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Cervical spine clearance in adult trauma patients

Yorkgitis, Brian K., PA-C, DO; McCauley, D. Michelle, DO

Journal of the American Academy of PAs: February 2019 - Volume 32 - Issue 2 - p 12–16
doi: 10.1097/01.JAA.0000552718.90865.53
CME: Emergency Medicine
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CME

ABSTRACT Up to 4% of adults with blunt trauma suffer cervical spine injury. Clinicians who evaluate trauma patients can use validated clinical decision tools to assess whether patients are at risk for these injuries. Beyond these tools, imaging (most often CT) remains the mainstay of evaluation. Further challenges exist when patients have persistent pain or cannot be evaluated clinically. This article reviews the evidence available to assist clinicians in evaluating adults for significant cervical spine injury after blunt trauma.

Brian K. Yorkgitis and D. Michelle McCauley practice in the Division of Acute Care Surgery at the University of Florida College of Medicine-Jacksonville. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http://cme.aapa.org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of February 2019.

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Clinicians often are asked to perform cervical spine clearance in adults after blunt trauma. Clinical decision tools and guidelines have been developed to help clinicians; however, challenges arise when the patient cannot be evaluated clinically because of altered mental status, distracting injuries, or other confounders.1,2 Clinicians must be able to approach each patient in an evidence-based manner.

Initially, a cervical collar often is applied to restrict cervical spine motion if the patient is at risk for spinal injury.2 However, prolonged cervical spine immobilization carries risks and complications. Patients are at an increased risk of developing pressure ulcers from the collar pressing on the mandible, chin, chest, and occipital region. The collar can interfere with airway patency and ventilation and can increase the patient's risk for infection. In patients with severe traumatic brain injuries, prolonged immobilization can cause increased intracranial pressure.2 Prompt identification of patients who no longer require cervical spine motion restriction is imperative to prevent these complications. Clinicians also must be able to recognize which patients need continued cervical spine precautions.

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PREVALENCE OF CERVICAL SPINE INJURIES

The rate of cervical spine injuries (CSIs) among trauma patients is estimated at 3.7%.3 As expected, the prevalence among alert patients is lower (2.8%), and prevalence is higher (7.7%) among patients who cannot be evaluated.3 Nearly 42% of patients with CSIs have cervical spine instability.3 Speed is crucial; a delayed CSI diagnosis can result in partial or full paralysis in up to 29% of patients.4 The incidence of CSI, particularly of the upper cervical spine, increases in older adults, even after low-energy mechanisms.5

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ASSESSING ALERT PATIENTS

Clinical examination in alert patients who are not intoxicated or do not have a distracting injury after blunt trauma has a sensitivity of 58.8%, specificity of 62.7%, positive predictive value of 8.1%, and negative predictive value of 96.4%.4 As an adjunct to clinical examination of the patient after blunt trauma, various clinical decision tools have been validated and can help clinicians with bedside evaluation of the cervical spine. The most common are the Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (Tables 1 and 2). These tools each have a high sensitivity and specificity. Although NEXUS has been more widely adopted because of its simplicity and ability to be easily memorized, studies have demonstrated CCR to be a more superior tool for helping clinicians with clinical clearance. The CCR has a higher sensitivity than NEXUS (99.4% versus 90.7% with 95% CI) for clinically important CSIs.6,7 Clinically significant CSIs include any fracture, dislocation, or ligamentous instability seen on imaging.7 Judicious use of CCR in place of NEXUS has the ability to lower unnecessary use of radiography and the need for immobilization in alert patients.6–8

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TABLE 1

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The efficacy of clinical clearance in the presence of distracting injuries in alert patients has raised some concern. However, a study by Rose and colleagues found that the severity of distracting injuries did not affect the efficacy and sensitivity of clinical examination.1 Sixty-one percent of patients with distracting injuries were clinically cleared with a negative predictive value greater than 99% and a sensitivity of 99%, reducing the use of CT imaging.1

Although NEXUS does not take patient age into account, the CCR considers age 65 years or older a high-risk factor and recommends cervical spine imaging for these patients. Several studies have demonstrated that imaging detected a cervical spine fracture in between 34% and 55% of older adults who did not have cervical spine tenderness.5,9 Considering patients age 65 years and older as higher risk was challenged in a study by Healey and colleagues, who examined patients ages 55 years and older with asymptomatic cervical spine fractures.10 They found that nearly 20% of patients without tenderness or pain on initial presentation had a cervical spine fracture.10 Many of these patients would have been deemed low-risk by CCR and NEXUS. Clinicians evaluating the cervical spine for injury should take patient age into account when deciding whether to order cervical spine imaging.

