Cervical Spine Controversies

“Collars & Clinical Clearance”

Dr D Reed FACEM Director of Trauma Gosford Hospital June 2017

Overview

• Cervical spine immobilisation

• How should we do it?

• Which collar should we use?

• Cervical spine clinical clearance

• How should we do it?

Let’s consider a case…. and a few questions……

I.M.I.S.T.

• I: 20 yr old male

• M: MVA driver rear ended at lights

• I: Sore neck & slightly sore chest and wrist

• S: HR 80 SBP 120 RR 20 GCS 15 SaO2 99% RA

• T: Immobilisation and collar and transfer

What level of immobilisation?

Which Collar Pre-Hospital?

VS VS

Which Collar in ED?

VS VS

Which Protocol to Clear?

VS

So what is the evidence?

What level of immobilisation?

What level of immobilisation?

• There is little evidence to support routine use of full spinal immobilisation pre-hospital or in-hospital

• No randomised trials as per Cochrane Review below

• Both ATLS/EMST and APLS moving away from recommending full immobilisation

• Real world use seems to be largely restricted to inter-hospital transport of high risk patients

ANZCOR 2016

Which Collar?

VS VS

Which Collar?

• There has been a lot of recent discussion in the trauma world about the lack of evidence for the use of stiff neck collars in the pre-hospital and ED settings

• Some groups have argued that collars should not be used in the pre-hospital setting for conscious patients while others have suggested the use of soft collars

• Evidence suggests that collars are not beneficial for patients with penetrating trauma

Penetrating Neck Injury

The British

The Scandinavians

The Americans

ANZCOR 2016

ANZCOR 2016

Stiff neck

PROS

• Widely used

• Familiar

• Relatively simple

• No significant proven harm in blunt trauma if used properly

• No clear proven reason to change

CONS

• Uncomfortable

• Compliance issues

• Airway compromise

• Raised ICP

• Hyperextension

• Cadaver studies suggest may not stop movement

• Penetrating trauma harm

• No proven benefit

Soft Collar

PROS

• Simple

• Easy to fit

• More comfortable

• Better tolerated

• Recent studies show no proven harm when compared to stiff neck collars

CONS

• Nil known

• Not proven to be better than stiff neck collars

The Queenslanders

The Queenslanders

The Queenslanders

Which Protocol to Clear?

VS

Which Protocol?

• There are two good evidence based clinical decision rules for clinically clearing the c-spine without imaging: namely the NEXUS Criteria (NEXUS) and the Canadian C-spine Rules (CCR)

• There are pros and cons to both protocols and different organisations use different protocols or a combination of the two

• Overall prompt clinical clearance prevents potential harm from unnecessary immobilisation and radiation

NEXUS Criteria

• 2001 NEJM - 34069 blunt trauma patients

• All ages and no specific exclusions

• Sensitivity 99.6% and specificity 12.9%

• Simple and emphasises clinical judgment

• Does specifically assess for drugs / alcohol /distracting injury

• Does not address low risk features on history

• Does not assess mechanism of injury

• Does not assess age

• Does not assess for pre-existing c-spine abnormality

• Does not assess neck movement

Canadian C-Spine Rules

• 2001 JAMA - 8924 stable alert adults blunt trauma • 100% sensitivity and 42.5% specificity

• Excluded abnormal vitals (inc altered LOC) • Excluded pre-existing c-spine abnormality

• Identified age >65 & dangerous mechanism as high risk • Identified low risk features eg mobilise or delayed onset • Identified range of movement as important

• Did not use drugs/alcohol/distracting injury • Did not assess pain on movement

Combined Protocol?

+

What’s happening in NSW?

ASNSW

>>

Gosford & Wyong NSW 2015 “Clinically Clear or Comfort Collar”

Cannot clear >>>>>>

Clinically clear on arrival

(Combined Protocol)

>>>>>>

St George NSW 2016 “Clinically Clear or Soft Collar Initially”

Cannot clear Within 1 hour >>>>>>

Clinically clear (Combined protocol) >>>>>>

# or neurology

>>>>>>>

Any comments or questions before we look at that case again and get some of your opinions about what to do?

???????????

So lets look at that case….

I.M.I.S.T.

• I: 20 yr old male

• M: MVA driver rear ended at lights

• I: Sore neck & slightly sore chest and wrist

• S: HR 80 SBP 120 RR 20 GCS 15 SaO2 99% RA

• T: Collar and transfer

Pre-hospital

• Which collar/immobilisation should be applied?

– Full spinal immobilisation?

– Stiff neck collar?

– Soft collar?

– No collar?

???????

Pre-hospital

• Should this patient be clinically assessed and cleared at the scene? – How often does this occur?

– What are the problems of using it in the field?

– What is the miss rate?

????????

Arrives in ED

• What sort of bed?

• What level of immobilisation?

• What sort of collar?

• How to clear?

???????

Time to Wrap Up

The Future?

Early Clinical Assessment Combined Protocol

Clinically cleared or cleared after assessment and adjunctive imaging

Long term comfort collar if fracture or neurology

ED

ASNSW & ED

ED

You decide !

So how do I do it?

• Combine NEXUS with CCR

– NEXUS clinical bedside exam

– CCR high and low risk features plus exclusions

– CCR range of movement plus pain on movement

– Plus bedside functional observation

• Lets run through that………

Steps to Clinical Clearance

• Initial Primary Survey ABCDEs

• Cervical Spine Assessment Steps

1. Initial clinical examination

2. Historical risk factor assessment

3. Range of movement assessment

4. Functional assessment

Cervical Spine Assessment

• Step 1 - Initial clinical examination

• Step 2 - Historical risk factor assessment

• Step 3 - Range of movement assessment

• Step 4 - Functional assessment

If patient fails any of these steps then will need medical imaging and further clinical assessment

Initial Clinical Examination

• Alert conscious cooperative

• No drug or alcohol intoxication (nb analgesia)

• No painful distracting injury (nb analgesia)

• Neurologically normal on Hx & Ex (nb paresthesia)

• No midline bony tenderness on palpation

History – High Risk

• Age > 65

• Pre-existing abnormal c-spine • Age >65

• Rheumatoid arthritis / ankylosing spondylitis

• Previous c-spine injury or surgery

• Dangerous mechanism • High speed MVA / rollover / ejection

• Fall from a height / down stairs / diving into surf

• High impact MBA / bicycle / pedestrian etc

History – Low Risk

• Healthy young adult

• Walked since accident

• Delayed onset neck pain

• Simple rear end MVA

Risk Factor Judgment

• Need to make a clinical judgment about the relative significance of the risk factors in light of the initial clinical examination

• Ask yourself - is it safe to assess neck movement?

• A young man who has fallen from a horse or bike is potentially high risk but if they subsequently walked at the scene they have already had a trial of neck movement so it is realistically safe to do a careful clinical examination.

Range of Movement

• Assess range of neck movement if reassuring initial clinical examination and favourable risk factor profile

• Able to actively rotate neck 45* to left and right without restriction or significant midline neck pain?

• Able to flex and extend neck without restriction or significant midline neck pain?

Note the ability of patient to actively rotate neck 45* to left or right regardless of neck pain was most predictive

of lack of c-spine injury in the CCR

Functional Assessment

• Remove collar

• Provide simple analgesics (paracetamol/ibuprofen)

• Observe & reassess

• Patients normally feel much better and start to move neck especially when distracted by family / friends

• Confirms clinical clearance

Pitfalls

• Age > 65

• Analgesia / alcohol / alertness

• Unstable patients / multi-trauma

• Paresthesia

• Pain on movement

• Unexpected abnormal cspines

C-Spine Clinical Clearance

• Step 1 - Initial clinical examination

• Step 2 - Historical risk factor assessment

• Step 3 - Range of movement assessment

• Step 4 - Functional assessment

If patient fails any of these steps then will need medical imaging and further clinical assessment