Tag Archives: Cervical spine

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Myth: Motorcycle Helmets and Cervical Spine Injury

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The number of motorcyclists has been increasing over the past decade. At the same time, the number of states repealing their helmet laws is increasing. The evidence is convincing that the number and severity of brain injuries is decreased with helmet use. But what about spine injury?

Many arguments against wearing helmets given by riders are derived from a report in 1986 by Goldstein*. One of the issues cited in this paper is the potential increase in cervical spine injuries due to the weight of the helmet. A recently published study using the National Trauma Data Bank (NTDB) corroborates several smaller studies which show that this just isn’t so.

All motorcycle collisions in the NTDB involving adults were analyzed by logistic regression. Missing data was compensated for using standard statistical techniques. Nearly 41,000 cases had complete records for analysis. About 77% of riders were wearing helmets, and the overall mortality was 4%. 

Nonhelmeted riders suffered the following statistically significant differences:

  • A higher proportion of severe head injury (19% vs 9% with helmets)
  • Higher incidence of shock on admission (6% vs 5% with helmets)
  • Higher injury severity score (ISS) (14.7 vs 13.4 with helmets)
  • Higher crude mortality (6.2% vs 3.5% with helmets)
  • Higher incidence of cervical spine injury (5.4% vs 3.5% with helmets)

Bottom line: Motorcyclists wearing helmets had a 22% reduction in the likelihood they would sustain a cervical spine injury in a crash. This is in addition to decreases in shock, injury severity and death. These data need to be considered when the future of helmet laws is considered in any state looking at repealing them.

References:

  • Motorcycle helmets associated with lower risk of cervical spine injury: debunking the myth. J Amer Col Surgeons 212(3):295-300, 2011.
  • *The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injury. Evaluation Rev 10:355-375, 1986.
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Cervical Spinal Cord Injury: Who Needs A Tracheostomy?

The sad truth is that patients with cervical spine injury may need a tracheostomy. In very high lesions (C1-2) the need may be permanent. Lower injuries (C3-5) frequently need a trach for a limited period of time while they develop enough reserve to compensate for the lost of chest wall muscle power.

It’s not always easy to tell which patient is likely to need intubation upon arrival in the ED. I’ve seen occasional patients fail while getting their CT scans, which is poor planning. Is there a way to predict who might fail, thus benefiting from early intubation and an early plan for tracheostomy?

The trauma group at LAC + USC Medical Center undertook a National Trauma Databank review to try to answer this question. They identified 5256 patients with cervical spinal cord injuries without a severe traumatic brain injury that would otherwise require intubation. About 21% received tracheostomies, and the common predictors were:

  • Intubation at the scene by EMS (they’ve done the job of deciding for us!)
  • Intubation in the ED
  • Complete cord injury at any level
  • Facial fractures
  • Chest trauma
  • Injury Severity Score >=16

Patients who received a tracheostomy generally spent more days on the vent, in the ICU and in the hospital than those who did not. However, their mortality was lower.

It’s generally recognized that patients with complete injuries from C1-C5 routinely require tracheostomy. The surprising thing about this study was that complete injuries at C6 or C7 did as well.

Bottom line: If you have a patient with a spinal cord injury who meets any of the criteria above, stand ready to intubate. I tell my trainees that, if at any time they see something that makes them think about intubating, they should have already done it. Likewise, the surgical ICU team should have a low threshold to performing an early tracheostomy on these patients.

Reference: Incidence of clinical predictors for tracheostomy after cervical spinal cord injury: a National Trauma Databank review. J Trauma 70(1): 111-115, 2011.

Picture: crossbow bolt through the mouth and cervical spinal cord.

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Dysphagia and Cervical Spine Injury

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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

A study in the Jan 2011 Journal of Trauma outlines 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. 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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Distracting Injury and Cervical Spine Clearance

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One of the tenets of clinical c-spine clearance is that there be no “distracting injury.” What does this mean exactly? Can the clinician adequately judge which injuries are too distracting?

The Loyola group prospectively looked at 160 patients needing c-spine clearance over a 9 month period. GCS had to be 14 or 15, and the patients were excluded if they were intoxicated or received an analgesic prior to the clearance attempt. A total of 84% had no neck pain, and 82% of those had no peripheral, potentially distracting pain. Patients with perceived distracting pain and those without had very similar Visual Analog Scores (VAS) for pain. 

Overall, the majority of patients and physicians did not believe that distracting pain was present, and when pain was present there was little agreement whether it was distracting. The few patients who did have spine fractures had a VAS for pain >5. The use of physician judgment for distracting pain and clearance worked just fine in this study.

Bottom line: The authors recommend using clinician judgment as to the degree of distracting pain when clearing the c-spine. If you want to be more objective, if the patient complains of a Visual Analog Score for pain of more than 5, then you may want to delay clearance. Note: this is a small study that really needs to be replicated before widespread use.

Reference: C-spine clearance: don’t be distracted – just trust your judgment. Presented at the 24th annual scientific assembly of EAST, Session II, Paper 9. Click here to see the abstract. 

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Cervical Spine Clearance and Altered Mental Status

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Clearance of the cervical spine is a complicated topic, with many opinions and anecdotes. EAST developed a set of practice guidelines in 1998 and updated them in 2000 and again in 2008. They are well-accepted and very helpful.

Spine clearance in an obtunded or intoxicated patient is made even more challenging. Here’s an approach based on the EAST guidelines that I find helpful:

  1. Clear the bones. Obtain a CT of the cervical spine from skull base to T2. Sagittal and coronal 2D reconstructions must be created for review. Conventional images (AP, lateral, odontoid) are of no additional value.
  2. If a fracture is identified, consult your spine service.
  3. If a neurologic deficit is present, obtain an MRI and consult your neurosurgery or spine service.
  4. Clear the ligaments. In the obtunded patient, there are 3 choices: 1) keep the collar on until the patient wakes up enough to be examined, 2) obtain an MRI to evaluate the ligaments, or 3) remove the collar on the basis of CT alone.

In patients that you don’t expect to wake up any time soon, I prefer MRI. Some say that it should be obtained within 72 hours of injury for best accuracy in detecting ligamentous injury. Unfortunately, I have not been able to find any specific literature support for this. If the MRI is negative, the collar can be removed immediately.

There is a growing body of research that suggests that CT alone is sufficient for clearance. My opinion is that this is probably true, but only if the scan is read by a radiologist who is especially skilled in reading CT scans of the cervical spine. A pool radiologist may miss subtle findings that might indicate a ligamentous injury.

Reference: Eastern Association for the Surgery of Trauma practice guideline: Identifying Cervical Spine Injuries Following Trauma – 2009 Update. Click here to download.