Jules BlackhamJules Blackham

Speciality Registrar Emergency Speciality Registrar Emergency MedicineMedicine

BASICS AvonBASICS Avon

Great Western Air AmbulanceGreat Western Air Ambulance

Clearing the cervical Clearing the cervical spinespine

2 major studies2 major studies

Clinically clearing Clinically clearing Cervical Spine Cervical Spine

Reviews of “current” Reviews of “current” practicepractice

Number of authors noted the patients with Number of authors noted the patients with [Neifield [Neifield

1988 , Saddison 1991, Hoffman 1992, Zabel 1997]1988 , Saddison 1991, Hoffman 1992, Zabel 1997] : :– Normal level of consciousness, Normal level of consciousness, – no focal neurological deficit, no focal neurological deficit, – no intoxication, no intoxication, – no distracting injury and no distracting injury and – no neck pain/tenderness no neck pain/tenderness

Did not have a c-spine injuryDid not have a c-spine injury Most studies were not very large (up to 1000 Most studies were not very large (up to 1000

patients), and only had relatively few c-spine patients), and only had relatively few c-spine fractures(3%).fractures(3%).

NEXUS GROUPNEXUS GROUP Hoffman JR, et al. “Validity of a set of Hoffman JR, et al. “Validity of a set of

clinical criteria to rule out injury to the clinical criteria to rule out injury to the cervical spine in patients with blunt cervical spine in patients with blunt trauma.” N Engl J Med 2000;343:94-9trauma.” N Engl J Med 2000;343:94-9

21 centres across US21 centres across US 34,069 patient underwent C-spine 34,069 patient underwent C-spine

radiography after blunt trauma.radiography after blunt trauma. All patient with blunt trauma All patient with blunt trauma

undergoing cervical radiography were undergoing cervical radiography were includedincluded

5 low risk criteria5 low risk criteria

No midline cervical tendernessNo midline cervical tenderness No focal neurological deficitNo focal neurological deficit Normal alertnessNormal alertness No intoxicationNo intoxication No painful distracting injuryNo painful distracting injury

ResultsResults

Identified all but 8 of the 818 patients Identified all but 8 of the 818 patients with C-spine injurywith C-spine injury

Sensitivity 99%[98-99.6%]Sensitivity 99%[98-99.6%] Sensitivity 12.9%Sensitivity 12.9%

3,065 patients under 183,065 patients under 18– 88 under 2 years88 under 2 years– 817 aged 2-8 years817 aged 2-8 years– 2,160 aged 8-17 yrs2,160 aged 8-17 yrs

30 (0.98%) had cervical spine injuries30 (0.98%) had cervical spine injuries– Lower incidence than in adult populationLower incidence than in adult population– ?due to lower threshold to x-ray children?due to lower threshold to x-ray children

Paediatric Subgroup analysis of Paediatric Subgroup analysis of NEXUSNEXUS

[Viccellio and colleagues 2001][Viccellio and colleagues 2001]

No cases of CSI who were negative to No cases of CSI who were negative to all 5 nexus criteriaall 5 nexus criteria

No cases of SCIOWRANo cases of SCIOWRA 45.9% of injuries occurred in lower 45.9% of injuries occurred in lower

cervical spine (C5-7)cervical spine (C5-7) However – No CSI in under 2s, and However – No CSI in under 2s, and

only 4 in under 8sonly 4 in under 8s

NEXUS should be used with caution in NEXUS should be used with caution in under 8sunder 8s– Case report of 3 year old child with a PEG Case report of 3 year old child with a PEG

fracture, who was low risk, fracture, who was low risk, but high mechanism of injury (RTC, fatality in but high mechanism of injury (RTC, fatality in

same vehicle)same vehicle)

Recommended that consider Recommended that consider mechanism of injury in young children mechanism of injury in young children and advised to return if child becomes and advised to return if child becomes reluctant to move head.reluctant to move head.

