The physical exam is an important part of the initial evaluation of trauma patients. Sometimes it actually makes the diagnosis, but much of the time it focuses further studies like x-rays or lab tests. But we can also use it as a tool to avoid further imaging. For example, consider clinical clearance of the cervical spine. A negative exam in a reliable patient allows us to remove the cervical collar.
Can we apply the same thinking to the thoracic and lumbar spines? Many of us do. No pain or tenderness equates to no imaging or log-roll precautions.
The trauma group at LAC+USC looked at this one a few years ago. They studied every blunt trauma patient over a 6-month period, and first determined if they were “evaluable.” This meant not intoxicated, head injured (GCS<15), and no distracting injury (determined very subjectively). All underwent a standard exam of the TL spine by a resident or attending surgeon.
Here are the factoids:
886 patients were enrolled, and 218 (25%) were not evaluable using the criteria above
11% of the non-evaluable patients were found to have a TL spine fracture by CT, whereas only 8% of the evaluable group did
Of the evaluable patients, half (29) had no signs or symptoms of fracture
Of those 29 without signs or symptoms, two had a “clinically significant” fracture. Both were younger (20 and 59). One had a T7 compression and a transverse process fracture, the other a T9 compression fracture. Both were treated with a TLSO brace.
Of the 27 who could not be examined, 11 had “clinically significant” fractures; 8 were treated with TLSO and 6 with surgery (obviously some overlap there)
Bottom line: So physical exam of the thoracic and lumbar spine sucks, right? Not quite so fast! First, this is a small-ish study, but with enough patients to be intriguing. The biggest issue is that we don’t really know what is “clinically significant.” Treatment of stable fractures of the spine is controversial, and our friendly neighborhood neurosurgeons vary tremendously in how they do it. Ask five neurosurgeons and you’ll get six different answers.
Braces are expensive, and the optimal choice is not clear yet. At my hospital, we are treating select ones with a binder for comfort or a simple backpack brace. The fancier ones like the TLSO easily cost over $1000!
At this point, I recommend that you use a good blunt imaging practice guideline like the one below, coupled with a good physical exam. If the patient has sufficient mechanism to break something (which decreases with patient age), then image them. If they don’t, but have an abnormal exam, image them anyway. And we’ll wait for the next bigger/better study!
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!
This 11 minute video provides information on the cervical spine clearance process in awake patients, reviews activity restrictions associated with the use of cervical collars, and discusses information about specific type of collars. It is designed for ED nurses and non-ED nurses who may encounter cervical spine collars.
Clearance of the cervical spine can often be done using clinical criteria alone (see this video at http://youtu.be/NhjF9kDOcjE). If this is not possible, a combination of radiologic and clinical evaluation is usually carried out.
In some cases, radiographic studies (usually CT) are normal, but there is pain on clinical exam. Our next step is to send the patient to xray for flexion and extension views. This exam is performed by removing the collar while the patient is sitting, so the thoracic and lumbar spines must be clear before ordering this. The patient then gently flexes and extends the neck to their limits of comfort. Images are then obtained at the limits of flexion and extension. The premise is that a normal, awake patient cannot and will not move their neck beyond their comfort level to the point where they could cause themselves neurologic injury.
It is very important that you look at the images yourself. The radiologist may review the images and will report that “there is no evidence of subluxation at the limits of flexion and extension.” But the patient may have barely moved their neck!
The question is: how much flexion and extension do you need to have to clear the spine?
The answer is not easy to find, and is buried in literature from the 1980s and 90s. According to the EAST guidelines, the ideal amount is 30 degrees from neutral for both flexion and extension. This is not always achievable in elderly patients, so in those cases you must use your judgment. Talk to the patient to find out if they stopped moving their neck forward or backward due to pain, or because they just can’t move it that far.
Trouble signs to look for are:
Subluxation of more that 2mm at any level
Angulation of more than 11 degrees
Any abnormality should prompt a spine consult.
If the study is not abnormal but the amount of flexion and/or extension is not adequate, there are two options. First, just leave the collar in place and try again in a week or so and try again. This will allow any soft tissue injuries to get better and may allow a successful repeat study. The alternative is a more costly and less well-tolerated MRI.