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ASSESSING CLINICALLY UNEVALUABLE PATIENTS

In some patients, clinical examination alone cannot rule out CSI. For example, patients may have a negative CT scan but altered mental status or decreased consciousness. Appropriate management for these patients is controversial. Multiple imaging modalities can be used, including radiography, CT, MRI, and flexion/extension (F/E) radiographic views.11 Some clinicians support using only a multidetector CT scan (MDCT) to rule out injury in patients who cannot be clinically cleared. Although others argue that this single modality is inadequate, MDCT allows for better detection of fractures and misalignment. MRI allows better visualization of soft-tissue disks and ligamentous structures.12

How to evaluate obtunded patients also is controversial. The clinical decision tools listed above are widely accepted for screening alert patients for CSI. However, evidence for their use in obtunded patients with blunt trauma is less robust. Guidelines from the Eastern Association for the Surgery of Trauma (EAST) were developed based on a systematic review of literature to guide clinicians in managing the trauma patients who could not be evaluated clinically. EAST concluded that cervical collars could be removed from obtunded patients only after a negative high-quality CT of the cervical spine alone failed to detect an injury.13 This is part of EAST's latest recommendations that no longer advocate for F/E radiographs. Emphasis is placed on the high negative predictive value of high-quality CT in eliminating clinically significant unstable injuries. High-quality was defined as an axial CT from the occiput to T1 with coronal and sagittal reconstructions.3,13

A retrospective study by Hogan and colleagues concluded that MRI findings did not change the management of obtunded patients when a CT scan was negative.14 Chew and colleagues found that, compared with MDCT, MRI provided no additional information when trying to identify unstable CSIs after blunt trauma in patients who did not show signs of motor deficits on examination.12 A meta-analysis performed by Panczykowski and colleagues showed that out of 14,327 obtunded or intubated patients, a negative CT scan was sufficient to rule out unstable cervical spine fractures, so the cervical collar could be removed.14 Hogan and colleagues similarly concluded that a negative MDCT in an obtunded patient did not need to be followed by an MRI.15 Tomycz and colleagues found that out of 180 patients with a normal CT, MRI identified 38 patients with acute findings, none of whom were found to have instability or required operative intervention.16 This suggests that MRI is unlikely to reveal unstable injuries after a normal CT in obtunded patients.16 In contrast, Menaker and colleagues recommended that MRI still be used in this patient population because late MRI findings may occur.17 In their study of 203 patients, 8.9% (18) had an abnormal MRI after no injury was identified on CT scan of the cervical spine.17 Two of these patients required operative fixation and 14 required extended use of cervical collar. Most patients (10) were diagnosed with ligamentous injury of only one ligament at only one level and 5 had a cord contusion alone.17

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PATIENTS WITH PERSISTENT NECK PAIN

Patients with persistent pain who undergo an MDCT that does not identify an acute injury remain a challenge for clinicians.18 The possibility of a missed CSI remains a feared complication in these patients. A body of literature supports removing the cervical collar if no CSIs are identified by high-quality MDCT. However, research supports further imaging to discern injuries that may not be detected on MDCT.

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F/E radiographs

Many institutions continue to obtain F/E radiographs routinely in patients with persistent neck pain despite a negative CT scan. An adequate F/E radiograph is defined by the ability to visualize the base of the occiput down to the top of T1 and when it shows at least 30 degrees of movement in both flexion and extension. Studies have shown that F/E radiographs were only able to detect significant injuries when the radiograph showed at least 30 degrees of movement of the cervical spine from the neutral position.19

The usefulness of these radiographs is questionable. In a study by McCracken and colleagues, 70% to 80% of F/E radiographs were inadequate by criteria previously described.11 In additional related studies, inadequacy ranged from 30% to 95%.20

In addition to their limited value, F/E radiographs are expensive. Tran and colleagues reported that nearly $172,000 was spent in 1 year on F/E radiographs.21 Of patients who were found to have ligamentous injury on F/E radiographs, none had a significant injury or subsequent neurologic deterioration.21 The researchers recommended that for awake, alert, and neurologically intact patients, F/E radiographs should be eliminated after a negative CT scan.21

Oh and colleagues reported that of the four patients who had negative F/E radiographs with a ligamentous injury found on subsequent MRI, none required any intervention.20 This suggests that MRI can be overly sensitive. They concluded that F/E radiographs do not contribute to diagnostic accuracy for the detection of ligamentous injury in the cervical spine following a normal CT scan.20 Similarly, after 69% of patient radiographs were deemed inadequate by radiologists, Khan and colleagues concluded that F/E radiographs do not appear to be clinically useful in assessing cervical spine instability.18 They recommended that patients be reassessed in 7 to 10 days for neck pain and if pain was still present, clinicians should reassess the need for F/E imaging. In patients with persistent neck pain, muscle spasms may prevent adequate F/E imaging; after 7 to 10 days, the muscles will have relaxed, allowing improved adequacy of F/E if one is deemed clinically necessary.18

