Utilization Study guidelines in a UK emergency department reduced the number of patients having cervical spine radiographs and altered the accuracy of diagnosis of cervical spine injury. METHODS: This was a prospective, observational study. The number of patients with recent neck injury who had cervical spine radiographs taken was assessed for 3 months before and three months after the introduction of the National Emergency X-ray Utilization Study guidelines to an urban emergency department in the UK. The number of injuries missed by emergency department doctors during the two 3-month periods was also recorded. RESULTS: Prior to using the guidelines, 252 of 715 patients (35%) were X-rayed and when using the guidelines, 268 of 706 patients (38%) were X-rayed. No significant difference was observed between the rates of X-ray in the two groups (P=0.288). No injuries were missed by emergency department doctors either before or after the introduction of the guidelines. CONCLUSION: Introduction of the National Emergency X-ray Utilization Study guidelines to a UK emergency department did not reduce the number of patients having cervical spine radiographs after neck trauma and had no effect on the pick-up rate for cervical spine injuries.     

Pitfalls in the clinical diagnosis of vertebral fractures: a case series in which posterior midline tenderness was absent

Objective: There is widespread belief among doctors that posterior midline tenderness is virtually a prerequisite for spinal fracture in alert, sober patients without any painful distracting injury or neurological deficit. This paper examines and challenges this belief.

Methods and results: We present three patients in whom significant thoracic and lumbar vertebral fractures were missed, or were thought to be "old", because of lack of posterior midline tenderness. We also present two further patients, one with a lumbar spine fracture and one with a cervical spine fracture, in whom posterior midline tenderness was absent but in whom the correct diagnosis was made. All these patients were sober and fully alert and none had a neurological deficit or a painful distracting injury.

Conclusion: The absence of posterior midline tenderness does not exclude significant spinal injury. We suggest that patients should satisfy both the Canadian and British guidelines before it is decided that imaging of the cervical spine is unnecessary.

     

Missed cervical spine fracture-dislocations: the importance of clinical and radiographic assessment

OBJECTIVE: To review the case of a patient who suffered a cervical spine fracture-dislocation missed at a hospital emergency department. CLINICAL FEATURES: A 77-year-old man involved in a motor vehicle accident was transported to a local emergency hospital where cervical spine x-ray films taken were reported as demonstrating no evidence of acute injury. The patient visited a chiropractic clinic 6 days later, where x-ray films were again obtained, finding that the patient sustained fractures of C5 and C6, as well as a bilateral facet dislocation at C5/C6. Computed tomography confirmed the fractures, and magnetic resonance imaging findings demonstrated cervical spinal cord compression and posterior spinal cord displacement. INTERVENTION AND OUTCOME: The patient was referred for preoperative medical evaluation. He underwent C5-6 closed reduction and anterior/posterior fusion surgery and was released without complication. Patient follow-up indicated full recovery with minimal neurologic symptoms. CONCLUSION: Cervical spine fracture-dislocations are often missed during standard radiographic examinations in emergency department settings. Chiropractors are encouraged to perform a comprehensive evaluation of patients presenting with cervical trauma even if they have had prior x-ray films reported as normal. Standard x-ray films taken at emergency department facilities are not entirely reliable for detecting or revealing cervical spine fracture-dislocations. This case stresses the importance of careful clinical assessment and imaging procedures on patients who have encountered cervical spine trauma.     

Prehospital clinical findings associated with spinal injury

Objective. The objective of this study was to identify clinical findings that are associated with spinal fracture and/or spinal cord injuries in prehospital trauma patients.

Methods. A retrospective chart review was performed at three tertiary referral centers in Southeastern Michigan. All charts of patients with spinal fractures or spinal cord injuries during 1992 and 1993 were reviewed. Patients with available pre-hospital records were included in the study analysis. Prehospital data points included documentation of head injury; altered mental status; neurologic deficit; evidence of intoxication; cervical, thoracic, and lumbar pain or tenderness; nonspecified back pain or tenderness; and a narrative for all other documented injuries. Hospital data collected included type and level of spinal injury and age and sex of the patient.

