Spinal Immobilization: Are we doing more harm than good ?

[Medic253]

Wow,

stcommodore where in the PA BLS Protocols does it state that you can do this? Number 2 where in the state can I take this class? I like to travel. What are are you prat icing in?

[PRPGfirerescuetech]

Ok. To my PA people.

There have been update Con ed research programs in Pennsylvania allowing for BLS spinal clearing protocols, developed to mimic the NEXUS protocol. Some were sucessful, others werent. I was a part of a study at one time, and know they still run a continuing education program that teaches the principals of NEXUS, but doesnt allow for it in the field.

I can only assume pumpkin is confused possibly? Or im tired and feeling generous, im not sure.

Just the same, it certainly isnt in the BLS protocols.

[PRPGfirerescuetech]

I don't recall hearing the term "selective immobilization" before but for what we are trying to refer to that works fine. Following the NEXUS criteria the doctor doesn't have to do xray, ct, or any scan like that to get someone off the board. I have also seen situations where the hospital took the word of EMS and called a level, and cases where they waited, nothing I'm sure we haven't all seen before. It all varies depending on the hospital, and tons of other factors.

Selective immobilization is exactly what this criteria were discussing is about. One could extrapolate that by using the NEXUS spinal protocol, your selectively immobilizing patients.

Regarding some of your other posts from this thread.

1. EMS absolutely should NOT be determining patient transport destination by a trauma centers class designation. This is simple kids. Trauma centers get trauma patients. It is not within any of our scopes to determine if a patient is "OK for a level two" or is "FUBAR'd for a level one". I encourage everyone to do some reading on what is required of each level of facility, and note the differences. BUT, keep in mind, delaying care for a patient by bypassing a appropriately level 2 facility for a level one will only serve to...how did asys put it...

give a greasy haired lawyer another 1000 dollar bag of coke to snort off a hookers ass.

Yeah...thats it. That was soooo classic line of the year...but anyway...

2. Call it what you want, but calling a "trauma alert" to any hospital is a good idea. Til your patient is complete BS, and your service gets the 1k bill for activating the team jammed directly in a place where it hurts...just a thought. Think it doesnt happen? PM me, ill give you the cell of the chief of the department who just went through it.

3. Your statements thus far are bordering practicing medicine without a license. Heres the thing. Performing the NEXUS protocol is great. If you do it right, its an awesome tool. Bottom line is, WE CANT DO IT. Period. First doc who hears you did it and get a bug up his behind is going to hang you for it. Lets also remember, PA BLS protocols stipulate all patients involved in MVA's and are transported are to be immobilized. This, of course, was a avoidance of liability move by the DOH, but as soon as they find out your toying with NEXUS, this is the protocol they are going to DE-cert you with...and send you off to Micky D'z patented burger flipper school.

4. Mike speaks of selective immobilization. Great idea. Err on the side of caution, and hope for the best. Not everyone needs a LSB. Everyone just keep in mind it only takes one time for a mistake in judgement to put us in the burger flipper class with commodore here.

Ok...thats all i got. Thanks for listening.

PRPG

[Ace844]

"stcommodore,"

Since you are having trouble with this topic and posting evidence to support or be against your claims let me add to the list of studies and information you should be reading in your quest for further EDUCATION, and add this to the extensive and growing compendium of evidence here. Please read this as well:

(Delayed or Missed Diagnosis of Cervical Spine Injuries

[Original Articles)

Platzer, Patrick MD; Hauswirth, Nicole MD; Jaindl, Manuela MD; Chatwani, Sheila MD; Vecsei, Vilmos MD; Gaebler, Christian MD

From the University of Vienna Medical School, Department for Traumatology, Vienna, Austria.

Submitted for publication September 20, 2004.

Accepted for publication August 10, 2005.

Address for reprints: Patrick Platzer, MD, University of Vienna Medical School, Department for Traumatology, Waehringer Guertel 18-20, A-1090 Vienna, Austria; email: patrick.platzer@guix.at.]

Abstract

Background: Correct diagnosis of cervical spine injuries is still a common problem in traumatology. The incidence of delayed diagnosis ranges from 5 to 20%. The aim of this study was to analyze the frequency and reasons for delayed or missed diagnosis at this Level I trauma unit and to provide recommendations for optimal examination of patients with suspected cervical spine injuries.

Methods: Analysis of clinical records showed 367 patients with cervical spine injuries who were admitted to this trauma department between 1980 and 2000. In all, 140 patients had an injury of the upper cervical spine (C1/C2), 212 patients had an injury of the lower cervical spine (C3–C7), and 15 patients had a combined injury of the upper and lower cervical spine.

Results: The diagnostic failure rate was 4.9% (n = 18). Results showed several profound reasons for missed or delayed diagnosis. In eight patients (44%), radiologic misinterpretation was responsible for delay in diagnosis; in five patients (28%), incomplete sets of radiographs were responsible. In four cases (22%), the injury was missed because inadequate radiographs did not show the level of the injury; in one case (6%), the treating surgeon did not see the radiographs.

Conclusion: For optimal examination of patients with suspected cervical spine injuries, we recommend establishing specific diagnostic algorithms including complete sets of proper radiographs with functional flexion/extension views, secondary evaluation of the radiographs by experienced staff, and further radiologic examinations (computed tomography, magnetic resonance imaging) if evaluation of standard views is difficult.

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Failure to diagnose cervical spine injuries occurs with a frequency of 5 to 20%.1–3 The incidence of delayed or missed diagnosis at the cervical spine has been reduced in the last years by increased availability and accuracy of radiologic examination (computed tomography [CT] scan, magnetic resonance imaging [MRI]) as well as improved diagnostic algorithms at trauma departments. Nevertheless, incomplete sets of radiographs, radiologic misinterpretation, and trauma patients with multiple injuries are still common reasons for delays in correct diagnosis.1,2 However, the early detection of cervical spine injuries is essential because false or delayed diagnosis might lead to tragic consequences for the patients, ranging from neurologic deficits to complete tetraplegia.4,5

The aim of this study was to analyze the frequency of delayed or missed diagnosis of cervical spine injuries and the factors involved in these diagnostic failures, and to develop recommendations for appropriate clinical and radiologic examination of patients with suspected cervical spine injuries to avoid delays in diagnosis.

PATIENTS AND METHODS

This study retrospectively analyzed the clinical records of 367 patients with fractures and/or dislocations of the cervical spine that were admitted to the Level I trauma center at Vienna General Hospital, University of Vienna Medical School between January 1980 and December 2000. Collected data included parameters such as age, sex, mechanism of injury, level of injury, treatment, neurologic state, significant concomitant injuries, and alteration of mental state during initial examination. Delayed or missed diagnosis was defined as any injury identified after primary trauma evaluation.

The patients were evaluated for cervical spine injuries corresponding to the diagnostic algorithm of this unit with physical examination and standard set of radiographs. The standard set of radiographs included an anteroposterior view, a lateral view, and an open-mouth view of the odontoid. Other series like oblique views, flexion-extension views, or swimmer's views were not used routinely. CT scan or MRI was ordered at the discretion of the trauma surgeon as indicated by the standard views (incomplete or inadequate radiographs) or by clinical suspicion because of persistent symptoms or neurologic deficits.

RESULTS

In all, 140 patients (38%) sustained an injury of the upper cervical spine (C1/C2), 212 patients (58%) an injury of the lower cervical spine (C3–C7), and 15 patients (4%) suffered from a combined injury of the upper and lower cervical spine.

Clinical records showed several mechanisms of injury. The injuries resulted from car or motorcycle accidents in 44%, falls in 22%, jumps into shallow water in 15%, various sports activities in 8%, scuffles in 1%, and from other mechanisms in 9%. Fifty-three patients (14%) came in walking, 138 patients (38%) were brought in by ambulance, 66 patients (18%) by emergency car or emergency helicopter, and 110 patients (30%) were transferred from other hospitals.

Forty-nine percent of the cervical spine injuries occurred isolated or combined with insignificant concomitant injuries (e.g., grazes, bruises, etc.) and 51% in combination with other severe injuries. In all, 222 patients (60%) were fully conscious during primary evaluation and examined both clinically and neurologically. Also, 145 patients (40%) had an alteration of their mental status so that clinical and neurologic evaluation was not reliable.

The overall incidence of neurologic deficits was 38% (n = 140). One patient showed motor deficits, 14 patients incurred sensory deficits, and 58 patients had motor and sensory deficits. Sixty-seven patients (18%) showed a complete tetraplegia.

In all, 185 patients (50%) were treated conservatively, 182 patients (50%) submitted to an operation, 325 patients (89%) were admitted to the ward, and 42 patients (11%) remained outpatients. One hundred twenty-four patients (34%) required intensive care treatment. The average duration at ICU was 15.3 days.

Forty-nine patients (13%) died: 16 because of the cervical spine injury, nine as a result of multiple injuries, nine because of a severe brain injury trauma, and 15 patients because of other reasons.

The analysis of clinical records revealed that 18 patients (4.9%) had delayed or missed diagnosis of their cervical spine injuries. The 18 diagnostic failures concerned 7 female and 11 male patients with an average age of 46.6 years (3.6–88.9 years). Seven delayed diagnoses occurred at the upper cervical spine, nine at the lower cervical spine, and two occurred in combined injuries of the upper and lower cervical spine (Fig. 1).

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[Email Jumpstart To Image] Fig. 1. Delayed diagnosis: distribution.

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The missed injuries of the upper cervical spine consisted of five fractures of the odontoid process, one Jefferson fracture, and a slightly displaced fracture of C2. The missed injuries of the lower cervical spine comprised a fracture of C4, two displaced fractures of C5, two fractures of C6, one displaced fracture of C7, and three discoligamentous instabilities. In the two patients with combined injuries of the upper and lower cervical spine level, once a fracture of C2 and C3 was missed and once a fracture of the atlas and C5 was failed to diagnose.

In eight cases (44%), delayed diagnosis was found to be the result of a misinterpretation of the standard radiographs (Fig. 2). Junior staff responsible for initial radiologic examination failed to diagnose the injuries. In six cases, correct diagnosis was made later on from the standard radiographs by more experienced senior surgeons following the control mechanism of the unit. Experienced staff evaluated all plain radiographs secondarily within 24 hours. In two cases, the injury was diagnosed after performing a CT scan because of continuous neck pain.

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[Email Jumpstart To Image] Fig. 2. Diagnostic failures: causes.

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In five cases (28%), incomplete sets of radiographs were responsible for delayed diagnosis (Fig. 2). Three discoligamentous injuries were missed because no functional flexion/extension views were performed. One of the patients had an isolated discoligamentous injury. He was polytraumatized and unconscious as a result of a severe brain injury during primary examination. Clearing the cervical spine with complete sets of standard radiographs and CT scan did not show the extent of the injury. After regaining consciousness, the patient had a complete tetraplegia. Functional flexion/extension views and MRI were ordered showing the discoligamentous injury. The other two patients sustained discoligamentous injuries combined with fractures at the lower cervical spine. The fractures were diagnosed during primary radiologic examination, but the discoligamentous instabilities were missed. Finally, in both cases the discoligamentous injuries were identified by functional flexion-extension views after the spinal precautions were discontinued. In the other two cases with incomplete sets of radiographs, fractures were missed because only a lateral view of the cervical spine was performed during initial evaluation. Both patients were polytraumatized and primary examination focused on other severe injuries. Correct diagnosis was made after performing complete sets of standard radiographs in one case and by autopsy in the other case.

In four cases (22%), the injury was missed because inadequate radiographs did not show the level of the injury (Fig. 2). All four delayed diagnosis occurred at the lower cervical spine level. Performing proper x-ray views was difficult because of degenerative spine disease, severe neck pain, or altered mental state. In two cases, correct diagnosis was made by a CT scan, in one case by tomography, and in another case after repeating standard radiographs.

