Cervical spine clearance is always a fun topic. Once upon a time, it was plain radiography, clinical re-assessment, and functional testing with dynamic radiography. Now, a zero miss culture has turned us mostly to CT – and, beyond that, even some advocate for MRI.
But, as far as clinical clearance of the cervical spine goes, we usually use the NEXUS criteria or the Canadian C-Spine criteria. One of the elements of the NEXUS criteria that is, essentially, subjectively defined is the presence of “distracting injury”. Many have questioned the inclusion of this element.
These authors looked at cervical spine clearance in the presence of “distracting injury”, which, for the purpose of research protocols, was essentially a fracture somewhere, an intracranial injury, or an intra-abdominal organ injury. They found, when assessing a GCS 14 or 15 trauma patient, even in the presence of these other injuries, clinical examination picked up 85 of 86 cervical spine injuries. One patient did not report midline cervical spine tenderness – with humerus and mandible fractures, as well as frontal ICH – and had a 2nd vertebrae lateral mass fracture.
So, clinical examination is mostly reliable in the presence of a “distracting injury”. I think the best interpretation of this study is “distracting injury” has to be determined on a case-by-case basis – one patient might be a reliable reporter in the presence of long-bone fracture, while another might need such a high level of pain control for initial management they are no longer aware of their cervical spine injury. It’s fairly clear it is reasonable to remove the cervical collar and forgo imaging for most patients who can be adequately clinically assessed.
“Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth”
http://www.ncbi.nlm.nih.gov/pubmed/23019677
Great post Ryan,
I'm not sure what the point of equipoise is for missing C-spine fractures.
The practice of many trauma and spine specialists that I see suggests they are not happy with missing 1 in 1,000…
Obviously the ED is different, heterogeneous world.
But I can see a court room full of medical experts reaching for more ammo if the defendant stood there saying but it was only a 1 in 86 chance…
Chris
Great post Ryan,
I'm not sure what the point of equipoise is for missing C-spine fractures.
The practice of many trauma and spine specialists that I see suggests they are not happy with missing 1 in 1,000…
Obviously the ED is different, heterogeneous world.
But I can see a court room full of medical experts reaching for more ammo if the defendant stood there saying but it was only a 1 in 86 chance…
Chris
Absolutely – which is why you can't always interpret these decision rules in a vacuum. Trauma is still a complex disease with more than just these few clinical predictors, with other features that have positive or negative likelihood ratios for clinically important cervical spine injury. I don't think a jury would be too excited about the case that would have been missed in this incidence, with intracranial bleeding, yet still attempting to classify the patient as a reliable reporter of physical findings.
I usually combine NEXUS and Canadian in my evaluation – I think Scott has a podcast about this.
Absolutely – which is why you can't always interpret these decision rules in a vacuum. Trauma is still a complex disease with more than just these few clinical predictors, with other features that have positive or negative likelihood ratios for clinically important cervical spine injury. I don't think a jury would be too excited about the case that would have been missed in this incidence, with intracranial bleeding, yet still attempting to classify the patient as a reliable reporter of physical findings.
I usually combine NEXUS and Canadian in my evaluation – I think Scott has a podcast about this.