Regardless of mechanism, resulting injuries, or ultimate disposition, it is mandatory that the cervical spine be addressed during the assessment of any patient presenting with blunt trauma. The practice of clinical clearance as a replacement for imaging each and every patient has been utilized since the adoption of the National Emergency X-Radiography Utilization Study (NEXUS) guidelines by the Eastern Association for the Surgery of Trauma (EAST). [1]
Unfortunately, there is an inherent subjectivity to the 5 criteria that comprise NEXUS and, even though they were intentionally written this way, debate may arise when evaluation of a patient's c-spine is undertaken. Within the NEXUS study, it is written:
"We chose not to define the individual criteria of the decision instrument explicitly, for two reasons. First, we do not believe such criteria can be precisely defined in a clinically meaningful way. An attempt to define a “distracting” injury, for example, with a long list of various injuries that could distract a patient from a cervical-spine injury would be extremely misleading... Therefore, we allowed the clinicians to judge whether the patients had an injury that could produce distracting pain and thus required cervical-spine imaging."[2]
In the past few years, it has been proposed that a distracting injury should not remain within the criteria, and that a patient meeting some combination of the other 4 criteria should be able to have his or her cervical spine cleared clinically. To support this hypothesis, several studies have been preformed and a few key outcomes have been collected below.
In the December 2009 issue of The Journal of Trauma, Gonzalez, et al. published a study titled "Clinical Examination in complement with computed tomography scan: an effective method for identification of cervical spine injury." In this prospective study, 1,687 patients were assessed and if the GCS was 14 or greater, clinical exam of the cervical spine was preformed regardless of distracting injury. Of the 1,439 patients with a GCS greater than or equal to 14, 897 had a negative clinical exam and the collar was removed. Two of the patients with a negative exam were subsequently found to have c-spine injuries.[3] This amounted to a 0.2% miss rate, which is in line with the figures calculated during the original NEXUS study. One miss occurred in a 60 year old man with a tibia-fibula fracture and the other in a 39 year old man with a posterior scalp laceration. This study concludes that distracting injury was not a significant cause of missed cervical injuries, as the rate of missed injuries was not increased when distracting injury was not a utilized criteria.
In September of 2011, The Journal of Trauma published another study that reached a similar conclusion titled "The presence of non-thoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study." In this study, 101 patients that were diagnosed with a c-spine injury were evaluated and 88 were found to have distracting injury. Out of these 88 patients with both c-spine injuries and distracting injuries, only 4 did not have pain or tenderness upon examination of the c-spine. These patients all had bruising and tenderness to the upper anterior chest. This study concludes that while upper thoracic injuries may distract patients from c-spine pain, patients with other injuries (rib fractures, upper extremity fractures, lower extremity fractures) could still be clinically cleared.[4]
Lastly, the Journal of Trauma and Acute Care Surgery published a study in August 2012 titled "Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth." This study was also presented as a poster at the 25th annual meeting of the Eastern Association for the Surgery of Trauma which took place Jan 10-12, 2012. In this study, 761 blunt trauma patients with GCS greater than or equal to 14 and at least one "distracting injury" were entered into the study protocol. 464 had their c-spine clinically cleared, and, of these, 1 patient (0.2%) was diagnosed with a c-spine injury.[5]
In light of these three well conducted, prospective studies presenting very convincing evidence, it seems that distracting injuries are not very distracting after all. Each of the studies presented above had a miss rate of c-spine injuries that was the same, if not less, than the original NEXUS study. Here at Cook County Trauma, one additional indicator that is utilized is the ability to maintain two-point tactile discrimination. It is proposed that if the patient has intact two-point tactile discrimination, then they are able to correctly identify and localize the pain that they are experiencing. Whether or not this criteria will receive broad acceptance is yet to be seen, but for now, it is one additional way to lend reliability to the clinical exam rather than relying solely on computed tomography.
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1- Como, John J., MD et al. "Cervical Spine Injuries Following Trauma." - Practice Management Guideline. The Eastern Society for the Surgery of Trauma, 2009. Web
2- Hoffman, Jerome R., MD et al. "Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma — NEJM." New England Journal of Medicine. New England Journal of Medicine, 13 July 2000. Web.
3- Gonzalez, Richard P., MD et al. "Clinical Examination in complement with computed tomography scan: an effective method for identification of cervical spine injury." The Journal of TRAUMA Injury, Infection, and Critical Care. U.S. Volume 67, Number 6, December 2009. Web.
4- Konstantinidis, Agathoklis, MD et al. "The presence of non-thoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study." The Journal of TRAUMA Injury, Infection, and Critical Care. U.S. Volume 71, Number 3, September 2011. Web.
5- Rose, MK, MD et al. "Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth." The Journal of Trauma and Acute Care Surgery. 2012;73: 498-502, August 2012. Web.
from Dr. Nicholas Wakim
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