In one case (6%) of delayed diagnosis, the injury was missed because the treating surgeon did not see the radiographs (Fig. 2). The patient returned later on with increasing neck pain. Correct diagnosis could then be made by another surgeon who checked the initial radiographs.

An appropriate clinical and neurologic evaluation of the patients was not possible in eight cases (44%). Five patients suffered from an altered mental state because of other severe injuries, two patients because of alcohol or drug usage. Six patients (33%) had other severe injuries that were focused on during initial evaluation. Immediate lifesaving measures for other injuries were necessary in three patients.

Correct diagnosis was made by senior surgeons following the control mechanism of the unit in seven cases. In four cases, the injury was diagnosed by a CT scan, in three cases by performing functional flexion/extension views, and in two cases after repeating standard radiographs. Once the injury was diagnosed by a conventional tomography and once by an autopsy (Fig. 3).

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[Email Jumpstart To Image] Fig. 3. Correct diagnosis.

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Seven (39%) of the 18 patients with delayed diagnosis remained outpatients after primary trauma evaluation. In four of them, correct diagnosis was made within 24 hours following the control mechanism of the unit. All four patients were informed to come in immediately. In the other three cases, correct diagnosis was made within a week after trauma, after patients had returned because of increasing neck pain and/or neurologic deficits.

Eleven patients (61%) with delayed diagnosis of their cervical spine injuries were admitted to the ward because of other injuries. In eight cases, correct diagnosis was made during stationary treatment after patients had complained about increasing neck pain or after developed neurologic deficits. In five of them, correct diagnosis was made within a week after trauma; in three of them, correct diagnosis was made after 10 to 15 days. In three cases, correct diagnosis was made after patients had been discharged. All of them returned with increasing neck pain or neurologic symptoms. In two of them, correct diagnosis was made within a week after trauma; in one of them, it was made after three weeks.

Complications attributed to delayed or missed diagnosis occurred in eight patients (44%), ranging from motor and/or sensory neurologic deficits to complete tetraplegia. Six patients had neurologic deficits during primary evaluation and developed progressive deficits subsequently. One patient returned with incipient neurologic deficits after being discharged. In one case, a polytraumatized and initially unconscious patient showed a complete tetraplegia after regaining consciousness. Finally, in six of those eight patients, we saw a complete recovery of neurologic function after change of treatment. In two patients, neurologic deficits resolved incompletely.

A change of treatment was necessary in 15 patients (83%). Seven patients underwent operative treatment after correct diagnosis had been made. In two patients, anterior cervical fusion was performed; posterior cervical fusion was performed in five patients. Eight patients were treated conservatively either by a halo brace (n = 3) or a cervical collar (n = 5).

Two patients (11%) died, but neither because of the cervical spine injury.

DISCUSSION

The incidence of delayed or missed diagnosis of cervical spine injuries is between 5 and 20%.1–3 Previous works have shown that common reasons for delays in diagnosis are radiologic misinterpretation, incomplete sets of radiographs, or inadequate radiographs.1,2 An inappropriate clinical and neurologic evaluation of the patients is another common problem for diagnostic pitfalls. This problem mainly appears in patients with an altered mental state or in patients with other severe injuries.4,5

The results of this retrospective study show an incidence of delayed diagnosis of 4.9%. Comparing to previous studies, the incidence rate at this trauma unit was relatively low, but the causes for delays in diagnosis appear not to have changed in the last 10 to 15 years.

An analysis of causes demonstrate that we had three main reasons for delayed or missed diagnosis at the cervical spine: (1) lack of experience in evaluating the radiographs leading to misinterpretation, (2) inadequate radiographs, and (3) incomplete sets of radiographs.

The most common cause of missed cervical spine injuries was a misinterpretation of the standard radiographs. In eight cases (44%), injuries were not detected because inexperienced junior staff responsible for initial radiologic examination failed to make the correct diagnosis. This requires establishing a policy for the department. More experienced senior surgeons are expected to evaluate all radiographs secondarily. In our patients, this helped to detect six primarily missed cervical spine injuries within 24 hours.

Incomplete sets of radiographs ranked as the second most common cause of missed cervical spine injuries. This error was responsible for five (28%) of 18 delayed diagnosis. In three cases, discoligamentous injuries were missed because no functional flexion/extension views were performed during initial examination. The functional flexion/extension views were made delayed (after spinal precautions were discontinued) because the patients had complained about continuous neck pain or neurologic deficits. In all three patients, the functional flexion/extension views showed discoligamentous instability of the cervical spine that was missed primarily. We recommend performing functional flexion/extension views as obligate completion to a three-view cervical-spine series (anteroposterior, lateral, and open mouth) in awake patients after excluding unstable bony injuries in the standard series. In comatose patients, flexion-extension studies are potentially dangerous to the unprotected spinal cord. If functional flexion/extension views are performed, strict adherence to an established guideline, including repeated review of the cervical spine radiographs by an experienced reviewer as well as complete visualization of the entire cervical spine, is necessary to ensure safety of the patients. If this protocol is obtained and patient safety can be ensured, flexion/extension studies appear to be an effective method to detect occult discoligamentous injuries. In patients with a suspected injury in the standard series, flexion/extension views should be avoided until the extent of the injury can be measured by cervical CT scan.

In two cases, bony injuries were missed because only a lateral view was made during initial examination in the trauma room. Both patients were severely injured and livesaving measures were focused on initially. Following several studies reporting that a lateral cervical spine view alone is associated with delays in diagnosis in 15% of patients with cervical spine injuries, we also recommend performing further standard radiographs to a complete three-view cervical-spine series after treatment of life-threatening injuries to improve sensitivity in detecting cervical spine injuries in these patients before they leave the trauma room.2,6–9

In four cases (22%), inadequate radiographs were responsible for delays in diagnosis. Injuries were missed either because the x-ray field did not show the level of the injury or because of the poor technical quality of the radiographs. All four delayed diagnosis occurred at the lower cervical spine, where it might be difficult to perform proper x-ray views. Particularly in patients with preexisting degenerative spine disease or severe neck pain, as we found it in this study, further radiologic examination (CT scan, tomography) might become necessary for complete visualization of the cervical spine. This helped in our cases to detect all four cervical spine injuries that were missed primarily.

Severely injured patients as well as patients with an altered mental status pose a further diagnostic problem because clinical and neurologic evaluation is often not reliable.2,4,5

In eight cases (44%), an appropriate clinical and neurologic evaluation of the patients was not possible at all. Five patients had an altered mental status because of other serious injuries, three patients because of alcohol or drug abuse. Finally, we had four patients with neurologic deficits that were missed primarily. We recommend that patients with altered mental status should remain in cervical spine precautions until they are awake and alert.1 A cervical collar might be indicated until a careful clinical and neurologic evaluation of these patients is completed.

Six patients (33%) had other serious injuries that were focused on during initial examination. Immediate lifesaving measures were necessary in three cases. Two patients only got a lateral view of the cervical spine and the injury was missed. In these cases, we recommend complete sets of cervical-spine radiographs before initial examination is completed and patients can leave the trauma room.

As our results show, most errors leading to delayed or missed diagnosis of cervical spine injuries were fundamental and did not require advanced diagnostic technology. For optimal examination of patients with suspected cervical spine injuries, we recommend establishing a specific diagnostic algorithm including physical examination, standard radiographs, and further radiologic evaluation (CT scan, MRI) as indicated (Figs. 4 and 5).

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[Email Jumpstart To Image] Fig. 4. Diagnostic algorithm in alert patients.

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[Email Jumpstart To Image] Fig. 5. Diagnostic algorithm in patients with altered mental status.

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For standard radiologic evaluation of the cervical spine, we recommend a three-view cervical spine series (anteroposterior, lateral, and open-mouth) followed by functional flexion-extension views. Some studies suggest that three-view cervical-spine series are limited and that improved sensitivity would be obtained with a five-view series (oblique views added) as “golden standard.”2,8 However, those reports were disapproved by other studies indicating that most “false-negative” three-view cervical spine series were interpreted retrospectively by other surgeons or radiologists as being abnormal.1,10 McDonald et al., for example, stated that a complete three-view cervical-spine series would miss significant fractures in less than 1% of patients.5

In patients with clinically suspected cervical spine injuries or significant trauma history, cervical spine precautions should be maintained until the radiographs are evaluated by experienced reviewers.1 Correct interpretations of cervical spine radiographs can be difficult, particularly for junior staff with lack of experience in evaluating those radiographs. Only experienced trauma surgeons should decide on a removal or a continuation of the spinal precautions.

After excluding significant injuries in the three-view cervical-spine series, flexion-extension views might be obtained to detect suspected discoligamentous injuries. In responsive and awake patients, those studies should be considered as obligate completion to a three-view cervical-spine series, but in comatose or anesthetized trauma patients, passive flexion/extension views are not without risk for the spinal cord. In addition, previous studies report that flexion/extension studies are not routinely necessary to clear the cervical spine in unconscious patients because isolated discoligamentous injuries without fractures are a rare occurrence.11,12 However, other studies have introduced those views as a safe and effective method for detecting discoligamentous injuries after excluding significant bony injuries or an instability pattern in the standard radiographs.13,14 If functional flexion/extension views are to be obtained in unresponsive patients, strict adherence to established guidelines, including review of the cervical spine radiographs by a skilled reviewer as well as complete visualization of the entire cervical spine, is mandatory to ensure patient safety.13

To avoid delays in diagnosis by misinterpretation of the radiographs, experienced surgeons are required to evaluate all x-ray studies secondarily as soon as possible. This control mechanism is a certain policy of the department to detect suspected cervical spine injuries that were missed primarily.

A careful physical examination should be obtained in alert patients.1,8 Severe neck pain, tenderness on palpation, spasm on active motion, or neurologic deficits are clinical signs referring to a suspected cervical spine injury.8 A meticulous physical examination of those patients is certainly helpful in determining the risk of a cervical spine injury, although it might not result in better compliance from the x-ray technicians in getting all the necessary views.

Patients with altered mental state and significant history of trauma should remain in cervical spine precautions until they are awake and appropriate evaluation is possible.1

Further radiologic examination becomes necessary when indicated by the standard radiographs or by clinical suspicion. Computed tomography has become the most important area for improvement in cervical spine clearance using newer technology. We recommend the use of cervical CT scan by suggestion of an injury on the standard cervical-spine series or an incomplete visualization of the entire cervical spine in patients with significant history of trauma. A CT scan of the cervical spine is also obligate in patients with neurologic deficits and should be used more liberally in patients with preexisting cervical pathologic conditions and in patients with persistent symptoms.

In patients with neurologic deficits but negative radiographs and CT scans, we perform MRI to detect suspected discoligamentous injuries. MRI poses as a further area using newer technology in cervical spine clearance and will become definitely more important by increased availability and decreased costs.

SUMMARY

In conclusion, most errors leading to delayed or missed diagnosis of cervical-spine injuries were fundamental (misinterpretation of radiographs, incomplete or inadequate cervical spine series). A three-view cervical-spine series including functional flexion/extension views should be obtained for radiologic evaluation. In patients with significant symptoms or trauma history, cervical spine precautions should be maintained until evaluation of the patients is completed and radiographs have been interpreted by skilled reviewers. Patients with altered mental status should also remain in cervical spine precautions until they are awake to complete evaluation. Further radiologic examination using cervical CT scan becomes necessary when indicated by the cervical spine series or by clinical suspicion.

Combining a more meticulous physical examination, standard cervical spine series, and the more liberal use of cervical CT scan should improve the detection of cervical spine injuries. Regarding the fact that most errors leading to delayed or missed diagnosis were fundamental and did not require advanced diagnostic technology, an error rate of 4.9% appears to be improvable if a specific diagnostic algorithm with standard and supplemental diagnostic tools for cervical spine clearance is accepted and obtained.

REFERENCES

1. Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missed cervical spine injuries. J Trauma. 1993;34:342–346. Bibliographic Links [Context Link]

2. Gerrelts BD, Petersen EU, Mabry J, et al. Delayed diagnosis of cervical spine injuries. J Trauma. 1991;31:1622–1626. Bibliographic Links [Context Link]

3. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed spine fractures. J Trauma. 1987;27:980–986. Bibliographic Links [Context Link]

4. Alker GJ, OH YS, Leslie EV, et al. Postmortem radiology of head and neck injuries in fatal traffic accidents. Neuroradiology. 1975;114:611–617. [Context Link]

5. MacDonald RL, Schwartz MD, Mirich D, et al. Diagnosis of cervical spine injury in motor vehicle crash victims: How many x-rays are enough? J Trauma. 1990;30:392–397. Bibliographic Links [Context Link]

6. Doris PE, Wilson RA. The next logical step in the emergency radiographic evaluation of cervical spine trauma: The five-view trauma series. J Emerg Med. 1985;3:371–377. Bibliographic Links [Context Link]

7. Shaffer MA, Doris PE. Limitation of the cross table lateral view in detecting cervical spine injuries: A retrospective analysis. Ann Emerg Med. 1983;12:508–513. [Context Link]

8. Wales LR, Knopp RK, Morishima MS. Recommendations for evaluation of the acutely injured cervical spine: A clinical radiologic algorithm. Ann Emerg Med. 1980;9:422–428. Bibliographic Links [Context Link]

9. Committee on Trauma, American College of Surgeons. Chicago: Advanced Trauma Life Support, 1989:166–174. [Context Link]

10. Ross SE, Schwab CW, David ET, et al. Clearing the cervical spine: Initial radiologic evaluation. J Trauma. 1987;27:1055–1060. Bibliographic Links [Context Link]

11. Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma. 2001;50:1044–1047. Ovid Full Text Bibliographic Links [Context Link]

12. Pasquale M, Marion DW, Domeier RM, et al. Practice management guidelines for trauma: EAST ad hoc committee on guideline development: identifying cervical spine instability after trauma. J Trauma. 1998;44:945–946. [Context Link]

13. Davis JW, Parks SN, Detlefs CL, et al. Clearing the cervical spine obtunded patients: the use of dynamic fluoroscopy. J Trauma. 1995;39:435–438. Ovid Full Text Bibliographic Links [Context Link]

14. Sees DN, Rodriquez-Cruz LR, Flaherty SF, et al. The use of bedside fluoroscopy to evaluate the cervical spine in obtunded trauma patients. J Trauma. 1998;45:768–771. Ovid Full Text Bibliographic Links [Context Link]

Based on your lack of further responses in this thread I hope you actuallt read this far.

For everyone else, I hope this helps,

ACE844

[Ace844]

Here are a few more relevant studies as well..

(A Statewide @ Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol

[Original Articles)

Burton, John H. MD; Dunn, Matthew G. DO; Harmon, Nathan R. DO; Hermanson, Tari A. MD; Bradshaw, Jay R. EMT-P

From the Department of Emergency Medicine (J.H.B., M.G.D.), Albany Medical College, Albany, New York; the Department of Emergency Medicine (N.R.H., T.A.H), Maine Medical Center, Portland, Maine; and Maine Emergency Medical Services (J.R.B.), Augusta, Maine.

Submitted for publication September 21, 2004.

Accepted for publication April 7, 2005.

Presented at the Annual Meeting of the Society for Academic Medicine, May 15–19, 2004, Orlando, Florida.

Address for reprints: John H. Burton, MD, Department of Emergency Medicine, Albany Medical College, 43 New Scotland Avenue, MC 139, Albany, NY 12208-3479; email: burtonj@mail.amc.edu]

Abstract

Background: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization.

Methods: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures—stable and unstable—were the primary investigational outcomes.

Results: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7–92.3) with a negative predictive value of 99.9% (95% CI, 99.8–100).

Conclusions: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS- assessed trauma patients.

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Injury to the spine has been a topic of tremendous interest in the latter part of the 20th century.1–6 As an effort to affect the devastating outcome of neurologic disability sustained from traumatic spine injury, the practice of prehospital spine immobilization has been implemented. The decision by emergency medical service (EMS) providers to enact spinal immobilization procedures affects the treatment and transport of millions of prehospital trauma patients in the United States each year.

The EMS spine immobilization intervention involves immobilizing the head, trunk, and extremities of the injured patient by means of cervical collar and restraining devices attached to a long, rigid board. To date, there has been no randomized controlled trial to assess the effect of spinal immobilization interventions on trauma patient mortality, neurologic injury, spinal stability, or adverse effects sustained from this practice.6

The EMS approach toward the acutely injured trauma patient has traditionally emphasized the immobilization of all trauma patients with no processes or protocols for selective patient immobilization. This practice has been based upon the belief that EMS providers cannot safely discriminate between injured patients who do not have spine injuries and those patients with unstable spine fractures who may benefit from transport in a neutral, immobilized spine position or who are at risk for secondary spine injury.3,4,7,8

The objective of this study was to evaluate the practice and outcomes associated with a statewide EMS protocol for trauma patient spine assessment and selective prehospital patient spine immobilization. The investigational primary outcomes of interest were the incidence of spine fractures among EMS-assessed trauma patients in addition to the correlation between EMS provider spine immobilization decisions and the presence of spine fractures, categorized as stable or unstable.

PATIENTS AND METHODS

The study evaluated the use of a selective spine immobilization protocol for all prehospital patients during the study period of July 1, 2002 through June 30, 2003. The investigational period represented the first 12-month period following the implementation of the statewide EMS selective patient immobilization protocol. The authors' Institutional Review Board for Research on Human Subjects and the State EMS Medical Direction and Practice Board approved the study.

This state EMS system is primarily a rural EMS system with advanced life support and basic life support personnel. The EMS providers in this state treat patients according to a statewide set of standardized treatment protocols. A physician Medical Direction and Practice Board derives and administers these protocols.

Prehospital providers document EMS patient encounters on standardized data collection sheets that are entered into a health records database and maintained by the state Health Information Center. The data entered include patient demographics, presumed injury type or illness, vital signs, physical assessment, and prehospital patient interventions and management. For prehospital spine immobilization management, the EMS data collection sheet includes indicators for the use of cervical spine immobilization (rigid cervical collar), spine long-board, and the Kendrick extrication device (KED).

Interventions

Before July 1, 2002, a spinal assessment protocol was in place for approximately 8 years. This EMS spine assessment protocol was revised by the state EMS Medical Direction and Practice Board over an approximately 18-month period and implemented by prehospital providers July 1, 2002. The revised spine assessment protocol (Fig. 1) implemented a “NEXUS-like” decision instrument, adapted from a previously published cervical spine assessment decision rule intended for physician use in the evaluation of acutely injured trauma patients.9

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Fig. 1. Prehospital EMS spine assessment protocol. Mechanism of injury: axial load (diving), blunt trauma, MVC (crashes of all motorized vehicles: e.g. automobile, motorcycle, snowmobile, etc.) or bicycle, fall >3 ft, adult fall from standing height. Clearance of the spine requires the patient to be calm, cooperative, sober, and alert. Distracting injury includes any injury that produces clinically apparent pain that might distract the patient from the pain of a spine injury.

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Teaching of the revised spine assessment protocol began approximately 12 months before the July 1, 2002 implementation date. The revised protocol, teaching slides, student learning materials, and a “frequently asked questions” resource were placed on the state EMS website as well as widely circulated and integrated into EMS personnel education activities. The spine assessment and immobilization curriculum for the state EMS provider consists of didactic presentation methods as well as patient-based scenario training. At the time of the spine assessment protocol implementation, all state and regional EMS offices included quality assurance reviews and training to ensure the adoption and practice of the selective spine immobilization protocol.

All EMS patient information, including spine immobilization interventions, were prospectively reported by EMS providers into the state EMS database as described above. This database was queried by study investigators and imported into an investigational database for the purposes of linkage with hospital data from the Maine Health Data Organization (MHDO).

The MHDO is a state legislature–established agency that attempts to establish uniform systems for health care data reporting with required submission by medical payors and providers within the state. Data elements within the MHDO database include International Classification of Diseases, 9th Clinical Modification (ICD-9) diagnosis and procedure codes, diagnosis-related group (DRG) information, expected source of payment, patient disposition, and several demographic variables.

The MHDO database was queried for patient encounters during the study period with ICD-9 diagnostic coding specific for the presence of any spine fracture. This selected data file was then subjected to a database linkage methodology with the state EMS data file.

Linkage between the two files utilized patient date of birth as the primary coding element to match cases. Once matching date of birth encounters were identified, secondary coding elements of sex and date of patient encounter were used to verify the validity of the matched dataset. Patient encounters were evaluated for patients transported by EMS providers between healthcare facilities as well as duplicate EMS transports of an individual subsequent to an initial spine fracture encounter.

Study Measurements and Outcome Variables

Primary outcome variables selected a priori included the incidence of spine fractures among EMS-assessed trauma patients in addition to the correlation between EMS provider spine immobilization decisions and the presence of spine fractures, categorized as stable or unstable. An unstable fracture was defined as any acute spine fracture requiring operative stabilization, identified in the study dataset by the presence of ICD-9 procedure codes.

The investigators categorized fractures based on injury stability, in preference to clinical significance. Recent investigations for emergency physician or trauma surgeon assessment of the patient with potential spine injury used a definition of clinically significant injury as a means for spine fracture categorization.9–11 We chose to categorize spine injuries as stable or unstable because of the rationale traditionally applied to the importance of prehospital spine immobilization for prevention of secondary injury or exacerbation of primary spine injury in the patient with an unstable spine injury.4,7,8

Following the successful linkage of EMS patient encounters with spine fracture findings, the EMS patient record was individually reviewed with attention to the EMS provider's handwritten report of the encounter. This narrative section of the EMS report was assessed for spine immobilization decisions or factors that would contribute to the data assessment for each patient, in addition to any discrepancy between the EMS run report and the written narrative.

Data Analysis

Linkage of study data took place in a blinded fashion, with study investigators unaware of the presence of patient fracture(s) during the data linkage between patient injuries and immobilization decisions. Measurements are reported using descriptive statistics with 95% confidence intervals (CIs) reported when appropriate. Selected continuous variables are reported as mean ± SD (SD). The software package utilized for data collection and analysis was SPSS 11.0 (SPSS Inc., Chicago, IL).

RESULTS

EMS Encounters and Immobilization Decisions

Prehospital EMS patient encounters during the study period are displayed in Figure 2. For the 31,885 patients categorized as trauma-related encounters, age was a reported variable for 31,881 encounters with a mean 48.1 ± 26.7 years (range 0–109 years). Prehospital providers reported patient sex in 31,780 encounters with patients categorized as male in 45.2% of encounters.

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[Email Jumpstart To Image] Fig. 2. Patient encounters documented within the EMS and hospital databases during study period of July 2002 to June 2003.

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Prehospital providers documented a decision to enact spine immobilization for 12,985 (40.7%) trauma-related patients (Table 1). This population consisted of 10,288 (79.2%) patients immobilized with cervical collar and long spine board, 946 (7.3%) patients immobilized with KED as a supplement to cervical collar and long spine board, and 1,751 (13.5%) patients with only one of these three devices or another combination with two of the three devices.

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[Email Jumpstart To Image] Table 1 EMS Provider Spine Immobilization Intervention and Presence of Acute Spine Fracture Injury in the Study Population

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Motor vehicle crash (MVC) trauma was documented as the mechanism of injury in 9,063 (28.4%) patients. This group was comprised of the following incident subcategorizations: 7,834 automobile or truck, 394 motorcycle, 197 snowmobile, 196 all-terrain vehicles, 197 pedestrian versus motor vehicle, 204 bicycle, 34 marine craft, and 7 aircraft. For the MVC cohort, 6,410 (70.7%) patients had documented immobilization with one or multiple devices. The following interventions were documented in this group: 5,232 (81.6%) patients immobilized with cervical collar and long spine board, 755 (11.8%) patients immobilized with KED as a supplement to cervical collar and long spine board, and 423 (6.6%) patients with only one of these three devices or another combination with two of the three devices.

Hospital Spine Fracture Patients

During the investigational period, there were 846 diagnostic spine fracture encounters in the MHDO database (Fig. 2). The spine fracture encounters included patients assessed by EMS providers on the initial and, in some cases, subsequent healthcare visits. This total also included patients who were not transported by EMS providers as well as patients with no acute trauma-related event.

EMS-Transported Spine Fracture Patients

The acute spine fracture incidence among all EMS trauma patients was 0.48%. The mean age of this spine fracture cohort was 48.7 ± 24.0 years (range 14–95 years). The anatomic location of the 154 EMS spine fracture patients included 47 (31%) cervical, 43 thoracic (28%), and 64 (41%) lumbar fractures. In all, 134 (87.0%) spine fracture patients were documented by EMS providers as undergoing spine immobilization interventions (Table 1).

All unstable spine fracture patients were immobilized by EMS providers except one patient, an 86-year-old female who had moved a piece of furniture resulting in subsequent back pain (Table 2 and 3). This ambulating patient called EMS providers for transport 1 week after her injury. The patient was diagnosed with T6/7 subluxation with no spinal cord injury with operative fusion as her stabilization treatment.

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[Email Jumpstart To Image] Table 2 EMS Provider Spine Immobilization Intervention and Presence of Acute, Unstable Spine Fracture Injury in the Study Population

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[Email Jumpstart To Image] Table 3 Twenty Trauma Patients with Acute Spine Fracture Transported by EMS without Documentation of Spine Immobilization

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The characteristics of the 20 nonimmobilized spine fracture patients are reviewed in Table 3. Patients in this group had a mean age of 73.2 ± 21.5 years (range 24–95 years). The performance of the EMS clinical assessment protocol for immobilization of spine fracture patients, both stable and unstable, is presented in Table 4.

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[Email Jumpstart To Image] Table 4 Performance of the EMS Clinical Spine Assessment Protocol for Immobilization of Trauma Patients with Acute Spine Fracture

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DISCUSSION

Our findings demonstrate that EMS providers were able to evaluate acutely injured prehospital trauma patients with a four-step clinical assessment protocol and discriminate between patients likely to benefit from spinal immobilization interventions and patients without unstable spine injury. The use of this EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma patient encounters.

The practice of prehospital spine immobilization has been adopted as a standard EMS practice for trauma patients in the United States of America and many other countries. The historical basis for application of spine immobilization devices has promoted the prevalence of unstable spine and spinal cord injuries as being sufficient to merit routine application of this intervention. The core of this rationale has been the assumption that prehospital medical provider movement of unstable spine-injured patients can inflict primary spinal cord injury or exacerbate existing spinal cord injury (secondary injury).

Two theories predominate regarding trauma to the spine and the potential for subsequent spinal cord injury at the hands of prehospital providers. One theory suggests that initial trauma to the spine is solely responsible for cord injury with subsequent care and treatment representing minimal risk of further injury—providing that major axial or rotational loading is minimized.2 Injury attributed to the immobilization intervention—including pain and discomfort, pressure sore development, respiratory compromise, and inadequate spine immobilization—is cited as a substantial consequence that outweighs the potential benefit derived from routine EMS immobilization of trauma patients.5

The competing premise submits that spine movement during EMS evaluation and transport may directly injure or contribute to the exacerbation of the initial trauma insult by inflicting secondary cord injury.3,4 The proponents of this view have advocated for EMS provider-applied spine immobilization as essential to prehospital secondary injury prevention. These proponents have also cited the potential for delayed development of signs and symptoms of spinal cord injury as a rationale for immobilization of trauma patients until definitive clinical and/or radiographic assessment is completed in the hospital setting.3,4,7,8

The EMS provider's decision not to immobilize patients in this investigation may not reflect an absence of findings with the spine immobilization protocol. Prehospital providers may have selectively enacted immobilization procedures based on undocumented elements including patient refusal, patient age, or injury circumstances.

The majority of nonimmobilized spine fracture patients were older patients (greater than 65 years of age) who suffered fractures of the lumbar and thoracic spine. This finding may suggest an EMS provider suspicion of lower risk for unstable injury in these spine segments, in preference to the cervical spine. Alternatively, patient immobilization on long spine boards is well recognized as uncomfortable for patients, with back pain inflicted by the immobilization intervention directly proportional to the amount of time restrained by these devices.5,12,13 Prehospital providers may have suspected that increased patient pain resulting from the use of an immobilization board would exceed the potential benefit derived from immobilization or the risk of an unstable spine injury.

The presence of fractures in older patients in the study may suggest a reluctance of EMS providers to enact spine immobilization decisions for this population or increased patient refusals. Recently, published cervical spine clinical assessment criteria have excluded patients older than 65 years of age from the clinical assessment population.10 Other investigators have noted that patients over 60 years of age have an overall lower incidence of cervical spine fractures, despite an increased propensity for fracture at C1 or C2.14 If this exclusion were applied to our study population, 16 of 20 nonimmobilized spine fracture patients would have undergone prehospital immobilization, including the single nonimmobilized unstable fracture patient—changing the sensitivity of the protocol to 97.4% for all spine fracture patients and 100% for unstable fracture patients.

During the investigational period, 10,084 of the assessed trauma patients were older than 65 years with 72.5% of these individuals undergoing no spine immobilization intervention. With a protocol that excluded these patients from selective spine immobilization, an additional 7,294 patients older than 65 years of age without spine fracture would have undergone immobilization.

Previous literature from trauma surgery, radiology, physiatry, and emergency medicine has addressed groups of patients suffering cervical spine fracture as an attempt to classify those at risk for spine injury and requirement of radiographic evaluation.3,9,10,15–18 Many investigators and position papers have included mechanism of injury as an independent variable to prompt radiographic evaluation of the trauma patient spine.4,9,15 Other authors have noted a lack of correlation between mechanism of injury and likelihood of cervical spine injury.9,17,19,20 We elected not to utilize mechanism as a criterion for the EMS provider decision to immobilize prehospital patients. Our study methodology did not allow an opportunity to discern patients that may have been immobilized, with cervical collar or other devices, upon arrival at the destination hospital. Therefore, we were not able to review the physician practices and decision-making with regard to immobilization and radiologic imaging of the spine during the course of the hospital visit. Similarly, we were unable to discern the impact of the EMS spine immobilization protocol on physician behavior.

We hypothesized that the clinical application of the NEXUS cervical spine assessment findings could be generalized to prehospital patients.9 We also hypothesized that the validity of the cervical spine assessment could be applied to patients with potential thoracic and lumbar spine injury. A retrospective review of prehospital indicators for spinal immobilization (alteration in mental status, evidence of intoxication, spine pain or tenderness, neurologic deficit, and/or sign of distracting injury) similar to our protocol demonstrated sensitivities of 100%, 99%, and 97% for cervical, thoracic, and lumbar fractures, respectively.12 This investigation was followed by a multicenter, observational validation in the ED setting in which 94.9% of fractures were identified.1

Limitations of the current study include chart review, identification, and dataset linkage methodology. Fracture descriptors were limited by the implemented ICD-9 identification of injuries. Therefore, we are unable to describe fractures (e.g., compression, transverse process; single-column, two-column, etc.) within the investigation beyond the study definition of unstable versus stable injuries. There may have been fractures deemed clinically unstable during the investigational period that did not undergo surgical stabilization procedures such as cervical collar, thoracolumbar orthosis (TLSO) brace, or activity restriction that were not captured by the ICD-9 procedure codes.

The state EMS database does not categorize the licensure level (i.e., paramedic, Basic Life Service [bLS], Advanced Life Service [ALS]) of the involved EMS provider(s) for any given prehospital encounter report. As a result of this limitation, we were unable to assess any potential impact of the EMS provider training level on the spine immobilization decision. The majority of EMS agencies in this state utilize a prehospital provider workforce with a combination of BLS-trained individuals and ALS-trained individuals for each encounter. The spine assessment protocol did not have separate teaching or implementation practices based on provider licensure level.

The 0.5% fracture incidence observed in this study is substantially lower than the 2.0% to 3.3% incidence described in recently published emergency department-based study populations from predominantly urban, tertiary-care centers.1,9,10 We believe that the lower fracture incidence in this study accurately reflects the frequency of traumatic spine fractures assessed by EMS providers in a large state that is predominantly rural in character.

Future investigations should focus on the apparent paradox of the older prehospital trauma patient during EMS evaluation and treatment. This group of patients appears to be at risk for a decision not to utilize spinal immobilization procedures, despite the presence of an acute fracture. However, the potential for injury incurred from the immobilization intervention is likely higher with the older patient given the prevalence of degenerative changes to the spine. Additionally, the enhanced likelihood of fracture from smaller energy mechanisms (e.g., fall from a standing height) may also decrease the potential for unstable injury and the potential benefit of spine immobilization in these patients.

In summary, the use of this prehospital EMS spine assessment protocol affected a decision not to immobilize greater than half of all trauma patients in this predominantly rural state. The presence and described accuracy of this EMS protocol did not appear to place trauma patients at substantial risk of adverse neurologic outcome as a direct consequence of the selective patient spine immobilization decision.

ACKNOWLEDGMENTS

We would like to acknowledge Jeri Kahl for her assistance with EMS record retrieval and run report analysis. Gene Stanton was instrumental in his assistance with interpretation and integration of the state's Health Data Organization. The assistance of many individuals throughout this state's emergency medical service organizations is gratefully acknowledged.

REFERENCES

1. Domeier RM, Swor RA, Evans RW, et al. Multicenter prospective validation of prehospital clinical spinal clearance criteria. J Trauma. 2002;53:744–750. Ovid Full Text Bibliographic Links [Context Link]

2. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5:214–219. Bibliographic Links [Context Link]

3. Sonntag VK, Douglas RA. Management of cervical spinal cord trauma. J Neurotrauma. 1992;9 Suppl 1:S385–S396. Bibliographic Links [Context Link]

4. Hadley MN. Injuries to the cervical spine. In: Rengachary SS, Wilkins RH, eds. Principles of Neurosurgery. London, England: Mosby Year-Book Europe;1994:20.1–20.6. [Context Link]

5. Vickery D. The use of the spinal board after the prehospital phase of trauma management. Emerg Med J. 2001;18:51–54. Buy Now Bibliographic Links [Context Link]

6. Kwan I, Bunn F, Roberts I. Spinal immobilization of trauma patients. Cochrane Database of Systematic Reviews. 2001;2:CD002803. Bibliographic Links [Context Link]

7. Ducker TB, Salcman M, Perot PL Jr, Ballantine D. Experimental spinal cord trauma, I: Correlation of blood flow, tissue oxygen and neurologic status in the dog. Surg Neur. 1978;10:60–63. [Context Link]

8. Ducker TB, Salcman M, Daniell HB. Experimental spinal cord trauma, III: Therapeutic effect of immobilization and pharmacologic agents. Surg Neur. 1978;10:71–76. [Context Link]

9. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Study Group. N Engl J Med. 2000;343:94–99. Ovid Full Text Bibliographic Links [Context Link]

10. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian cervical spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–1848. [Context Link]

11. Hoffman JR, Wolfson AB, Knox T, Mower WR. Selective cervical spine radiography in blunt trauma: Methodology of the national emergency radiography utilization study (NEXUS). Ann Emerg Med. 1998;32:461–469. Bibliographic Links [Context Link]

12. Domeier RM, Evans RW, Swor RA, Rivera-Rivera EJ, Frederiksen SM. Prehospital clinical findings associated with spinal injury. Prehosp Emerg Care. 1997;1:11–15. Bibliographic Links [Context Link]

13. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23:48–51. Bibliographic Links [Context Link]

14. Prasad VS, Schwartz A, Bhutani R, Sharkey PW, Schwartz ML. Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Spinal Cord. 1999;37(8):560–568. Bibliographic Links [Context Link]

15. Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical Spine Imaging in Patients with Trauma: Determination of Fracture Risk to Optimize Use. Radiol. 1999;211:759–765. [Context Link]

16. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical Spine Injury: A Clinical Decision Rule to Identify High-Risk Patients for Helical CT Screening. Am J Roentgenol. 2000;174:713–717. Bibliographic Links [Context Link]

17. Patton JH, Kralovich KA, Cuschieri J, Gasparri M. Clearing the cervical spine in victims of blunt assault to the head and neck: what is necessary? Amer Surg. 2000;66:326–330. Bibliographic Links [Context Link]

18. Touger M, Gennis P, Nathanson N, et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med. 2002;40:287–293. Bibliographic Links [Context Link]

19. American College of Surgeons. Advanced Trauma Life Support Student Manual. Chicago, IL: American College of Surgeons;1997:242. [Context Link]

20. Domeier RM, Evans RW, Swor RA, et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999;3:332–337. Bibliographic Links [Context Link]

(Thoracolumbar Fracture in Blunt Trauma: Is Clinical Exam Enough for Awake Patients?

[Original Articles)

Sava, Jack MD; Williams, Michael D. MD; Kennedy, Susan RN; Wang, Dennis MD

From the Washington Hospital Center (J.S.), Washington, DC.

Received for publication August 8, 2005.

Accepted for publication March 22, 2006.

Presented as a poster at the 63rd Annual Meeting of the American Association for the Surgery of Trauma, September 29–October 2, 2004, Maui, Hawaii.

Address for Reprints: Jack Sava, MD, Division of Trauma, Washington Hospital Center Room 4B-39, 110 Irving St NW, Washington, DC 20010; email: jack.a.sava@medstar.net.]

Abstract

Background: Physical examination is widely used to screen trauma patients for thoracolumbar fracture (TLFx). Retrospective data suggests that patients with altered sensorium may not manifest symptoms after TLFx. This study was designed to prospectively test the sensitivity of physical examination for detection of TLFx in patients with altered mentation.

Methods: Prospective data collection in a large urban Level I trauma center from April 2002 to December 2003. During the study period, thoracolumbar radiography was performed on patients with signs or symptoms of TLFx, and also on patients with significant blunt trauma and any alteration in mentation, including drowsiness or apparent intoxication. All patients were classified as reliable if Glasgow coma score was >13 and the treating physician judged them capable of accurately reporting pain, and those who did not met both these conditions were deemed unreliable. Patients with normal mentation and no signs or symptoms were excluded. Injuries, mental status, symptoms, physical examination, and X-ray film results were recorded.

Results: There were 3,028 blunt trauma patients evaluated during the study period. Thoracolumbar radiography was performed on 537 patients. Of these, 442 patients were deemed reliable, and 166 had no signs or symptoms of TLFx. Of these asymptomatic patients, 10 were found to have TLFx. Of these 10 reliable patients with TLFx despite negative examination, none required surgery, but four required a brace.

Conclusions: Thoracolumbar fractures are often clinically silent in blunt trauma patients with altered sensorium, even when they appear able to reliably report pain. X-ray screening of these patients is appropriate to prevent missed injury.

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There is general agreement that clinical examination alone cannot be used to rule out spinal fracture in obtunded patients. Conversely, alert unintoxicated patients with no distracting injuries are often selected for clinical spinal clearance. Between these two groups (the comatose and the unaltered) is a third group. These patients have slight alteration in mental status, whether mild intoxication, slight lethargy, or concussion. These patients are often conversant, and may appear fully capable of reporting pain. Many will calmly and reliably describe discomfort from other injuries, procedures, and needlesticks. This study was designed to prospectively test the reliability of clinical examination in detecting thoracolumbar fracture in these patients.

METHODS

Data were collected prospectively in a large urban Level I trauma center between April 2002 and December 2003. During the study, patients with signs or symptoms of TLFx after blunt trauma underwent thoracolumbar radiography. These signs and symptoms included back pain, midline back tenderness, spinal deformity, and subjective or objective peripheral neurologic deficits like paralysis, weakness, paresthesia, or numbness.

In addition, blunt trauma patients with any alteration in mentation (from deep coma to mild lethargy or ethanol use) also underwent thoracolumbar X-ray evaluation, regardless of the presence or absence of signs or symptoms. Altered mentation mandated radiography, even if the cognitive abnormality was subtle, and the patient subjectively seemed able to report pain. Patients with trivial blunt trauma or with a mechanism of injury not involving the torso were excluded. All patients undergoing thoracolumbar radiography were included in the study, whether the films were done for signs/symptoms or for abnormal mentation. Patients with no cognitive impairment whatsoever, and no signs or symptoms of TLFx did not undergo thoracolumbar radiography, and were not included in the study.

At the time of initial evaluation, all patients in the study were evaluated by senior surgical residents or attendings using a worksheet. In addition to demographic information, injuries, physiologic data, and a complete thoracolumbar and neurologic examination, the worksheet documented several variables related to the patients' reliability. These included Glasgow Coma Score (GCS), suspected intoxication, brain injury, distracting torso injuries, and the evaluator's subjective answer to the question “Do you think that this patient is able to reliably report back pain?”

Each patient was classified as either reliable or unreliable. Patients were classified as reliable if Glasgow coma score was >13 and the treating physician subjectively judged them able to report pain reliably. Those who did not meet these conditions were deemed unreliable. Some patients who underwent thoracolumbar radiography because of subtly altered mentation (rather than getting the films because of signs or symptoms of TLFx) were nonetheless subjectively classified as reliable, presumably because their cognitive impairment did not seem to get in the way of clinical spinal examination. These 166 patients (asymptomatic, awake, and conversant, but subtly altered) were the specific subset of interest in this study, because they represent a group that would not necessarily have been evaluated radiographically before the institution of our protocol (Fig. 1).

The results of thoracolumbar radiographs were documented, along with details of the further evaluation, management, and outcomes of patients with spinal fractures. Since this project essentially tests the yield of performing additional X-ray screening on a group of patients who are asymptomatic and awake but subtly cognitively impaired, we calculated the number of screening thoracolumbar radiographs that would need to be done on patients in this category to discover one occult fracture. Using standard Medicare reimbursement rates for professional and technical fees, we calculated the cost of this additional screening as well.

RESULTS

There were 3,028 blunt trauma patients evaluated during the study period. Thoracolumbar radiography was performed on 537 patients (see Fig. 2). Among all study patients deemed reliable, bedside clinical examination identified 39 of 49 thoracolumbar fractures, yielding a sensitivity of 80%. The negative predictive value of clinical examination in these patients was 94% (156/166), reflecting the relative rarity of spinal injury. There were ten patients who were classified as reliable, had no signs or symptoms of TLFx, and were found to have thoracolumbar fractures (Table 1). Four of these patients were treated with a brace. None required spinal surgery.

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[Email Jumpstart To Image] Fig. 2. Outcomes of patients who underwent thoracolumbar radiography. Reliable patients had GCS > 13 and were subjectively judged reliable reporters of pain.

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DISCUSSION

Missed spinal fractures are among the most feared events in trauma care and may have tragic consequences. During 3 years of prospective data collection, Reid et al. found a delay in diagnosis in 22.9% of cervical spinal fractures, and 4.9% of thoracolumbar fractures.1 Of these patients with delayed diagnosis, 10.5% developed secondary neurologic deficits. Born et al. documented five missed spinal injuries over an 18-month period of data collection, despite an ongoing, protocol-driven study on missed fractures.2 A review of 147 patients diagnosed with thoracolumbar fractures by Dai showed that 19% had a delay in diagnosis.3

There are two critical questions with regard to the role of clinical examination in detecting spinal injury: First, is clinical examination adequately sensitive, and if so, in which patients can it reliably be used? There is substantial data, though largely retrospective, regarding the sensitivity of clinical examination in detecting thoracolumbar fracture in patients without neurologic impairment. A review by Samuels of 99 patients who had thoracolumbar X-rays found no fractures among asymptomatic patients when “clinical assessment was reliable”, though criteria for reliability were not provided.4 Meldon also found no asymptomatic thoracolumbar fractures in patients with normal sensorium.5

Likewise, a retrospective review by Durham et al.6 found no occult injuries in patients who were awake, alert, not intoxicated, and had no sign of injury. However, in this study, several occult thoracolumbar fractures were identified in patients who were awake, alert, and asymptomatic, but had used drugs or alcohol. Another retrospective review identified 13 of 181 patients with TLFx who had GCS of 15 and no clinical evidence of fracture. Eleven of these patients were critically injured, but the other two were stable at the time of examination.7

Several other studies suggest that clinical examination is substantially less sensitive when the examinee's sensorium is clouded by intoxicants, subtle cognitive impairment, or distracting pain. Cooper found occult thoracolumbar fractures in patients with GCS of 13 or 14, or major injury,8 as did a retrospective review by Meldon.5 Chang et al. studied patients who underwent spinal radiography because of distracting injuries, and found that bony injuries were particularly effective at masking TLFx pain.9

Retrospective study of any clinical examination technique suffers from one substantial limitation: the absence of documentation of a finding is equated with absence of the finding. This pitfall is especially important in studying occult injuries and missed fractures. The thorough evaluation of the back and extremities may fall to a relatively junior trauma caregiver, and may be perceived as “routine,” rather than critical. Subtle findings may be missed, or may not make it into the medical record. These factors would lead to an underestimation of the sensitivity of clinical examination. In contrast, in a busy emergency area, the results of preliminary radiographs may be available before documentation is completed. These X-ray results can bias the physical examination and its documentation.

The current study was done prospectively, and required a complete, template-guided examination on each patient. We did not study patients with unimpaired cognition and no signs or symptoms of TLFx. Instead, we focused on patients with cognitive impairment, whether from intoxication, brain injury, shock, or pain. We documented the type of cognitive impairment, its severity, and also a subjective statement by the treating physician as to whether he/she thought the patient could reliably report symptoms. The goal was to find the subset of patients that had some impairment, but were felt to be reliable because of a GCS of 14 to 15 and the subjective assessment of the treating physician. These are patients in whom one might be tempted to forgo radiographic screening of the TL spine.

Of the 442 reliable patients, 276 reported signs or symptoms of TLFx (Fig. 1). Of the remaining 166 reliable patients who had no signs or symptoms of TLFx, 10 fractures were found. None of these 10 patients required surgical stabilization, but four required a brace (Table 1). Our data suggests that among subtly impaired patients who appear subjectively reliable and have no clinical evidence of TLFx, radiography must be performed on sixteen patients to find one with occult fracture. Using an estimate of $60 (typical Medicare reimbursment for professional plus technical fees) per thoracolumbar radiographic series, identification of each occult fracture would cost $960.

