REVIEW ARTICLE ANZJSurg.com

Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm Timothy R. Lukins,* Richard Ferch,* Zsolt J. Balogh† and Mitchell A. Hansen* *Department of Neurosurgery, John Hunter Hospital, Newcastle, New South Wales, Australia and †Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia

Key words cervical trauma, collar, imaging, immobilization, trauma. Correspondence Dr Timothy R. Lukins, Department of Neurosurgery, John Hunter Hospital, 2 Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia. Email: [email protected] T. R. Lukins MBBS, GradDipAnat; R. Ferch MBBS, FRACS; Z. J. Balogh MD, PhD, FRACS; M. A. Hansen MBBS, FRACS. Accepted for publication 16 May 2015. doi: 10.1111/ans.13221

Abstract Background: Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient. Methods: The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies. Results: Awake, asymptomatic patients may be ‘cleared’ without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be ‘cleared’ without magnetic resonance imaging. There is no longer a role for flexion–extension films. In the obtunded patient, findings remain conflicting. Conclusion: Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion–extension film in detecting injury. Management of the obtunded patient remains controversial.

Introduction In the pre-hospital setting, it has become commonplace to apply a cervical spine (CS) collar to all trauma patients, as the consequences of overlooking an unstable injury can be disastrous. The use of hard collars is ubiquitous, but there is controversy regarding the investigation and management of patients with suspected CS trauma. This particularly relates to patients that can be safely ‘cleared’ without further radiological investigation, and those that cannot. For those that do require imaging, a rational approach to selecting the appropriate imaging modality must be exercised. Streamlining this pathway minimizes the length of hospital stay, health expenditure and incidence of collar-associated morbidity. © 2015 Royal Australasian College of Surgeons

A contemporary and widely accepted protocol on the use of CS collars in trauma was the result of a collaboration between the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS).1 These guidelines highlighted the paucity of Class I data in the management of these potential injuries. Furthermore, the Class II and Class III evidence is conflicting, with significant heterogeneity of study populations, imaging modalities, and delegated ‘gold standards’. Since this publication was made, further evidence has emerged that has the potential to reshape clinical practice. Much of this shifting evidence places increasing reliance on computed tomography (CT) correlating with improvements in the ability to capture exquisite voluminous data married with advances in image processing software. The aim of this review, therefore, is to ANZ J Surg 85 (2015) 917–922

918

Lukins et al.

appraise this recent evidence beyond the AANS/CNS guidelines and use the information contained within to develop a treatment algorithm applicable to Australian trauma centres, without many of the discrepancies of earlier efforts.

Methods We complied with the Centre for Reviews and Dissemination (CRD) guidelines in conducting this systematic review. Seeking to represent an update on the earlier AANS/CNS guidelines, a similar search methodology was utilized. Similarly, the systematic review that ensues is structured to reflect the various clinical presentations following blunt cervical injury. Two separate searches were conducted of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014. The first used the terms ‘spinal cord injury’ or ‘spinal fractures’ or ‘spinal injuries’; the second used the terms ‘clearance’ or ‘diagnosis’ or ‘radiographs’. The searches were then combined using ‘and’ and were limited to English language and human subjects. A single reviewer (TRL) evaluated study abstracts to identify those reporting the diagnostic potential of an imaging technique. Studies were excluded if they were based on case reports, a nonadult sample group (99.9% for CT. NPV of CT 100%. Conclusion: MRI not indicated. Quantitative summations not possible due to data heterogeneity, but ‘CT performed favourably in clearing injury’. Conclusion: CT alone ‘may be sufficient to safely clear significant CS injury’.

II

*CT scans and MRI were considered clinically significant if they detected one of the following: ligamentous injury in two adjacent spinal columns, subluxations, cord injury, nerve root injury, disc herniations, and fractures except the following types as specified by the National Emergency x-radiography Utilization Study (NEXUS)2: spinous process fracture without involvement of the lamina, transverse process fracture without involvement of the facet joint, osteophyte fracture not including corner or teardrop fracture, isolated avulsion without associated ligamentous injury, simple wedge-compression fracture without loss of greater than or equal to 25% of vertebral body height, endplate fracture, type 1 odontoid fracture, and injury to the trabecular bone.22 CS, cervical spine; CT, computed tomography; MRI, magnetic resonance imaging.

evidence supporting this practice, with further Class III evidence failing to identify superior sensitivity over CT in detecting these injuries. Similarly, in patients with persistent non-neurological symptoms, mounting Class II evidence has failed to demonstrate superior sensitivity of MRI relative to CT. Regarding the role for an adjunctive MRI in the obtunded patient, a review of current data reveals a series of Class II and III studies with heterogeneous inclusion criteria, drawing conflicting results.24,27,34,35 Clearance is made challenging in this group by the inability to perform a detailed clinical assessment. Furthermore, the incidence of CS injury in these patients has been reported as high as 34.4%.36

Conclusion Several recommendations supported by recent evidence that deviate from the 2013 AANS/CNS guidelines1 are listed: (1) ‘Symptomatic’ patients should be categorized as either ‘neurological’ or ‘non-neurological’. Those with persistent nonneurological symptoms may be cleared on the basis of normal CT, whilst those with neurological symptoms and a normal CT should proceed to MRI. (2) FEF can be excluded from the list of options for investigation in the awake, symptomatic patient. (3) Management of the obtunded patient with a normal CT remains controversial. Given evidence does not unanimously © 2015 Royal Australasian College of Surgeons

Cervical spine clearance following blunt trauma

Fig. 1. Cervical spine ‘clearance’ algorithm in separate attachment. CT, computed tomography; GCS, Glasgow Coma Scale; MRI, magnetic resonance imaging.

contradict specialist clearance on the basis of CT alone, this remains a viable option. Unfortunately, there has been no Class I evidence to date regarding appropriate management in this situation. Future studies require: • Use of gold-standard MRI in all patients; • Consistency in defining which injuries are significant; • Consistency in defining which interventions are significant; and • Agreement regarding the optimal timing for the conduct of MRI. The American College of Radiologists37 recommends doing so only once clinical examination has been unable to be performed for 48 h. A clinical algorithm incorporating data from recent evidence and reflecting change from previously published guidelines has been presented (Fig. 1). Further Class I evidence in this area is needed, particularly given the conflicting evidence currently in existence. However, discrepancy between research outcomes is likely to continue for as long as there is controversy regarding what constitutes a clinically significant cervical injury, and what constitutes significant intervention.

References 1. Ryken TC, Hadley MN, Walters BC et al. Radiographic assessment. Neurosurgery 2013; 72: 54–72. 2. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. For the National Emergency X-Radiography Utilization Study Group. NEJM 2000; 343: 94–9.

© 2015 Royal Australasian College of Surgeons

921

3. Stiell IG, Wells GA, Vandemheen KL et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001; 286: 1841–8. 4. Como JJ, Diaz JJ, Dunham CM et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma practice management guidelines committee. J. Trauma 2009; 67: 651–9. 5. Daffner RH. Cervical radiography for trauma patients: a time-effective technique? AJR Am. J. Roentgenol. 2000; 175: 1309–11. 6. Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. AJR Am. J. Roentgenol. 2001; 177: 677–9. 7. Blackmore CC. Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clin. N. Am. 2003; 13: 283–91. 8. Bailitz J, Starr F, Beecroft M et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J. Trauma 2009; 66: 1605–9. 9. Mathen R, Inaba K, Munera F et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J. Trauma 2007; 62: 1427–31. 10. Griffen MM, Frykberg ER, Kerwin AJ et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J. Trauma 2003; 55: 222–6, discussion 226-7. 11. Daffner RH, Sciulli RL, Rodriguez A, Protetch J. Imaging for evaluation of suspected cervical spine trauma: a 2-year analysis. Injury 2006l; 37: 652–8. 12. Resnick S, Inaba K, