Cervical Spine Injuries in the ED

In this episode, I discuss the diagnosis of c-spine injuries. I argue that we should not send patients to imaging unless we have used the NEXUS rule and then added the Canadian C-spine Rule to the sequence. If we are imaging, it should be with a 3-view reconstructed CT scan. And even after that is done, you still need a clearance exam before removing the collar.

 The Fine Print of the NEXUS rule

You Need to Read Your Footnotes

The folks from Virginia think (J Trauma. 2011 Apr;70(4):829-31. & J Trauma2011;70(4):829-831) Nexus can't be used, but I think if you follow my advice in the podcast, you are probably going to come as close to 100% as a rule can provide. The Canadians also showed less than 100% Sens when using NEXUS (N Engl J Med. 2003 Dec 25;349(26):2510-8), but I would make the same argument--did they really do it the same as the NEXUS study advocates? Do you do it the same? If not, you may be missing injuries.

Then add the Canadian C-Spine Rule if there is Midline Tenderness, but no other NEXUS Criteria

Click on the Image for the Whole Algorithm

Plain Films Suck!

Want the evidence, check out the Spinal Cord Injury chapter at CrashingPatient

Injuries Missed on CT scan

Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. (Ann Emerg Med. 2011 Dec;58(6):521-30)

Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet? (J Trauma. 2008;64:898 –904.)

Update: this article is hot off of the presses: JAMA Surg. 2014 Sep;149(9):934-9. doi: 10.1001/jamasurg.2014.867. Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study.

Guidelines

Check out the c-spine guidelines from the Eastern Assoc of Surgeons for Trauma (EAST)

And now to the podcast...