Results. Of 867 injury patients identified, 536 were excluded, leaving 346 analyzable fractures in 331 patients. The 346 spinal fractures/spinal cord injuries were distributed as: 100 (29%) cervical, 83 (24%) thoracic, 128 (37%) lumbar, and 35 (10%) sacral. Prehospital documentation of altered mental status, neurologic deficit, evidence of intoxication, spinal pain, or suspected extremity fracture was found for every patient with a cervical injury, 82/83 patients with thoracic injuries (99%), and 124/128 patients with lumbar injuries (97%). All five patients who were not documented as having one of the predictors had stable injuries.

Conclusion. Prehospital clinical findings of altered mental status, neurologic deficit, evidence of intoxication, spinal pain, and suspected extremity fracture were documented for all patients with significant spinal injuries in this series. These findings may be useful to identify patients who require prehospital spinal immobilization.     

Efficacy of the posttraumatic cross table lateral view of the cervical spine

This is a retrospective study of 128 patients with a discharge diagnosis of cervical spine fracture, dislocation, or subluxation. The study was undertaken to establish the accuracy of the posttraumatic cross table lateral view radiograph of the cervical spine (CTLV). The radiographs were read by the faculty emergency physician author. If his diagnosis differed from the patient's final radiologic diagnosis, the radiograph was reevaluated by the radiologist author. The accuracy in diagnosing posttraumatic cervical spine abnormalities on CTLV alone was 74.2% and 79.7% for the emergency physician and radiologist, respectively. Thirty percent of cases undiagnosed by the emergency physician were subsequently treated as unstable injuries. Thirty-five percent of C1, 14.8% of C2, and 42.4% of C6 abnormalities were missed on CTLV by both the emergency physician and the radiologist. The results indicate that the CTLV, alone, is unreliable and potentially dangerous as a screening exam in diagnosing posttraumatic abnormalities of the cervical spine.     

Cervical whiplash syndrome. Hyperextension-hyperflexion injury

Cervical whiplash syndrome, or hyperextension-hyperflexion injury, is a common traumatic injury to the soft tissue structures around the cervical spine. The mechanisms of injury that cause cervical whiplash syndrome vary, yet they may be sufficient enough to cause cervical spine fracture, resulting in partial or complete neurologic deficit. The pathogenesis of cervical whiplash syndrome are presented.     

The emergency department management of near-hanging victims

A 7-year retrospective review was performed to assess the complications of near-hangings injuries. Thirty-nine cases of near hanging were seen during this period. There were no hanging drops greater than 5 feet and no cervical spine fractures. One patient required intubation for soft tissue swelling. The adult respiratory distress syndrome (ARDS) occurred in three patients. All victims with field Glasgow Coma Scale levels > 3, and three of eight with GCS = 3 survived to discharge with a normal mental status. We conclude that aggressive resuscitation and treatment of postanoxic brain injury is indicated even in patients without evident neurologic function in the field, as full recovery may still occur. Cervical spine fractures have not been reported in near-hanging victims and should only be considered if there is a possibility of a several foot drop or if a focal neurologic deficit is present. Injury to the anterior soft tissues of the neck may cause respiratory obstruction. Close attention to the development of pulmonary complications is required.     

Distracting injuries in patients with vertebral injuries

To describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. A prospective cohort study was conducted at an urban Level I trauma center. All patients undergoing radiographic evaluation of the cervical, thoracic, or lumbar vertebrae after blunt trauma were enrolled. Patients had a data collection form completed by the treating physician before radiographic imaging and were evaluated for the following upon initial presentation: tenderness to the cervical, thoracic, or lumbar spine, distracting injuries, altered mental status, alcohol or drug intoxication, or neurological deficits. Patients with distracting injuries as the sole documented indication for vertebral radiographs were reviewed for the types of injuries present. A total of 4698 patients were enrolled in the study. There were 336 (7.2%) patients who had distracting injuries as the sole documented indication for obtaining radiographic studies of the vertebrae. Eight (2.4%, 95% CI 1.0-4.6%) of the 336 patients had 14 acute vertebral injuries including compression fractures (5), transverse process fractures (7), spinous process fracture (1), and cervical spine rotatory subluxation (1). There were 13 thoracolumbar injuries and one cervical spine injury. Distracting injuries in the eight patients with acute vertebral injuries included 13 bony fractures. Distracting injuries in those patients without vertebral injuries included bony fractures (333), lacerations (63), soft tissue contusions (62), head injuries (15), bony dislocations (12), abrasions (11), visceral injuries (8), dental injuries (5), burns (3), ligamentous injuries (3), amputation (1), and compartment syndrome (1). In conclusion, in patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries.     

Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level

Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. Two hundred radiographs (14%) were misinterpreted, including 141 chest (16%), 24 extremity (8%), 20 abdomen (12%), 14 lateral neck (18%), and 1 cervical spine radiograph (2%). Physicians-in-training misinterpreted 16% of their radiographs versus 11% for PEM attendings (P = .01). Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.     

Diagnosing cervical spine instability: role of the post-computed tomography scan out-of-collar lateral radiograph

BACKGROUND: Cervical spine injuries may have devastating neurological consequences, which makes accurate diagnosis of injury a key part of the trauma evaluation. Imaging plays a significant role in making the diagnosis and guiding management. Current American College of Radiology Appropriateness Criteria guidelines recommend computed tomography (CT) of the cervical spine with multi-planar reformats as the highest-rated imaging examination for patients meeting clinical criteria, without subsequent need for further imaging with a negative scan in a neurologically intact and non-obtunded patient. Although CT is fast and accurate for evaluation of bony injury, it may overlook ligamentous injury. OBJECTIVE AND CASE REPORT: We report a case in which ligamentous instability was demonstrated as subluxation with an out-of-collar lateral radiograph after a CT scan showed no subluxation or fracture in a patient without neurological deficits. Our Radiology Department routinely performs an out-of-collar lateral radiograph after a negative CT scan, and this case suggests that there may be an important role for this practice. CONCLUSION: Magnetic resonance is the optimal study for soft tissue and ligamentous evaluation; however, a simple lateral out-of-collar radiograph after CT clearance, in an otherwise neurologically intact and non-obtunded patient, may be a quick and cost-effective means to assess for instability of the cervical spine.     

False-positive preliminary radiograph interpretations in a pediatric emergency department: Clinical and economic impact

A prospective, case control study at a university-affiliated, academic pediatric emergency department was undertaken to determine the clinical impact and cost of false-positive preliminary radiograph interpretations and to compare the cost of false-positive interpretations with the estimated cost of a 24-hour on-site pediatric radiologist. Data were collected on all patients undergoing radiography of the chest, abdomen, lateral (soft tissue) neck, cervical spine, or extremities during a 5-month period. A total of 1,471 radiograph examinations was performed, and 200 (14%) misinterpretations (false-positive and false-negative) by the pediatric emergency medicine physicians were identified. As reported previously, 20 (10%) of the false-negative interpretations were noted to be clinically significant. In the current analysis, 103 (7%) false-positive radiograph interpretations were identified. False-positive interpretations were noted more frequently (14%) for soft tissue lateral neck radiographs than for any other radiograph type. Of the 103 total false-positive radiographs, nine (0.6%) resulted in an increased patient cost totaling $764.75. These data show that false-positive radiograph interpretations have limited economic and clinical impact.     

Delayed Diagnosis of Thoracolumbar Fractures in Multiple-trauma Patients

Objectives: To determine the frequency of delayed diagnosis of major thoracolumbar vertebral fractures (T-L Fxs) in ED multiple-trauma patients, and to determine the differences between cases of delayed and nondelayed diagnoses of T-L Fx. Methods: A retrospective chart review was conducted of 181 trauma patients with 310 major T-L Fxs (compression, burst, or chance Fxs or dislocations). Data collected included the time of the diagnosis of T-L Fx, the patient's clinical presentation in the ED, the mechanism of injury, and the outcome. Results: Of the 181 patients with major T-L Fxs, 138 were diagnosed in the ED (nondelayed group), and 43 were diagnosed after the patient left the ED (delayed group). Of these, 33 cases occurred in unstable patients requiring emergent medical imaging and/or operation, 7 occurred when emergency physicians failed to detect subtle compression Fxs on ED radiographs, and 3 occurred in stable patients who were not radiographed in the ED. The delayed group were more often critical, and hypotensive, and had lower Glasgow Coma Scale (GCS) scores than did the nondelayed group. The delayed group patients also had more cervical spine injuries, multiple noncontiguous spinal Fxs, high-energy mechanisms of injury, and direct blunt assaults to the back than did the nondelayed group patients. There were 13 patients with T-L Fxs, GCS scores = 15, and normal back examinations. There were 43 patients who had neurologic deficits associated with their injuries; 11 patients with incomplete cord lesions progressed, including 3 in the delayed group. Conclusions: A delay in the diagnosis of T-L Fx in hospitalized trauma patients is frequently associated with an unstable patient condition that necessitates higher-priority procedures than ED T-L spine radiographs. Such patients should receive spinal precautions until more complete evaluation can be performed. The decision to selectively radiograph T-L spines in multiple-trauma patients should consider the mechanism of injury, the presence of possible confounders to physical examination, and clinical signs and symptoms of back injury.     