One interpretation of this data are that no fracture requiring surgery was missed by clinical examination, and therefore clinical examination is adequate. This interpretation presumes that unstable fracture patterns can be relied upon always to produce symptoms. A less optimistic view is that whatever cognitive or neurologic derangement allows an awake patient to have an occult spinal fracture might exist in a patient with an unstable fractures requiring surgery. In this case, the absence of these injuries among the occult fractures we found would simply be because of sample size.

One explanation for missed fractures may lie in examination technique. In contrast to the cervical spine, range of motion is rarely part of the initial examination of the thoracolumbar spine. This may allow for more occult fractures than are commonly seen in the cervical spine. Furthermore, the logroll necessary for examination of the back may exacerbate pain from distracting injuries. Six of the 10 patients with occult injuries in our series had other potentially distracting truncal injuries. On additional patient had extremity injury, and the remaining three had no injuries apart from the thoracolumbar spine.

We recommend thoracolumbar spinal imaging in all patients with significant blunt trauma and any alteration in cognition, however slight. Even when these patients seem objectively and subjectively reliable, they frequently harbor occult thoracolumbar fractures that may require therapy.

REFERENCES

1. Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma. 1987;27:980–986. Bibliographic Links [Context Link]

2. Born CT, Ross SE, Liannacone WM, Schwab CW, DeLong WG. Delayed identification of skeletal injury in multisystem trauma: the ‘missed' fracture. J Trauma. 1989;29:1643–1646. Bibliographic Links [Context Link]

3. Dai LY, Yao WJ, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment: a review of 147 cases. J Trauma. 2004;56:348–355. Ovid Full Text Bibliographic Links [Context Link]

4. Samuels LE, Kerstein MD. ‘Routine' radiologic evaluation of the thoracolumbar spine in blunt trauma patients: a reappraisal. J Trauma. 1993;34:85–89. Bibliographic Links [Context Link]

5. Meldon, S. Moettus L. Thoracolumbar spine fractures: clinical Presentation and the effect of altered sensorium and major injury. J Trauma. 1995;39:1110–1114. Ovid Full Text Bibliographic Links [Context Link]

6. Durham RM, Luchtefeld WB, Wibbenmeyer L, Maxwell P, Shapiro MJ, Mazuski JE. Evaluation of the thoracic and lumbar spine after blunt trauma. Am J Surg. 1995;170:681–685. Bibliographic Links [Context Link]

7. Anderson S, Biros MH, Reardon RF. Delayed Diagnosis of thoracolumbar fractures in multiple-trauma patients. Acad Emerg Med. 1996;3:832–838. Bibliographic Links [Context Link]

8. Cooper C, Dunham M, Rodriguez A. Falls and major injuries are risk factors for thoracolumbar fractures: cognitive impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma. 1995;38:692–695. Ovid Full Text Bibliographic Links [Context Link]

9. Chang CH, Holmes JF, Mower WR, Panacek EA. Distracting injurie in patients with vertebral injuries. J Emerg Med. 2005;28:147–152. Bibliographic Links [Context Link]

[JPINFV]

Of course none of those goes into if full immbolization is actually helpful (see above study, plus these)

http://www.co-criticalcare.com/pt/re/cocri...9856145!8091!-1

Spinal immobilization in trauma patients: is it really necessary?

[Trauma]

Hauswald, Mark MD*†; Braude, Darren MD, MPH†‡§

*Office of Clinical Affairs, †Department of Emergency Medicine, ‡Lifeguard Air Transport, and §Emergency Medical Service Academy, University of New Mexico, Albuquerque, New Mexico, USA.

Correspondence to Mark Hauswald, MD, Office of Clinical Affairs, University of New Mexico Health Sciences Center, CRTC Room B-30, Albuquerque, NM 87131-5121, USA; e-mail: Mhauswald@salud.unm.edu

Abstract

The acute management of potential spinal injuries in trauma patients is undergoing radical reassessment. Until recently, it was mandatory that nearly all trauma patients be immobilized with a back board, hard cervical collar, head restraints, and body strapping until the spine could be cleared radiologically. This practice is still recommended by many references. It is now clear that this policy subjects most patients to expensive, painful, and potentially harmful treatment for little, if any, benefit. Low-risk patients can be safely cleared clinically, even by individuals who are not physicians. Patients at high risk for spinal instability should be removed from the hard surface to avoid tissue ischemia. Understanding the rationale for these changes requires knowledge of mechanisms of injury, physiology, and biomechanics as they apply to spinal injuries.

Abbreviations:EMS emergency medical service, NEXUS National Emergency X-Radiography Utilization Study

In the early days of trauma care, patients were brought to the hospital by any means available. Eventually, ambulances began transporting many of these patients but without providing medical treatment en route. It was not until the early 1970s that emergency medical technicians were routinely trained to provide care before the patient arrived at the hospital. Initially, the care provided was not based on direct evidence of efficacy; rather, it was based on reasonable assumptions and extrapolation from in-hospital treatment. Prehospital care came to include spinal immobilization based on the logical premise that some trauma patients had spinal injuries, and some of these injuries destabilized the spinal column. Deterioration of spinal cord injuries has been attributed to movement of these destabilized injuries after the initial event and before definitive fixation [1••], but this relationship is not well substantiated in the literature. Spinal immobilization offered the promise of preventing the exacerbation of devastating injuries with apparently little downside. Soon these practices became a fundamental tenet of trauma care. Spinal immobilization, however, has never been proven to prevent secondary spinal injury [2]. This dogma is now undergoing radical reassessment, and researchers are asking whether spinal immobilization is necessary in the routine early treatment of trauma patients [3].

The basis for this heresy lies in a reevaluation of the underlying mechanism for spinal cord injury. Permanent spinal cord injury requires partial or complete transection of the cord or axonal necrosis, which requires energy deposition within the cord or its blood vessels. Because most spinal cord injuries are the result of blunt trauma, this energy transfer occurs at the point of impact. Often there are several impacts involved. For instance, a patient may strike the windshield during a rapid deceleration motor vehicle collision and subsequently strike the pavement at a high rate of speed after ejection. At the time of impact, tremendous energy is transferred to the cord. In some cases, the cord is actually partially or completely transected by bone fragments or extreme movement of the bones out of their normal alignment. It seems intuitively unlikely that subsequent movement of the spine within its normal range of motion and essentially without resistance would add significantly to the damage already done. Cases of deterioration from movement of unstable spinal injuries during extrication, transport, and initial evaluation undoubtedly do occur, but it is clear from clinical experience and the literature that this is an uncommon problem. In fact, the only study that compared patients who were and were not immobilized during transport showed an increased risk of neurologic injury in the immobilized population [3].

The term unstable is used differently among different specialties and for different clinical situations. A patient may be at risk for neurologic deterioration for a variety of reasons and yet be mechanically stable. Other patients may be at risk for bony remodeling and physical deformity from long-term, unopposed gravitational force [4•] but may be both neurologically and mechanically stable in the short term. In most cases, the term unstable denotes injuries meeting the standard radiologic definition of two-column disruption [5]. This is a sensitive rather than specific definition; injuries that have two-column disruption may have no associated spinal cord injury and will not necessarily deteriorate from movement. The remainder of this report concerns injuries that have short-term biomechanical instability—that is, those that may result in increased neurologic injury if not protected during initial evaluation and treatment.

If it is assumed that spinal manipulation is not the major factor causing secondary injury, then how does one explain the clinical deterioration of spinal cord injury seen commonly in clinical practice? A variety of factors contribute to spinal cord ischemia, including vascular compromise, hypotension, hypoxia, edema, electrolyte shifts, free radical formation, and inflammatory mediators [6,7,8••]. Although it is clearly impossible to perform controlled trials comparing outcomes with and without these factors, strong evidence from animal models and clinical associations indicates that these factors are crucial determinants of final outcome.

This whole issue would be irrelevant if immobilization was benign, but it is not. Documented adverse effects include pain [9,10•], restriction of breathing [11–13], tissue ischemia [14] with resulting decubiti formation [15,16], and increased intracranial pressure [17–19]. Other adverse effects include difficult nursing care, increased risk of aspiration, increased ambulance transports, treatment and evaluation delays, increased radiographs, and increased costs.

Therefore, the answer to the title question is that spinal immobilization in trauma patients is necessary sometimes; however, this answer provides no practical guidance to the practitioner. The real issue is how harm to the patient can be minimized from underimmobilization or overimmobilization. The issue can be restated as several clinically relevant questions:

1. Which trauma patients might benefit from spinal immobilization during transport and initial evaluation?

2. How should these patients with possible unstable injuries be immobilized?

3. Which trauma patients require radiography in the emergency department?

4. How can the spine be cleared in the obtunded patient?

5. Are there special considerations for pediatric patients?

6. Are there significant differences between patients with blunt versus penetrating injury?

Which trauma patients might benefit from spinal immobilization during transport?

Traditional prehospital guidelines have called for the immobilization of any patient who has sustained a traumatic mechanism of injury with any potential for energy transfer to the neck. This practice is unnecessary [20]. Some emergency departments routinely perform radiographs on anyone who arrives immobilized [21], and many patients develop pain from immobilization itself [9,10•]. For every patient seen by the trauma team or ICU, tens to hundreds are evaluated and cleared by emergency physicians.

Several recent studies have demonstrated that emergency medical service (EMS) providers can use simple guidelines to determine which patients are at risk for clinically significant (ie, potentially unstable) spinal injuries and forego immobilization in the rest [20,22–24]. This practice of selective immobilization is distinguished from actual spine clearance [20]. Interestingly, these protocols for selective prehospital spinal immobilization are independent of mechanism of injury. They evaluate for neck pain, neck tenderness, neurologic deficit, and reliability of the physical examination, thereby excluding intoxicated, hemodynamically unstable, and obtunded patients. Many EMS systems also exclude multisystem trauma patients. Therefore, most patients seen by the trauma team will still arrive immobilized. These selective immobilization protocols are becoming more common and are endorsed by the National Association of EMS Physicians [25]. The new American Association of Neurological Surgeons guidelines, however, still emphasize mechanism of injury rather than the physical examination as a means to make these decisions in the prehospital setting [1••].

How should patients with possible unstable injuries be immobilized?

Most trauma patients in the United States arrive at the hospital immobilized. Routinely, this immobilization includes a hard spine board, a cervical collar, and a means to prevent rotation of the head. Spine boards were developed as a means of extricating patients from a motor vehicle while maintaining spinal precautions; they were not intended as an immobilization device [26]. Some EMS services use padded boards or vacuum splints, which lessen but do not eliminate pain [10•,14]. Because most trauma patients are close to a hospital, and leaving the patient on the board after extrication is efficient and eases transfer to and from the ambulance stretcher, it is often reasonable to leave the patient on the board. Unfortunately, this practice has been extrapolated to imply that leaving the patient on the board is necessary for immobilization, and patients remain inappropriately on hard spine boards in the emergency department [27,28]. A hard cervical collar and a firm mattress are the standard means of immobilizing patients with documented unstable injuries in the emergency department or ICU before the application of traction or definitive stabilization.

Patients who arrive at the hospital immobilized on a spine board or vacuum splint should be evaluated immediately. If continued spinal immobilization is deemed necessary, the patient should be carefully log rolled off of the board and placed on a firm mattress. This transfer may be briefly delayed for initial stabilization and emergency radiographs, but leaving patients on a board for other reasons is medically inappropriate. Prehospital patients with prolonged transport times or patients being transferred from one facility to another should not remain on a hard board.

Which trauma patients require radiography in the emergency department?

