Clearing the Cervical Spine Sheeraz Qureshi, MD,MBA Associate Professor, Orthopaedic Surgery Spinal Surgery, Mount Sinai Hospital Icahn School of Medicine at Mount Sinai Co-Director, Spinal Surgery Fellowship

Disclosures 1.

Committee Appointments 1. AAOS Evaluations Committee 2. CSRS Research Committee 3. CSRS Program Committee 4. CSRS Survey Committee 5. NASS Evidence-Based Guidelines Committee 6. NASS Value Committee

2.

Journals 1. Spine Journal 2. Spine 3. Clinical Orthopaedics and Related Research 4. Global Spine Journal

3.

Royalties 1. Zimmer 2. Stryker 3. Biomet 4. RTI

4.

Consulting 1. Medtronic 2. Stryker 3. Zimmer 4. Orthofix

5.

Teaching 1. Medtronic 2. Stryker 3. Globus

6.

Advisory Boards 1. MTF Medical Board of Directors 2. Pacira Pharmaceutical Spine Advisory Board

Clearance 1. Definition 1. Accurately confirming absence of a cervical spine injury 2. Does not entail injury detection, classification, or treatment determination

2. Objective 1. Establish an INJURY DOES NOT EXIST

ATLS Protocol 1. Reproducible approach to rapidly identify injuries and initiate intervention for limb and life threatening injuries 1. Airway 2. Breathing 3. Circulation

2. Spinal precautions 1. Presume cervical spine injury until proven otherwise 2. Initiate and maintain C collar until directed exam during secondary evaluation

ATLS Protocol 1. Current recommendations 1. Immediate collar removal if all of the following 1. 2. 3.

Awake, alert, sober, neurologically normal patient No tenderness to palpation in cervical spine Full painless ROM

2. Screening cervical multidetector CT if any of the following 1. 2. 3. 4.

Midline cervical tenderness with palpation Neck pain with active ROM Altered level of consciouness Distracting injuries

3. Major exception 1.

Patient in extremis unable to undergo CT then lateral plain radiograph until patient stable

4. When C spine cannot be cleared clinically 1. 2. 3. 4.

Patient is “suspected unstable cervical injury” Collar left in place Spine surgeon consulted Criteria that spine surgeon should use not specified by ATLS

Clinical examination 1. Essential to clearance 2. Review history of trauma 3. Identify pain or tenderness 4. Identify any neurologic changes 5. Palpate from occiput to sacrum 6. ROM only in the asymptomatic patient

Clinical Examination 1. ROM testing 1. 2. 3. 4.

Only in asymptomatic patient First ask patient to turn head 45 degrees to each side If no symptoms, then ask patient to actively flex and extend head Detailed neurologic exam

2. Low sensitivity even in the awake, alert patient (79-93%) 3. Most injuries not identified by clinical exam minor with none requiring surgery or resulting in neuro deficit 1. Duane et al, J Trauma, 2007

Classification 1. Initial step – must determine patient’s level of alertness 1. Only patient with unimpaired level of consciousness can be conclusively cleared

2. Second step – alert, oriented patient should be assessed for intoxication and distracting injuries 3. All blunt trauma patients acutely categorized as: 1. 2. 3. 4.

Asymptomatic Temporarily nonassessable Symptomatic Obtunded

Anderson et al, JAAOS, 2010

Treatment Algorithm 1. Asymptomatic 1. Reliably cleared by clinical exam alone without imaging 2. Patient cannot be intoxicated or have distracting injury

Treatment Algorithm 1. Temporary nonassessable 1. Asymptomatic but evidence of intoxication or distracting injury 2. Expectation that these temporary conditions will resolve in 24-48 hours

Treatment Algorithm

1. Symptomatic patient 1. Fully alert with neck pain, tenderness, or neuro deficit 2. Require diagnostic imaging in addition to clinical exam to clear

Treatment Algorithm 1. Obtunded, intubated, pharmacologically compromised

Asymptomatic 1. Can receive cervical spine clearance based on clinical examination without imaging studies

2. NEXUS protocol

3. Canadian C-Spine Rule

Asymptomatic 1. NEXUS Protocol

1. Low risk 1. 2. 3. 4.

Awake, alert No history, signs, lab evidence of intoxication or distracting injury No cervical spine pain or midline tenderness No neuro signs or symptoms

2. Overall sensitivity 99% for all cervical injuries, 99.6% for significant cervical injuries 3. NPV – 99.8% (patient who does not meet criteria for radiographs extremely unlikely to have significant cervical injury 4. Specificity low at 12.9% (thus many unnecessary radiographs taken)

Asymptomatic 1. Canadian C-spine Rule 1. Awake, non-intoxicated patient with GCS score 15 2. Identifies those who require radiographs if 1.

Is patient high-risk? 1. Age >65 2. Reports paresthesia 3. Dangerous mechanism of injury (fall from height >1m, axial load to head, high speed)

2.

Is there low risk factor to allow safe assessment of ROM? 1. Simple rear-end 2. Patient siting upright or ambulatory 3. Delayed onset of pain and absence of tenderness

3.

Can patient actively rotate head 45 degrees to right and left without pain

3. If not high risk and able to rotate then cleared clinically without radiographs 4. 100% sensitive and 42.5% specific

Asymptomatic 1. Hadley et al, Neurosurg, 2002 1. Level 1 evidence that Asymptomatic patients do not need radiographic evaluation

2. Tontz et al, Spine J, 2006 1. Meta-analysis of >63000 patients 2. Overall sensitivity 98.1% and specificity of 35% 3. 28 missed injuries, 2 deemed significant, none associated with neuro deteriation

Asymptomatic 1. Clinically evaluate by NEXUS or Canadian C-Spine Rule 2. If negative then cervical spine can be cleared without radiographs

Temporarily Nonassessable 1. Short-term cognitive dysfunction 1. Intoxication or distracting injury

2. Expected to have recovery of cognitive dysfunction within 24-48 hours 3. Reliability of clearance methods not adequately determined

Temporarily Nonassessable 1. Maintain collar immobilization and repeat clinical exam 2448 hours after initial presentation following management of distracting injuries and return of normal cognitive function 2. Then if patient asymptomatic, (s)he cleared 3. If urgency required for treatment other injuries, patient evaluated as if obtunded

Symptomatic 1. Patient has neck pain, tenderness, or neurologic symptoms 2. Radiographic imaging required as adjunct to physical exam 1. 2. 3. 4.

Plain radiographs Flexion-extension radiographs CT MRI

Symptomatic 1. Plain Radiographs 1. 2. 3. 4.

Often first screening modality No validated guidelines for its use Sensitivity low (50-85%) Major limitation 1.

Unable to delineate injuries at OC and CT junctions in many patients

5. Standard set 1. 2.

Lateral, odontoid, AP If further imaging required CT recommended

Symptomatic 1. Flexion-Extension Radiographs 1. Used to identify unstable C spine injuries often missed by plain radiographs 2. Only appropriate for alert patient with negative cervical radiographs and persistent symptoms 3. Patient must voluntarily undergo study and entire C spine must be visualized 4. Efficacy controversial

Symptomatic 1. Computed Tomography 1. Has replaced plain radiographs for clearance 2. Identifies 99.3% of all C spine fractures 3. Becoming primary method for detection in many trauma centers

Symptomatic 1. Magnetic Resonance Imaging 1. Primarily indicated for patient with neuro deficit 2. Indicated when ligamentous injury is suspected 3. Not indicated for primary clearance 1. 2. 3.

Time consuming Expensive Equipment challenge

4. Can be most helpful when other imaging not consistent with neuro presentation

Symptomatic 1. Imaging of C spine required 2. 3-view xray versus MDCT 3. Flex-ex appropriate in sub-acute setting (2 weeks post) if persistent symptoms 4. MRI not for screening but good for eval of cord injury, ligament injury, or neuro deterioration

Obtunded 1. Clearance in this group controversial 2. Discontinuing collar not always synonymous with clearance in this group 3. Must balance risk of occult injury against morbidity of prolonged immobilization 4. Consensus – imaging required

Obtunded 1. CT 1. Harris et al – CT identified all clinically significant cervical spine injuries in obtunded trauma patients 2. Tomcyz et al – MRI identified acute abnormalities in 21% of patients with negative CT (none were deemed clinically significant) 3. Stelfox et al – CT and MRI equal sensitivity but CT faster and 67% less adverse events awaiting imaging

Obtunded 1. MRI 1. Menaker et al – 9% incidence of abnormality identified by MRI in patients with normal CT with 2 patients requiring surgery for ligament injury and 14 patients requiring immobilization in orthosis 2. Muchow et al – meta-analysis of 5 level 1 studies 1. 2. 3.

21% incidence of abnormalities on MRI not detected by xray or CT MRI sensitivity 97%, specificity 98.5%, NPV 100% Conclusion – MRI definitive standard for C spine clearance in obtunded patient

3. ACR (American College of Radiology 1.

CT and MRI most appropriate for C spine eval in obtunded trauma patient

Obtunded 1. Dynamic Radiographs 1. Done under MD supervision using bedside fluoro, traction, and general anesthesia 2. Mostly inadequate due to inability to evaluate CervicoThoracic junction 3. Can result in neurologic deterioration 4. NOT RECOMMENDED

Obtunded 1. Upright Radiographs 1. Upright lateral – functional test 2. Often used to assess stability in nonsurgical treatment of spinal fracture 3. NOT EFFECTIVE SCREENING TOOL

Obtunded 1. No equivocal standard 2. Obtunded patient must have radiographic evaluation 3. Initial screening likely best with MDCT 4. If CT normal 1. Accept as clearance 2. Obtain MRI

Take Home Points 1. Clearance means excluding presence of significant injury 2. Patients classified into 4 groups 1. 2. 3. 4.

Asymptomatic Temporarily nonassessable Symptomatic Obtunded

3. Asymptomatic – clinical assessment w/o radiographs 4. Temporarily nonassessable – immobilize for 24-48 hours then reassess 5. Symptomatic – evaluate with CT 6. Obtunded – MDCT +/- MRI