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:
- 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.
- If a fracture is identified, consult your spine service.
- If a neurologic deficit is present, obtain an MRI and consult your neurosurgery or spine service.
- 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.
Overall, omega-3 fatty acids (O3FA) are thought to be an important and beneficial part of our diet. Recently, the Journal of Neurosurgery published an online paper that looked at the potential benefits of fish oil supplementation on recovery from brain injury.
Originally, axonal damage from TBI was thought to occur at the time of impact. Recent research has shown that the injury is really a progressive event that leads to swelling and axon disconnection during the hours to days after the initial injury. Building on a few animal studies over the past 6 years, a project to look at the effect of omega-3 fatty acid supplementation on brain injury was developed.
The authors performed a controlled study in rats, comparing supplementation with 10 or 40 mg/kg/day of O3FA for 30 days after brain injury with no supplementation. After 30 days, the rats were sacrificed and their brains were examined. The investigators found that a chemical marker of axonal injury (beta amyloid precursor protein) was very significantly decreased in the supplemented animals. The decrease was fairly dramatic and was similar for both doses.
The actual mechanism by which the protective effect of O3FA was not determined in this study. There is speculation that it may be due to stabilization of brain cell membranes and reduction in the number of reactive oxygen molecules.
This research is very intriguing and appears to have been designed and executed well. The only downside to the work is that the senior investigator is the founder and trustee for the Inflammation Research Foundation. The foundation promotes research on the treatment of diseases with nutritional supplements such as fish oil. The Foundation provided the supplements used in this study. Readers must always be careful when interpreting positive data that is funded or supported by an organization that may benefit from positive results.
Bottom line: Interesting study, and certainly one that should be followed up with human studies. As far as we know, fish oil supplements are relatively safe, so it should be a little easier to move this work along to human studies. It is not sufficient to recommend adding O3FA to the nutritional regimen of head injured patients yet.
Reference: Omega-3 fatty acid supplementation and reduction of traumatic axonal injury in a rodent head injury model Laboratory investigation. Sears et al. J Neurosurg online July 16, 2010.
Epley’s Maneuver For Vertigo After TBI
Some people experience vertigo after suffering a TBI. This may occur because small calcium carbonate crystals that are normally attached to a membrane in the middle ear are dislodged by the trauma. They can then settle within the semicircular canals. When the head is turned or moved, they brush against the sensitive hairs, sending false signals to the brain. This can result in dizziness, nausea and vertigo.
The Epley maneuvers were designed to move the crystals back out of the semicircular canals, where they can adhere to the membrane again. They consist of a pattern of head movements that should be performed by a trained professional. This is very important because the maneuvers may induce nausea requiring antiemetics. Certain head movements must be limited for a few days after the maneuvers to make sure the crystals stay in position. The overall success rate is about 80%, but on occasion the maneuvers must be repeated for success.
The video demonstrates the basics of the maneuvers. Remember, don’t try this at home by yourself. Seek out a therapist who is experienced with them.
Emergency physicians and trauma surgeons routinely assess patients with potential neurotrauma and decide whether to obtain CT scans and/or neurosurgical consultations. The criteria they use to make these decisions are not always clear.
The neurosurgery department at the University of California – Davis performed a prospective study that looked at the appropriateness of consults they received and of CTs of the head ordered by other physicians in trauma and non-trauma patients. A total of 99 patients entered the study (32 head trauma, 29 spine trauma, 34 other disease, 4 not documented).
After reviewing the consultations, they found that 69 were appropriate, 32 were not appropriate, and 7 could not be classified. Additionally, they felt that 10 of the head CTs in injured patients (31%) were not indicated.
“Appropriateness” was difficult to define well in this study, and there is certainly a great deal of subjectivity involved. The authors recommend using the Canadian CT Head Rule to fine-tune use of head CT in trauma patients.
The bottom line: 1 in 4 consults were not appropriate, and 1 in 3 head CTs were not indicated. Despite its flaws, this study shows that we need to be better at evaluating our patients to reduce unnecessary consults and radiation!
Reference: (In)appropriate neurosurgical consultation. van Essen et al. Clinical Neurology and Neurosurgery. In press, for publication 10/2010.
There is an increasing public interest regarding exposure to medical radiation. It represents the major exposure source for the population at large. There may be a presumption on the part of medical providers that “what you can’t see can’t hurt you” but this is just not the case.
A number of studies have shown that there is risk association with repeated exposure to xray. This risk is particularly important when dealing with pediatric patients. It’s time to start critically looking at our imaging practices and to start critically thinking about every one that we order.
One common source of repeat radiation is the repetitive CT scans of the head that patients who suffer TBI undergo. Frequently, there is little rhyme or reason to the patter of these scans. Should we repeat in 6 hours? 24 hours? When any lesions finish evolving?
It turns out that there is a reasonable amount of guidance in the brain literature. For the most part, they suggest that patients who are not in an ICU only need a repeat CT if their mental status changes. Any others obtained did not result in any management change. The first 6 papers listed below agree with this.
However, number 7 is interesting. It was published in the Journal of the American College of Surgeons and was a retrospective study of patients seen at a Level I Trauma Center. All patients had a lesion seen on initial scan, and underwent repeat scanning. The authors found that 6% of their patients underwent a surgical or medical “intervention” based on changes on the repeat head CT. What troubled them the most was that 21 of these 51 patients did not have any substantial neurologic change. They conclude that routine repeat head CT is very useful.
It’s not clear why their results are so disparate from the others. It is retrospective, and the authors do not state what the interventions exactly are. Nor do they speculate on why their results are so different from others. Nor do they show any difference in outcomes.
The bottom line: Repeat head CT is probably not needed in patients with mild TBI who are not on anti-coagulants or anti-platelet agents. However, regular mental status checks and GCS measurements must be taken.
- Is repeated head computed tomography necessary for traumatic intracranial hemorrhage? American Surgeon 2005 Sep;71(9):701-4.
- Routine repeat head CT for minimal head injury is unnecessary. J Trauma 2006, Mar;60(3):494-9.
- A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed. J Trauma 2006 Oct;61(4):862-7.
- Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury. J Trauma 2007 Jun;62(6):1339-44.
- The role of early follow-up computed tomography imaging in the management of traumatic brain injury patients with intracranial hemorrhage. J Trauma 2007 Jul;63(1):75-82.
- Value of repeat cranial computed tomography in pediatric patients sustaining moderate to severe traumatic brain injury. J Trauma 2008 Dec;65(6):1293-7.
- Schedule repeat CT scanning for traumatic brain injury remains important in assessing head injury progression. J Amer Coll Surgeons 2010 May;210:824-32.