This is one of the best-researched questions in emergency medicine. The multicenter National Emergency X-Radiography Utilization Study (NEXUS) enrolled 34,069 patients [29]. The investigators determined that only patients with midline neck tenderness, focal neurologic deficit, altered mental status, intoxication, or painful distracting injury require radiographs to exclude spinal injury. Neck pain was not a criterion nor was a mechanism of injury. These criteria were 99.6% sensitive for clinically significant (ie, potentially unstable) injuries. A large trial in Canada derived a different set of criteria, which appear to be equally sensitive but more complicated to use [30••]. These criteria are currently undergoing validation.

The NEXUS criteria are very similar to the prehospital criteria mentioned. Therefore, as more EMS systems use selective spinal immobilization protocols, more of the patients who arrive immobilized will indeed require radiographs. For trauma and critical care specialists, the spectrum bias of their patient population will less commonly allow clearance without radiographs. However, these criteria can be applied to any patient who has a reliable clinical examination. Although many clinicians automatically consider any fracture to be a distracting injury affecting examination reliability, others are more comfortable making case-by-case decisions.

How is the spine cleared in the case of the obtunded patient?

There seem to be two major schools of thought on this issue. One group obtains a definitive study to rule out ligamentous injury in all obtunded trauma patients, regardless of whether the results of their cervical spine radiographs and computed tomography (CT) scans are negative [31–33]. This definitive study may be a magnetic resonance image or dynamic fluoroscopic flexion/extension studies. Usually, this study is deferred for as long as 1 week until the patient improves enough to be clinically evaluated, or dies. During this period, the patient is maintained with routine spinal precautions. Unfortunately, these precautions significantly complicate nursing care in the ICU and expose the patient to all of the aforementioned risks. The other group counts on the rarity of unstable ligamentous injury in the setting of completely normal radiographs. If the results of the initial spine work-up, including radiographs and possibly CT, are normal, spinal precautions are discontinued [34,35]. The current recommendations of the American Association of Neurological Surgeons encompass all of these options [36••].

Are there special considerations for pediatric patients?

Because most young children do not tolerate immobilization well, it is ideal to avoid it whenever possible. Children tend to injure their upper spine and often die before transport. Fortunately, pediatric spinal injuries are rare, and many of the injuries that do occur do not involve an underlying unstable spinal injury [37,38]. Therefore, if pediatric trauma patients were never immobilized, an unstable injury would rarely be missed. However, considering the potential tragic outcome of an unrecognized injury, the goal should still be to identify patients at high risk for unstable injury and immobilize them appropriately.

Given the lower numbers of pediatric spine injuries, it is much harder to conduct powerful research. There is insufficient evidence to recommend applying selective immobilization criteria to young children in the prehospital setting. However, the criteria are commonly applied, and the practice seems reasonable in some cases, particularly in children old enough to converse. There is evidence to suggest that children who can communicate adequately may be evaluated for clinical clearance in the emergency department in the same manner as adults [39••,40••]. Once the decision is made to immobilize, anatomic differences must be considered to achieve a neutral position, particularly the proportionally larger head and prominent occiput.

Are there significant differences between patients with blunt versus penetrating mechanisms of injury?

Patients with certain kinds of penetrating injuries are extremely unlikely to have biomechanical unstable cervical or thoracic spines. For example, patients who are shot in the head do not absorb enough energy to break the spine. Kaups and Davis [41] looked at 215 patients with gunshot wounds to the head. The only three patients with spinal injury had direct wounds to the spinal column with entrance or exit wounds suggesting transcervical trajectory. There were no indirect spinal injuries. Newtonian physics requires that the energy imparted by a bullet decelerated to a stop by tissue is equal to that of the recoil of the pistol. If the recoil from a weapon placed against the side of a head does not deposit enough energy to break the neck, then being shot in the head should not, either.

The situation is perhaps different for patients who have direct penetrating injuries to the spine. Spinal cord injury from penetrating trauma usually occurs at the time of injury from direct cord damage and not from the creation of a biomechanically unstable lesion. However, firearms can generate enough energy to disrupt the classic two columns, and unstable injuries have been reported in a small percentage of patients [42–44].

In the absence of controlled studies, a logical approach is to immobilize any victim of penetrating firearm trauma who has a focal neurologic deficit or altered mental status in whom the trajectory likely traverses the spinal column, provided that immobilization does not interfere with management of the airway or bleeding vessels.

Conclusions

Like much of medicine, spinal immobilization is a concept that became the standard of care based on common sense rather than research. There are convincing biomechanical arguments and some preliminary research that suggest that spinal immobilization may not be necessary, even in many trauma patients with unstable injuries. Until further research clarifies which injuries, if any, truly benefit from immobilization, immobilization will remain the standard practice. The clinician's goal should be to apply it only to those patients predicted to be at risk for unstable injury and to do as little harm from immobilization as possible.

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:

• Of special interest

•• Of outstanding interest

1.•• McCormick P: Cervical spine immobilization before admission to the hospital. Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons. Neurosurgery 2002, 50(suppl): S7–S17. This is the first chapter in the latest Guidelines for the Management of Acute Cervical Spine Injuries from the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, which appeared as a supplement in Neurosurgery. This is a great resource for anyone taking care of trauma patients. Each chapter begins with a summary of the evidence, followed by a review of the literature. Unfortunately, we disagree with the conclusions of this particular chapter. There is enough evidence that selective immobilization based on clinical criteria rather than mechanism of injury should at least be an option for prehospital management. [Context Link]

2. Kwan I, Bunn F, Roberts I: Spinal immobilization for trauma patients. In The Cochrane Library, issue 2. Oxford: Update Software; 2002. [Context Link]

3. Hauswald M, Ong G, Tandberg D, et al.: Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med 1998, 5:214–219. [Context Link]

4.• Vaccaro AR, Silber JS: Post-traumatic spinal deformity. Spine 2001, 26(suppl):S111–S118. This review examines the long-term issues associated with spine injury and presents alternative perspectives on instability and neurologic deterioration. [Context Link]

5. Davis F: Spinal stability as defined by the three-column concept in acute spine trauma. Clin Orthop Rel Res 1984, 189:65–76. [Context Link]

6. Harrop JS, Sharan AD, Vaccaro AR, et al.: The cause of neurologic deterioration after acute cervical spinal cord injury. Spine 2001, 26:340–346. Ovid Full Text Bibliographic Links [Context Link]

7. Amar A, Levy M: Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal cord injury. Neurosurgery 1999, 44:1027. Ovid Full Text Bibliographic Links [Context Link]

8.•• McCormick P: Blood pressure management after acute spinal cord injury. Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons. Neurosurgery 2002, 50:58–62. This is another chapter from the Neurosurgery guidelines and is a good review of the evidence on the effects of hypotension on spinal cord injury. [Context Link]

9. Chan D, Goldberg R, Tascone A, et al.: The effect of spinal immobilization on healthy volunteers. Ann Emerg Med 1994; 23:48–51. Bibliographic Links [Context Link]

10.• Cross DA, Baskerville J: Comparison of perceived pain with different immobilization techniques. Prehosp Emerg Care 2001, 5:270–274. This study involved healthy volunteers placed on hard spine boards or two different vacuum mattresses. Not surprisingly, the spine boards caused more pain. [Context Link]

11. Bauer D, Kowalski R: Effect of spinal immobilization on pulmonary function in the healthy, non-smoking man. Ann Emerg Med 1988, 17:915–918. Bibliographic Links [Context Link]

12. Schafermeyer R, Ribbeck BM, Gaskins J, et al.: Respiratory effects of spinal immobilization in children. Ann Emerg Med 1991, 20:1017–1019. Bibliographic Links [Context Link]

13. Totten V, Sugarman D: Respiratory effects of spinal immobilization. Prehosp Emerg Care 1999, 3:347–352. [Context Link]

14. Hauswald M, Hsu M, Stockoff C: Maximizing comfort and minimizing ischemia: a comparison of four methods of spinal immobilization. Prehosp Emerg Care 2000, 4:250–252. [Context Link]

15. Linares H, AR M, Suarez E, et al.: Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987, 10:571–573. [Context Link]

16. Mawson AR, Biundo Jr, JJ Neville P, et al.: Risk factors for early occurring pressure ulcers following spinal cord injury. Am J Phys Med Rehabil 1988, 67:123–127. [Context Link]

17. Kolb JC, Summers RL, Galli RL: Cervical collar-induced changes in intracranial pressure. Am J Emerg Med 1999, 17:135–137. Bibliographic Links [Context Link]

18. Hunt K, Hallworth S, Smith M: The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anesthesia 2001, 56:511–513. [Context Link]

19. Mobbs R, Stoodley M, Fuller J: Effect of cervical hard collar on intracranial pressure after head injury. Aust N Z J Surg 2002, 72:389–391. [Context Link]

20. Stroh G, Braude D: Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med 2001, 37:609–615. [Context Link]

21. Cone D, Wydro G, Mininger C: Current practice in clinical cervical spine clearance: implication for EMS. Prehosp Emerg Care 1999, 3:42–46. [Context Link]

22. Domeier RM: Prospective validation of out-of-hospital spinal clearance criteria: a preliminary report. Acad Emerg Med 1997, 4:643–646. [Context Link]

23. Domeier RM: Prehospital clinical findings associated with spinal injury. Prehosp Emerg Care 1997, 1:11–15. [Context Link]

24. Domeier RM, Evans RW, Swor RA, et al.: The reliability of prehospital clinical evaluation for potential spinal injury is not affected by mechanism of injury. Prehosp Emerg Care 1999, 3:332–337. [Context Link]

25. Domeier RM: Indications for prehospital spinal immobilization. National Association of EMS Physicians Standards and Practice Committee. Prehosp Emerg Care 1999, 3:251–253. [Context Link]

26. Hauswald M, McNally T: Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J 2000, 19:126–127. [Context Link]

27. Lerner EB, Moscati R: Duration of patient immobilization in the ED. Am J Emerg Med 2000, 18:28–30. [Context Link]

28. Cooke MW: Use of the spinal board within the accident and emergency department. J Accid Emerg Med 1998, 15:108–109. [Context Link]

29. Hoffman JR, Mower WR, Wolfson AB, et al.: Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma: National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000, 343:94–99. Bibliographic Links [Context Link]

30.•• Stiell I, Wells GA, Vandemheen KL, et al.: The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 2001, 286:1841–1848. This study is the Canadian answer to the NEXUS trial. This is actually just the derivation of a clinical decision rule for when to obtain c-spine radiographs in asymptomatic trauma patients but includes almost 9000 patients. Prospective validation of the rule is pending. [Context Link]

31. Brooks RA, Willett KM: Evaluation of the Oxford protocol for total spinal clearance in the unconscious trauma patient. J Trauma 2001, 50:862–867. Ovid Full Text Bibliographic Links [Context Link]

32. Harris MB, Kronlage SC, Carboni PA, et al.: Evaluation of the cervical spine in the polytrauma patient. Spine 2000, 25:2884–2891; discussion 2892. Ovid Full Text Bibliographic Links [Context Link]

33. Sees DW, Rodriguez Cruz LR, Flaherty SF, et al.: The use of bedside fluoroscopy to evaluate the cervical spine in obtunded trauma patients. J Trauma 1998, 45:768–771. Ovid Full Text Bibliographic Links [Context Link]

34. Chiu WC, Haan JM, Cushing BM, et al.: Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma 2001, 50:457–463. Ovid Full Text Bibliographic Links [Context Link]

35. Davis JW, Kaups KL, Cunningham MA, et al.: Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma 2001, 50:1044–1047. Ovid Full Text Bibliographic Links [Context Link]

36.•• McCormick P: Radiographic assessment of the cervical spine in symptomatic trauma patients. Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons. Neurosurgery 2002, 50(suppl):S36–S43. This chapter of the Neurosurgery supplement reviews the evaluation of the spine in the obtunded trauma patient. Based on the available evidence, the authors support very diverse practices. [Context Link]

37. Kokoska ER, Keller MS, Rallo MC, et al.: Characteristics of pediatric cervical spine injuries. J Pediatr Surg 2001, 36:100–105. [Context Link]

38. Patel JC, Tepas JJ, Mollitt DL, et al.: Pediatric cervical spine injuries: defining the disease. J Pediatr Surg 2001, 36:373–376. [Context Link]

39.•• McCormick P: Management of pediatric cervical spine and spinal cord injuries. Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons. Neurosurgery 2002, 50(suppl): S85–S99. This chapter of the Neurosurgery guidelines reviews all of the critical issues in the early assessment and management of pediatric spinal injury. Most interestingly, they support the use of clinical rather than radiographic assessment of the spine in selected pediatric patients. [Context Link]

40.•• Viccellio P, Simon H, Pressman BD, et al.: A prospective multicenter study of cervical spine injury in children. Pediatrics [serial online] 2001, 108:E20. This study presents the pediatric subgroup data from the NEXUS trial. Because spinal injury is rare in young children, the numbers are small, but these are the best data available on clinical spine clearance in pediatric patients. [Context Link]

41. Kaups KL, Davis JW: Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma 1998, 44:865–867. Ovid Full Text Bibliographic Links [Context Link]

42. Apfelbaum JD, Cantrill SV, Waldman N: Unstable cervical spine without spinal cord injury in penetrating neck trauma. Am J Emerg Med 2000, 18:55–57. [Context Link]

43. Cornwell III, EE Chang DC, Bonar JP, et al.: Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary? Arch Surg 2001, 136:324–327. [Context Link]

44. Isiklar ZU, Lindsey RW: Low-velocity civilian gunshot wounds of the spine. Orthopedics 1997, 20:967–972. [Context Link]

[JPINFV]

Patients with Gunshot Wounds to the Head Do Not Require Cervical Spine Immobilization and Evaluation

[Article: Presented At The 57Th Annual Meeting Of The American Association For The Surgery Of Trauma And The Japanese Association For Acute Medicine, September 24-27, 1997, Waikoloa, Hawaii]

Kaups, Krista L. MD; Davis, James W. MD

From the Department of Surgery (K.L.K.), UCSF/Fresno, University Medical Center, Fresno, California, and Division of Trauma (J.W.D.), Department of Surgery, University of South Florida, Tampa, Florida.

Presented at the 27th Annual Meeting of the Western Trauma Association, March 1-8, 1997, Snowbird, Utah.

Address for reprints: Krista L. Kaups, MD, Department of Surgery, 4th Floor, University Medical Center, 445 S. Cedar, Fresno, CA 93702.

Article Outline

* Abstract

o MATERIALS AND METHODS

o RESULTS

o DISCUSSION

o REFERENCES

* Citing Articles

Figures/Tables

* Figure 1

Abstract TOP

Objective: The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head.

Methods: A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded.

Results: A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008).

Conclusions: Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

The risk of cervical spine injury associated with head injury has been reported to be from 3.5% up to 10% of cases. [1-7] This occurrence, however, represents all trauma patients, from both blunt and penetrating mechanisms. Numerous studies have evaluated cervical spine injury in blunt trauma patients and its association with facial and head injuries. Additionally, the need for cervical spine evaluation and clearance has been extensively studied in blunt trauma patients. [8-12].

The occurrence of cervical spine injury in patients sustaining penetrating trauma to the head is essentially unknown. Despite this lack of knowledge, these patients routinely are immobilized in rigid collars and are treated with cervical spine precautions. These interventions have implications for airway management and necessitate diagnostic intervention (i.e., cervical spine clearance), accordingly, their utility should be determined. This study was performed to test the hypothesis that cervical spine injury, other than from direct bullet injury, does not occur in patients who sustain gunshot wounds (GSW) to the head and that these patients do not require cervical spine immobilization or clearance.

MATERIALS AND METHODS TOP

The trauma registry records of all patients admitted to University Medical Center, a Level I trauma center, between July 1, 1990, and September 30, 1995, were reviewed, and patients with GSW to the head were identified. Hospital records were reviewed and data were abstracted, including age, sex, Glasgow Coma Scale score at emergency department (ED) presentation, other injuries, the use of cervical spine immobilization, cervical spine radiographs, and survival or autopsy results. The presence of cervical spine injury and direct (penetrating) or indirect (from associated blast injury of fall) mechanism was also recorded. Cervical spine clearance was by clinical or radiologic criteria in survivors; in nonsurvivors, clearance was by radiologic or postmortem examination (including the cervical ligaments, vertebrae, and spinal cord). Criteria for clinical clearance included alert mental status and absence of neurologic findings or cervical pain. Radiologic criteria included a five-view cervical spine series and an alert patient. In the obtunded patients, dynamic fluoroscopy was also used in conjunction with plain radiography. [13] Patients with GSW to the neck and those dead on arrival to the ED were excluded from the study.

RESULTS TOP

There were 215 patients identified as having sustained GSW to the head over the study period. The majority were men (188 patients, 87%), with an average age of 28 years. The mean patient Glasgow Coma Scale score was 8 at the time of ED arrival. The injuries resulted from assault in 136 patients, and the remaining 79 patients had self-inflicted injuries. Forty-three patients sustained multiple gunshot wounds with the other wounds being to the torso or extremities. Death occurred in 123 of 215 patients (57%) with 64 patients dying in the ED (29%).

One hundred eighty patients (84%) had cervical spine immobilization instituted in the prehospital setting or the ED. Cervical spine clearance was determined either clinically (45 patients) or radiographically (47 patients) in survivors, and radiographically (37 patients) or by autopsy (73 patients) in nonsurvivors (Figure 1). Patients had clinical clearance only if they had a Glasgow Coma Scale score of 15, either at the time of admission or later in the hospital course. Cervical spine films were obtained in 84 patients (40%). Cervical spine clearance was possible for 199 patients (93%) overall. Twelve patients who committed suicide had no autopsies performed, and the autopsy report for one homicide victim could not be located.

Figure 1

Figure 1. Cervical spine clearance in patients with gunshot wounds to the head.

Three patients were found to have bullet injuries of the bony cervical spine; all had entrance or exit wounds suggesting a cervical trajectory. Two of these patients survived without neurologic deficit related to the cervical spine injury; the third patient's injury was found at autopsy. No bony or ligamentous injury, other than from direct bullet injury, was identified in any patient.

Endotracheal intubation was attempted in the field in 38 patients and was unsuccessful in 16 (42%). Intubation failures occurred in 14 patients with cervical spine immobilization and in only two patients whose cervical spines were not immobilized. Additionally, multiple efforts at intubation were attempted: 49 attempts in 34 patients with immobilization and five attempts in four patients without immobilization (chi squared test, p = 0.008).

Furthermore, there were six patients who required reintubation in the ED for endotracheal tube malposition or dislodgement not recognized in the field. Five of these six patients had cervical spine immobilization (chi squared test, p < 0.001).

DISCUSSION TOP

Although it has been theorized that patients sustaining GSW to the head may incur cervical spine injury either from the blast of the gunshot or from falling to the ground after the injury, these assertions have never been demonstrated. The Advanced Trauma Life Support program manual states "Any patient sustaining an injury above the clavicle or a head injury resulting in an unconscious state should be suspected of having an associated cervical spinal column injury," and obligates the care provider to immobilize the patient until cervical spine injury can be excluded. [14]

Research to support cervical spine immobilization and clearance in patients with GSW to the head is limited. In a recent retrospective review of patients with GSW to the head, none of 105 patients who had complete lateral cervical spine films and GSW confined to the calvaria had cervical spine injury. In an additional 52 patients who had complete neck films and who also had entrance or exit wounds not limited to the head, five direct injuries to the cervical spine or spinal cord were identified. In that study, the authors also noted no diagnosed cervical spine injury in the 109 patients who had no cervical spine radiographs and survived. [15]

Cervical spine immobilization has important implications for airway management. This group of patients with serious head injury is at high risk for hypoxia and aspiration. Airway control and the administration of oxygen are of paramount importance in these patients. Numerous studies have demonstrated the frequent occurrence of hypoxia in head injured patients and its detrimental effects. Chesnut et al., in reviewing data from the National Traumatic Coma Bank, found a 22% incidence of hypoxia at the time of initial evaluation. [16] Others have reported that 30% to 46% of patients with severe head injury have initial hypoxia (PaO2 less than 65 torr). [17] For patients with head injury, any occurrence of hypoxia is linked with not only an 85% increase in mortality, but also an increased likelihood of permanent disability. [18,19] In the prehospital setting, in which intubation is done with limited personnel, suboptimal conditions, and frequently without pharmacologic intervention, cervical spine precautions may significantly limit the provider's ability to secure the airway.

Although the importance of intubation and hyperventilation are recognized, the presence of cervical spine immobilization complicates airway control and management. [20] In the present study, unsuccessful attempts at intubation were closely associated with patients in cervical spine immobilization. Although attempts were made to intubate 38 patients in the prehospital setting, 16 patients could not be intubated in the field or required reintubation upon ED arrival. Additionally, immobilized patients had multiple intubation attempts when compared with nonimmobilized patients. All but two of these patients were in cervical spine immobilization. In the previous study of GSW and cervical spine injury, 45% of patients with intracranial injury required immediate intubation, but only three patients were intubated in the prehospital period, emphasizing the problems cervical spine immobilization causes for prehospital providers in obtaining airway control.

In this series of 215 patients, 202 had examinations for cervical spine injury after GSW to the head, and no occult cervical spine injuries were found. No patient had a blast effect, or indirect ligamentous cervical spine injury from the GSW to the head clinically, radiographically, or by detailed autopsy. The three cervical spine injuries diagnosed were all from direct bullet contact, and in all three patients, the position of the entrance and/or exit wounds indicated cervical spine traverse.

Cervical spine immobilization, although a routine part of trauma care, is unnecessary for the patient with a gunshot wound to the head without evidence of bullet traverse of the neck. The use of cervical spine precautions may, in fact, impede airway management and oxygenation of the patient. The patient with a GSW to the head who has no evidence of neck traverse does not need or benefit from cervical spine immobilization. However, if the bullet trajectory cannot be determined or if the patient had focal neurologic deficit suggestive of spinal column injury, cervical spine immobilization should be implemented.

Obtaining multiple view radiographs of the neck simply for the sake of protocol adds unnecessary expense and delay to the care of the patient. Routine cervical spine clearance after GSW to the head should be abandoned unless trajectory indicates direct injury.

http://www.jtrauma.com/pt/re/jtrauma/fullt...9856145!8091!-1

[Ace844]

"JP,"

I believe that I may have posted those already previously here, though I am not sure of it was in this particular thread. Either way, great work doing the research and finding relevant articles!!! As for the studies I posted the ones above because "stcommodore," was talking out of a non vertical facing orfice surrounded by a vertical line and muscleus that sound like gleutus; about spinal 'assessment' and nexus criteria, etc... Not surprisingly, he has yet to respond to ANYONE....Till then, we'll be waiting.

Out here,

ACE

[JPINFV]

And the abstract from the study in the Bledsoe article.

"JP,"

I believe that I may have posted those already previously here, though I am not sure of it was in this particular thread. Either way, great work doing the research and finding relevant articles!!! As for the studies I posted the ones above because "stcommodore," was talking out of a non vertical facing orfice surrounded by a vertical line and muscleus that sound like gleutus; about spinal 'assessment' and nexus criteria, etc... Not surprisingly, he has yet to respond to ANYONE....Till then, we'll be waiting.

Out here,

ACE

True, but let's try to move this thread back to the original point of, "Does doing what we do actually help our patients?"

[Ace844]

And the abstract from the study in the Bledsoe article.

My big issue with this study is it is a retro-spective chart review vs. clinical.