Canadian C-Spine rulesCanadian C-Spine rules Stiell IG, et al. “The Canadian C-spine rule for Stiell IG, et al. “The Canadian C-spine rule for

radiography in alert and stable trauma patients.” radiography in alert and stable trauma patients.” JAMA. 2001 Oct 17;286(15):1841-8.JAMA. 2001 Oct 17;286(15):1841-8.

Prospective cohort study in 10 large EDs Prospective cohort study in 10 large EDs 20 standardized clinical findings were noted prior 20 standardized clinical findings were noted prior

to radiographyto radiography 8,924 patients, including 151 (1.7%) clinically 8,924 patients, including 151 (1.7%) clinically

significant CSI.significant CSI. Excluded children <16 and all patients with GCS Excluded children <16 and all patients with GCS

<15<15

Resultant model asks 3 questions:Resultant model asks 3 questions: Is there any high risk factor present Is there any high risk factor present

which mandates radiographywhich mandates radiography Is there any low risk factor that allows Is there any low risk factor that allows

safe assessment of range of motionsafe assessment of range of motion Is the patient able to actively rotate Is the patient able to actively rotate

neck 45⁰ to left and rightneck 45⁰ to left and right By cross validationBy cross validation

› Sensitivity = 100% [98-100%]Sensitivity = 100% [98-100%]› Specificity 42.5% [40-44%]Specificity 42.5% [40-44%]

High risk factorsHigh risk factorsyes to any mandates x-rayyes to any mandates x-ray

Age >65 yearsAge >65 yearsOROR

Dangerous MechanismDangerous Mechanism› Fall from ≥ 1 metre/5 stairsFall from ≥ 1 metre/5 stairs› Axial load to head e.g. divingAxial load to head e.g. diving› MVC High speed (>100km/hr), rollover, ejectionMVC High speed (>100km/hr), rollover, ejection› Motorized recreational vehiclesMotorized recreational vehicles› Bicycle collisionBicycle collision

OROR Paraesthesia in ExtremitiesParaesthesia in Extremities

low risk factor that allows safe low risk factor that allows safe assessment of range of motionassessment of range of motion

Simple read-end MVCSimple read-end MVC– ExcludesExcludes

Pushed into oncoming trafficPushed into oncoming traffic Hit by bus/large truckHit by bus/large truck RolloverRollover Hit by high-speed vehicleHit by high-speed vehicle

OrOr Sitting position in EDSitting position in ED

OrOr Ambulatory at any timeAmbulatory at any time

OrOr Delayed onset of neck painDelayed onset of neck pain

OrOr Absence of midline c-spine tendernessAbsence of midline c-spine tenderness

Able to actively rotate Able to actively rotate neckneck

45º to left and right45º to left and right

If able to do above then no radiograph If able to do above then no radiograph is required.is required.

Independent judgement or CCRIndependent judgement or CCR[Bandiera et al. 2003][Bandiera et al. 2003]

Prospective cohort study (10 EDs)Prospective cohort study (10 EDs) Compared physician’s judgement with CCR Compared physician’s judgement with CCR

in 6,265 patientsin 6,265 patients Physicians asked to estimate probability of Physicians asked to estimate probability of

unstable c-spine # from 0-100%unstable c-spine # from 0-100% Judgement – sensitivity = 93%Judgement – sensitivity = 93% CCR = 100%CCR = 100% Poor correlation between physicians for Poor correlation between physicians for

“zero probability of injury” Kappa=0.46 “zero probability of injury” Kappa=0.46 [0.28-0.65][0.28-0.65]

2 studies comparing NEXUS 2 studies comparing NEXUS with CCRwith CCR

Dickenson et al [2004] applied Dickenson et al [2004] applied retrospectively the NLC to the original retrospectively the NLC to the original CCR data. CCR data. – Did not accurately apply the rules as Did not accurately apply the rules as

differences in definitions differences in definitions e.g. “no evidence of intoxication “ and e.g. “no evidence of intoxication “ and

“unreliable findings due to alcohol or drugs”“unreliable findings due to alcohol or drugs”

– Sensitivity of 92%Sensitivity of 92%

Stiell et al 2003Stiell et al 2003 Prospective cohort study in 9 Canadian Eds.Prospective cohort study in 9 Canadian Eds. patient’s were examined with both guidelinespatient’s were examined with both guidelines 10% did not have range of movement applied10% did not have range of movement applied CCR was more sensitive than the NLC (99.4% cf. CCR was more sensitive than the NLC (99.4% cf.

