Clinical clearance of the cervical spine is a standard of care. It is usually the first method to determine if there might be an injury in patients who are awake, cooperative, and don’t have other painful distracting injuries. But appreciation of pain may be different in elderly patients, and they will frequently not notice pain from some injuries. Could this possibly impact clearance of the cervical spine?
A group at Iowa Methodist performed a retrospective review of patients > 55 with diagnosed cervical spine fractures over a four year period. They were considered to have an asymptomatic injury if they did not complain of pain, or of tenderness to palpation.
Here are the factoids:
A total of 173 elderly patients presented with a cervical spine injury during the study period
38 of them (22%) were asymptomatic
The asymptomatic patients tended to have higher injury severity (ISS 15 vs 10), have a significant injury in another body region (71% vs 47%), and stayed in the hospital longer (7 days vs 5)
A third of patients had multiple cervical fractures (symptomatic or asymptomatic?)
C2 was the most common fracture level
Bottom line: I have witnessed this phenomenon myself. Not all of our elders perceive pain the same way younger patients do. This study shows that it is a very significant problem. Most of the previous papers and the only review I could find do not separate out the elderly when making cervical clearance recommendations. We will probably have to develop some specific criteria to determine when a CT scan is necessary in the asymptomatic elderly patient. In the algorithm used at my hospital, age > 65 is already used to bypass clinical clearance. Looks like I’ll have to drop that to 55!
Questions and comments for the authors/presenters:
Since they were asymptomatic, how do you know that you didn’t miss any patients?
Do you have a practice guideline for cervical spine evaluation? Has it changed based on your study?
Be sure to break your data down by mechanism of injury for the presentation. Were there more asymptomatic patients from falls rather than car crashes? Associated fracture patterns for each mechanism?
What do you now recommend for clearance?
Suggestion: change your title to “cervical spine fractures”, not “neck fracture”.
There are multiple ways to clear a cervical spine! Most centers use a combination of clinical decision tools and CT scan in adults. The gold standard tie breaker, warranted or not, seems to be MRI. This tool is only used in select cases where conventional imaging is in doubt, or the clinical exam is puzzling.
Some centers clear based on CT only as long as imaging is indicated. Some use MRI in cases where patients continue to complain of midline neck pain or tenderness after negative CT. A multi-center trial encompassing 8 Level I and II centers prospectively performed MRI on patients who could not be clinically evaluated, or had persistent midline cervical pain after normal CT.
A total of 767 patients were seen over a 30 month period. Besides looking at the usual data points, the authors were interested in new diagnoses and changes in management based on the MRI results.
Here are the factoids:
Neck pain and inability to evaluate occurred with equal frequency, about 45%; the remaining 10% had both
23% of MRIs were abnormal, with 17% ligament injury, 4% swelling, 1% disk injury, and 1% dural hematomas.
Patients with normal and abnormal MRI had neurologic anomalies about equally (15-19%). [Why are these patients included? Were they initially not evaluable?]
The cervical collar was removed in 88% of patients with normal MRI (??), and in 13% with abnormal MRI
After (presumably) positive MRI, 14 (2%) underwent spine surgery; 8 of these had neurologic signs or symptoms
Bottom line: I’m a bit confused. If the authors were really trying to figure out the rate of abnormal MRI after negative CT, they should have excluded the patients with known neurologic findings. These patients should nearly always have an abnormal MRI. And why did they not take the collar off of the 12% of patients with both normal CT and MRI??
Hopefully, details in the presentation next week will help explain all this. I suspect that the study will show that there are cases where CT is normal but MRI is not. The abstract does not clearly describe how many of these are clinically significant.
I admit, I’m not very comfortable clearing the cervical spine in a patient with negative CT (even if read by a neuroradiologist) and obvious midline neck pain/tenderness. I hope this study helps clarify this issue. We shall see…
Reference: Cervical spine MRI in patients with negative CT: a prospective, multicenter study of the research consortium of New England centers for trauma (ReCONECT). AAST 2016, Paper 61.
Nurses who take care of trauma patients run into this all the time. “The cervical spine is cleared,” they say. But who is “they?” How did “they” do it? What is the patient now allowed to do? And what’s the deal with this funky collar?
This 11 minute video will provide the answers to these questions and more! Enjoy!
A reader recently asked what the optimal method for inline stabilization is. We’ve been pondering this question for nearly 30 years. In 1983, trauma surgeons at UCLA looked at a number of devices available at that time and tested them on normal volunteers. They measured neck motion to see which was “best.”
Here’s what they found:
Soft collar – In general, this decreased rotation by 8 degrees but insignificantly protected against flexion and extension. Basically, this keeps your neck warm and little else.
Hard collars – A variety of collars available in that era were tested. They all allowed about 8% flexion, 18% lateral movement, and 2% rotation. The Philadelphia collar allowed the least extension.
Sandbags and tape – Surprisingly, this was the best. It allowed no flexion and only a few percent movement in any other direction.
The Mayo clinic compared four specific hard collars in 2007 (Miami J, Miami J with Occian back, Aspen, Philadelphia). They found that the Miami J and Philadelphia collars reduced neck movement the best. The Miami J with or without the Occian back provided the best relief from pressure. The Aspen allowed more movement in all axes.
And finally, the halo vest is the gold standard. These tend to be used rarely and in very special circumstances.
For EMS: Rigid collar per your protocol is the standard. In a pinch you can use good old tape and sandbags with excellent results.
For physicians: The Miami J provides the most limitation of movement. If the collar will be needed for more than a short time, consider the well-padded Occian back Miami J (see below).
Efficacy of cervical spine immobilization methods. J Trauma 23(6):461-465, 1983.
Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. J Trauma 63(5):1120, 1126, 2007.
Cervical spine injury presents a host of problems, but one of the least appreciated ones is dysphagia. Many clinicians don’t even think of it, but it is a relatively common problem, especially in the elderly. Swallowing difficulties may arise for several reasons:
Prevertebral soft tissue swelling may occur with high cervical spine injuries, leading to changes in the architecture of the posterior pharynx
Rigid cervical collars, such as the Miami J and Aspen, and halo vests all force the neck into a neutral position. Elderly patients may have a natural kyphosis, and this change in positioning may interfere with swallowing. Try extending your neck by about 30 degrees and see how much more difficult it is to swallow.
Patients with cervical fractures more commonly need a tracheostomy for ventilatory support and/or have a head injury, and these are well known culprits in dysphagia
Normal soft tissue (<6mm at C2, <22mm at C6)
A study in the Jan 2011 Journal of Trauma outlined the dysphagia problem seen with placement of a halo vest. They studied a series of 79 of their patients who were treated with a halo. A full 66% had problems with their swallowing evaluation. This problem was associated with a significantly longer ICU stay and a somewhat longer overall hospital stay.
Bottom line: Suspect dysphagia in all patients with cervical fractures, especially the elderly. We don’t use halo vests very often any more, but cervical collars can exacerbate the problem by keeping the neck in an unaccustomed position. Carry out a formal swallowing evaluation, and adjust the collar (or halo) if appropriate.
Reference: Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation. J Trauma 70(1):46-50, 2011.
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