Paramedic evaluation of clinical indicators of cervical spinal injury

Purpose. Standard prehospital practice includes frequent immobilization of blunt trauma patients, oftentimes based solely on mechanism. Unnecessary cervical spine (c-spine) immobilization does have disadvantages, including morbidity such as low back pain and splinting, increased scene time and costs, and patient-paramedic conflict. Some emergency physicians (EPs) use clinical criteria to clear trauma patients of c-spine injury. If paramedics were able to apply clinical criteria in the out-of-hospital setting, then unnecessary c-spine immobilization could be safely avoided. The authors designed a prospective, randomized, simulated trial to determine the level of agreement between paramedic and EP assessments of clinical indicators of c-spine injury, hypothesizing that there would be substantial agreement between them.

Methods. A convenience sample of ten paramedics and ten attending EPs participated. Ten standardized patients, with various combinations of positive and negative findings, were examined simultaneously by EP-paramedic pairs. Each pair evaluated five randomly assigned patients for six clinical criteria: 1) alteration in consciousness, 2) evidence of intoxication, 3) complaint of neck pain, 4) cervical tenderness, 5) neurologic deficit or complaint, and 6) distracting injury. If any criterion was positive, clinical clearance was considered to have failed, and the simulated patient would have been immobilized. Fifty pairs of examinations were performed. The kappa statistic was utilized to determine level of agreement between the two groups for each criterion and for the immobilization decision. A kappa of 0.40 to 0.75 denotes good agreement and >0.75 denotes excellent agreement.

Results. The kappas for the six criteria were: 1) 0.77; 2) 0.68; 3) 0.62; 4) 0.73; 5) 0.68; and 6) 0.62. The kappa statistic for the immobilization decision was 0.90. In only one case did the immobilization decisions differ; the paramedic indicated immobilization, whereas the physician did not.

Conclusion. In this model, there was excellent agreement between paramedics and physicians when evaluating simulated patients for possible c-spine injury. No patient requiring immobilization would have been clinically cleared by paramedics. These data support the progression to a prospective field trial evaluating the use of these criteria by paramedics.     

Lateral cervical curve changes in patients receiving chiropractic care after a motor vehicle collision: a retrospective case series

OBJECTIVE: To examine radiological changes of the lateral cervical curve in patients who received chiropractic care after motor vehicle collisions. DESIGN: A retrospective case series. Thirteen patients who had received chiropractic care after motor vehicle collisions were selected from a northeastern Washington chiropractic office. Patients had a lateral cervical radiograph taken prior to the initiation of chiropractic treatment and a comparative lateral cervical radiograph subsequent to a period of care. Cases were included if they met the previously stated criteria and if the radiographs were of sufficient quality to determine the lateral cervical curve from C2-C7. RESULTS: Adjustments rendered using an Activator Adjusting Instrument. Eleven of the subjects were also instructed to perform stretching exercises. Compared to the initial lateral cervical radiograph, the comparative radiographs demonstrated a mean increase in cervical lordosis between C2 and C7 of 6.4 degrees (SD = 8.2). The standard error estimate of the population was 2.3 degrees, with a 95% confidence interval of 1.4 degrees to 11.4 degrees. CONCLUSION: There was a mean increase in the cervical lordosis of 6.4 degrees (SD = 8.2). The standard error estimate of the population was 2.3 degrees, with a 95% confidence interval of 1.4 degrees to 11.4 degrees. We were not able to determine the individual effects of adjustment, stretching, and natural progression of the condition. The results suggest that further study of this phenomenon should be undertaken.