90.7%)90.7%) CCR missed 1 clinically significant C-spine injury, CCR missed 1 clinically significant C-spine injury,

while NLC missed 16.while NLC missed 16. ProblemsProblems

› Definition of distracting injury is difficult and is not Definition of distracting injury is difficult and is not defined in study (or original NLC)defined in study (or original NLC)

› Study performed in Canada by CCR investigators - Study performed in Canada by CCR investigators - ?bias?bias

2 studies comparing NEXUS 2 studies comparing NEXUS with CCRwith CCR

Dickenson et al [2004] applied Dickenson et al [2004] applied retrospectively the NLC to the original retrospectively the NLC to the original CCR data. CCR data. – Did not accurately apply the rules as Did not accurately apply the rules as

differences in definitions differences in definitions e.g. “no evidence of intoxication “ and e.g. “no evidence of intoxication “ and

“unreliable findings due to alcohol or drugs”“unreliable findings due to alcohol or drugs”

– Sensitivity of 92%Sensitivity of 92%

Stiell et al 2003Stiell et al 2003 Prospective cohort study in 9 Canadian Eds.Prospective cohort study in 9 Canadian Eds. patient’s were examined with both guidelinespatient’s were examined with both guidelines 10% did not have range of movement applied10% did not have range of movement applied CCR was more sensitive than the NLC (99.4% cf. CCR was more sensitive than the NLC (99.4% cf.

90.7%)90.7%) CCR missed 1 clinically significant C-spine injury, CCR missed 1 clinically significant C-spine injury,

while NLC missed 16.while NLC missed 16. ProblemsProblems

› Definition of distracting injury is difficult and is not Definition of distracting injury is difficult and is not defined in study (or original NLC)defined in study (or original NLC)

› Study performed in Canada by CCR investigators - Study performed in Canada by CCR investigators - ?bias?bias

Nurses - NEXUSNurses - NEXUS Pitt et al. 2006Pitt et al. 2006

– More conservative than doctorsMore conservative than doctors– 59/112 removed by triage nurses, further 7 59/112 removed by triage nurses, further 7

removed by Drs.removed by Drs.– Reduced duration of immobilisation by a mean Reduced duration of immobilisation by a mean

of 23 mins (p<0.005)of 23 mins (p<0.005) Hsieh 2000Hsieh 2000

– 211 patients. Good agreement between nurses 211 patients. Good agreement between nurses and doctors (k=0.65)and doctors (k=0.65)

– Poor agreement on what was a distracting injury Poor agreement on what was a distracting injury (k=0.35)(k=0.35)

Nurses - CCRNurses - CCR Kelly et al 2004Kelly et al 2004

– Good agreement between doctors and nurses Good agreement between doctors and nurses (K=0.55)(K=0.55)

– Nurses less likely to Nurses less likely to – clear spine (P=<0.001), reporting more tenderness clear spine (P=<0.001), reporting more tenderness – test range of movement – also noted in original test range of movement – also noted in original

study where 10% of patients did not have ROM study where 10% of patients did not have ROM tested.tested.

