How To Apply A Miami J Collar
There is quite a bit of controversy surrounding clearing the cervical spine in children. The trauma and emergency medicine literature have few high quality studies to base recommendations on. However, a few very good studies have been carried out that did include children, and they are the basis for this suggested method for clearance.
There are a few key concepts that must be understood before approaching spine clearance in this patient group.
- Clinical clearance is key! The majority of children’s cervical spines can be cleared clinically
- Limit routine radiographic evaluation, especially by CT. The head and neck is packed with glandular tissue that is sensitive to radiation, especially in early childhood.
- If radiographs are required, be sure to have them read by a radiologist who routinely reads pediatric images. There are many nuances in ossification and bony positioning that may falsely lead to injury diagnoses.
- Memorize the NEXUS criteria. This study included enough children to allow treatment recommendations to be validated. They are:
- Midline cervical tenderness
- Focal neurologic deficit
- Altered level of consciousness
- Evidence of intoxication
- Painful distracting injury
The first step is to determine whether the child is eligible to be clinically cleared. They must be able to verbalize and cooperate with your exam. They may not have a developmental delay, since this may interfere their ability to cooperate with your exam. Frequently, younger children are apprehensive around doctors, and I recommend that you have a parent perform appropriate parts of the exam under your verbal guidance.
Next, evaluate to see if any of the NEXUS critieria are met. The distracting injury criterion is the most difficult to assess. This is a judgment call, but if the child is aware of multiple potentially painful areas, then a distracting injury is probably not present.
If no NEXUS criteria are met, the spine is cleared and should be documented as such. If any are present, a lateral cervical spine xray should be ordered. If the child is >8 years old, a plain odontoid xray should also be obtained. If all are normal, the spine is cleared and should be documented. Children 8 or younger do not have an odontoid that visualizes well. In such cases, a CT from occiput to the base of C2 should be obtained, with appropriate shielding in place.
If, at any point, an abnormality is encountered, expert consultation must be sought in order to safely clear the cervical spine and remove any stabilization.
This is the first in a series of articles on interesting abstracts presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma in Phoenix, Arizona.
C-spine clearance in obtunded trauma patients has been problematic for some time. The options have been:
- CT plus MRI. This is probably only valid for the first 72 hours after injury, and entails some risk in placing a critically ill patient inside the MRI for 30 minutes or more.
- CT plus flexion/extension images under fluoroscopy. These are generally only performed by a few brave souls.
- Leave the collar on until a clinical exam can be performed. This frequently leads to significant skin breakdown problems.
The authors have been reviewing their experience with using CT scan alone. In this paper, they used this technique in patients who met the following criteria:
- Blunt trauma
- CT normal, as read by a neuroradiologist
- Moving all extremities
They studied 197 patients, and found no injuries in all surviving patients (11% were lost to followup). One deceased patient had a stable ligamentous injury without spine fracture seen at autopsy. Using this technique resulted in a decrease in the average number of days to spine clearance from 7.5 to 3.3 days, a decrease in skin breakdown from 5% to 0.5%. A decreased length of stay from 23.4 to 13.8 days was also seen, but this could not be attributed to the collar.
Very intriguing! However, the fear of SCIWORA is high in all who clear c-spines. The rarity of this catastrophic problem means that no existing study has the statistical power to show that this type of clearance is safe.
Bottom line: We all need to decide “How many missed injuries is okay?” We will never be able to absolutely clear 100.000% of c-spines by xray alone, or even by adding a clinical exam. This study provides support for one technique, but eventually a catastrophic injury will occur. Who will decide what constitutes an acceptable complication and with what frequency they will occur?
Reference: A Normal CT Alone May Clear the Cervical Spine in Obtunded Blunt Trauma Patients with Gross Extremity Movement – A Prospective Evaluation of a Revised Protocol. Leukhardt, Como, Anderson, Wilczewski, Samia, Claridge. MetroHealth Medical Center, Cleveland, OH.