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MRI

In addition to F/E imaging in patients with persistent neck pain, researchers have investigated the usefulness and appropriateness of MRI in patients with a normal CT scan. Chew and colleagues reported that ligamentous injury was found in 34% of all abnormalities on MRI following a normal CT.12 However, none of these patients required surgical intervention or a halo for cervical instability.12

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CT scan

Several studies support the adequacy of CT scan alone to rule out CSI.12,22-25 Schuster and colleagues found that no patient with a negative CT scan and the absence of neurologic deficits had an MRI that revealed clinically significant injuries.26 Resnick and colleagues found that of 2.2% of patients with a normal CT scan and persistent neck pain and/or sensory deficits had a new finding on MRI; none of these patients required surgical intervention.25 No clinically significant injury was missed on CT scan. Researchers concluded that MRI did not alter management in alert patients with a normal CT.25 Malhotra and colleagues found that CT has a negative predictive value (NPV) of 79.1% for CSI in patients who are clinically suspicious for injury or who cannot be evaluated; for unstable injury, the NPV for CT was 98.5%.27 MRI may be useful in patients with persistent abnormal neurologic examinations.27 Ackland and colleagues compared patients with a positive finding on early MRI following a negative CT with those with negative findings on early MRI.28 At 1 year, no associated adverse long-term outcomes were found in patients with MRI-detected injuries compared with patients without MRI-detected injuries. Delay in return to work was associated with the presence of other injuries to the limbs.28

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CONCLUSION

Cervical spine evaluation for adults with blunt trauma continues to be a challenge for clinicians. Clinical decision tools are a foundation to begin the evaluation, and the CCR appears to be a more sensitive tool than NEXUS. Age and mechanism of injury is important when evaluating patients after blunt trauma; asymptomatic patients ages 55 years and older who would be deemed low-risk using clinical decision tools have been found to have cervical spine fractures. The available literature does not support the use of F/E radiographs when evaluating patients with persistent neck pain. In addition, significant evidence concludes that MRIs have not been of added benefit in patients who have normal CT scans but have persistent pain or altered mental status. Selective use of additional imaging tests beyond CT appears to be more appropriate than broad-based use in these populations.

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REFERENCES

1. Rose MK, Rosal LM, Gonzalez RP, et al Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth. J Trauma Acute Care Surg. 2012;73(2):498–502.
2. Halpern CH, Milby AH, Guo W, et al Clearance of the cervical spine in clinically unevaluable trauma patients. Spine. 2010;35(18):1721–1728.
3. Milby AH, Halpern CH, Guo W, Stein SC. Prevalence of cervical spinal injury in trauma. Neurosurg Focus. 2008;25(5):E10.
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18. Khan SN, Erickson G, Sena MJ, Gupta MC. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma. 2011;25(1):51–56.
19. Sim V, Bernstein MP, Frangos SG, et al The (f)utility of flexion-extension C-spine films in the setting of trauma. Am J Surg. 2013;206(6):929–934.
20. Oh JJ, Asha SE, Curtis K. Diagnostic accuracy of flexion-extension radiography for the detection of ligamentous cervical spine injury following a normal cervical spine computed tomography. Emerg Med Australas. 2016;28(4):450–455.
21. Tran B, Saxe JM, Ekeh AP. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan. J Surg Res. 2013;184(1):411–413.
22. Mavros MN, Kaafarani HM, Mejaddam AY, et al Additional imaging in alert trauma patients with cervical spine tenderness and a negative computed tomographic scan: is it needed. World J Surg. 2015;39(11):2685–2690.
23. Vanguri P, Young AJ, Weber WF, et al Computed tomographic scan: it's not just about the fracture. J Trauma Acute Care Surg. 2014;77(4):604–607.
    24. Steigelman M, Lopez P, Dent D, et al Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination. Am J Surg. 2008;196(6):857–863.
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    26. Schuster R, Waxman K, Sanchez B, et al Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg. 2005;140(8):762–766.
    27. Malhotra A, Durand D, Wu X, et al Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT. Eur Radiol. 2018;28(7):2823–2829.
    28. Ackland HM, Cameron PA, Wolfe R, et al Outcomes at 12 months after early magnetic resonance imaging in acute trauma patients with persistent midline cervical tenderness and negative computed tomography. Spine. 2013;38(13):1068–1081.
    Keywords:

    cervical spine; CT; MRI; obtunded; trauma; neck injury

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