Stiell et al 2006Stiell et al 2006– Trained 112 nurses in 6 EDs to use CCRTrained 112 nurses in 6 EDs to use CCR– 47.5% of pts could safely have c-spine cleared47.5% of pts could safely have c-spine cleared– Inter-observer agreement Excellent (second = Inter-observer agreement Excellent (second =

nurse/physician) K=0.81nurse/physician) K=0.81 Miller et al 2006Miller et al 2006

– Good agreement between doctors and nurses K=0.6Good agreement between doctors and nurses K=0.6

Pre-hospital GuidelinesPre-hospital Guidelines EAST [Como et al 2009]EAST [Como et al 2009]

– Based on NEXUS guidelinesBased on NEXUS guidelines NICE Head Injury guidelines Sept 2007 – NICE Head Injury guidelines Sept 2007 –

section 5section 5– Based on NEXUSBased on NEXUS

JRCALC [Fisher et al. 2006]JRCALC [Fisher et al. 2006]– Based on NEXUSBased on NEXUS

Pre-hospital Studies – Pre-hospital Studies – NEXUSNEXUS

Brown 1998Brown 1998– EMS staff and Emergency Physicians completed a EMS staff and Emergency Physicians completed a

questionnaire on NEXUS findings for 451 patientsquestionnaire on NEXUS findings for 451 patients– Reasonable agreement – kappa=0.48Reasonable agreement – kappa=0.48– 44 (9.8%) of patients EMS would have removed c-spine 44 (9.8%) of patients EMS would have removed c-spine

protection, EM physicians wouldn’t.protection, EM physicians wouldn’t. No comments whether any had injuriesNo comments whether any had injuries

Sahni et al 1997Sahni et al 1997– 10 standardised patients examined by 10 paramedics 10 standardised patients examined by 10 paramedics

and 10 EPsand 10 EPs– Good agreement –Kappa=0.62-0.77 for each criteriaGood agreement –Kappa=0.62-0.77 for each criteria– 1 pt where 2 groups disagreed, EPs would have cleared, 1 pt where 2 groups disagreed, EPs would have cleared,

paramedics notparamedics not

One UK based study [Armstrong et al. One UK based study [Armstrong et al. 2007]2007]– Based on NEXUSBased on NEXUS– 103 patients, of whom 67% would have 103 patients, of whom 67% would have

had the c-spine cleared on scene with had the c-spine cleared on scene with no cases of missed CSIno cases of missed CSI

Stroh and Braude 2001Stroh and Braude 2001 Retrospective chart review over 6 years.Retrospective chart review over 6 years. Spinal immobilisation protocol of Fresno county Spinal immobilisation protocol of Fresno county

EMS implemented at beginning of study period EMS implemented at beginning of study period by by Ferno/Kings/ Madera (FKM) EMS serviceby by Ferno/Kings/ Madera (FKM) EMS service

861 patients discharged diagnosis of cervical 861 patients discharged diagnosis of cervical spine injuriesspine injuries– 357 eliminated as inter-hospital transfers or not 357 eliminated as inter-hospital transfers or not

transferred by FKM EMS servicetransferred by FKM EMS service– 504 transported by EMS504 transported by EMS

495 immobilised495 immobilised

9 not immobilised:9 not immobilised:– 2 refused2 refused– 1 combatitive1 combatitive– 1 severe kyphosis1 severe kyphosis– 2 protocol violations2 protocol violations

C6 # (stable)C6 # (stable) Odontoid # (post chiropractor treatment)Odontoid # (post chiropractor treatment)

– 3 protocol misses3 protocol misses Sensitivity of immobilisation protocol for Sensitivity of immobilisation protocol for

confirmed c-spine injury=99% (97.7-99.7%)confirmed c-spine injury=99% (97.7-99.7%)

Canadian prospective studyCanadian prospective studyVaillancourt et al. 2007Vaillancourt et al. 2007

Study of 2,397 patients using CCR over 50 months Study of 2,397 patients using CCR over 50 months in 10 Ontario citiesin 10 Ontario cities

Patients examined by paramedics using CCR and Patients examined by paramedics using CCR and then immobilised and transferred to hospital for then immobilised and transferred to hospital for assessmentassessment

clinically important c-spine injury 12 patients (0.5%), clinically important c-spine injury 12 patients (0.5%), – Sensitivity =100%[74-100] specificity 38.2% [36-40].Sensitivity =100%[74-100] specificity 38.2% [36-40].

Kappa = 0.94Kappa = 0.94 Comfortable in applying in 81.5% of patientsComfortable in applying in 81.5% of patients Would have cleared 916 (38%) of spine pre-Would have cleared 916 (38%) of spine pre-

hospitallyhospitally

CAN YOU CLEAR THE CAN YOU CLEAR THE SPINE?SPINE?

ExamplesExamples

Example 1Example 1 An 85 yr old woman reportedly unconscious An 85 yr old woman reportedly unconscious

after she fell over in her bathroom banging her after she fell over in her bathroom banging her forehead on the bath before falling to the forehead on the bath before falling to the ground, landing flat on her face. On your arrival ground, landing flat on her face. On your arrival she is conscious and talking complaining about she is conscious and talking complaining about the blood from her forehead making a mess on the blood from her forehead making a mess on her bathroom floor and apologising profusely her bathroom floor and apologising profusely for wasting your time. She has a 3cm vertical for wasting your time. She has a 3cm vertical laceration in the centre of her forehead, and laceration in the centre of her forehead, and appears to have no other injuries. She is tender appears to have no other injuries. She is tender in the midline over the upper portion of her in the midline over the upper portion of her neck, but has no pain in her neck at rest.neck, but has no pain in her neck at rest.

Example 2Example 2

You are called to a 25 yr old seat belted You are called to a 25 yr old seat belted male driver who was involved in a rear male driver who was involved in a rear ended shunt at traffic lights in the centre ended shunt at traffic lights in the centre of Gloucester. His car was hit from behind of Gloucester. His car was hit from behind by another car who had failed to spot that by another car who had failed to spot that the car in front had stopped. The driver the car in front had stopped. The driver has got out of the car and is complaining has got out of the car and is complaining of pain in the centre of his neck. He has no of pain in the centre of his neck. He has no complaints of altered sensation or complaints of altered sensation or weakness in his limbs.weakness in his limbs.

Example 3Example 3

A 30 yr old man has had a “couple of drinks” this A 30 yr old man has had a “couple of drinks” this evening and has been involved in a fight. He has evening and has been involved in a fight. He has been punched in the face a number of times. He been punched in the face a number of times. He has not been knocked out, but has a black eye, has not been knocked out, but has a black eye, bleeding nose and fractured right cheek. He has bleeding nose and fractured right cheek. He has not neck tenderness and no distracting injuries. A not neck tenderness and no distracting injuries. A private ambulance RRV has arrived on scene private ambulance RRV has arrived on scene before you and the paramedic is applying a collar before you and the paramedic is applying a collar to the patient. He says as the patient has been to the patient. He says as the patient has been drinking it is drunk it is not possible to clear his drinking it is drunk it is not possible to clear his cervical spine and he has injuries above the cervical spine and he has injuries above the clavicle so needs a collar applying.clavicle so needs a collar applying.

Example 4Example 4

You are called to a 20 yr old girl who You are called to a 20 yr old girl who has been thrown from a horse, has been thrown from a horse, landing on her back. She is landing on her back. She is complaining of severe pain in her complaining of severe pain in her lower back and pins and needles in lower back and pins and needles in the front of her thighs. She is the front of her thighs. She is unwilling to move as the pain is so unwilling to move as the pain is so severe.severe.

Example 5Example 5

A 14 yr old boy has been pulled out of A 14 yr old boy has been pulled out of a swimming pool after diving in and a swimming pool after diving in and hitting the bottom, by life guards. You hitting the bottom, by life guards. You find him lying on the side of the pool in find him lying on the side of the pool in the recovery position. He is conscious the recovery position. He is conscious and complaining of a head ache. He is and complaining of a head ache. He is tender in his upper cervical spine, but tender in his upper cervical spine, but has no neurology in his upper limbs.has no neurology in his upper limbs.

SummarySummary C-spine injuries are rareC-spine injuries are rare C-spine immobilisation in a common C-spine immobilisation in a common

procedureprocedure Majority of c-spines can be cleared Majority of c-spines can be cleared

clinically.clinically.

Any Questions?Any Questions?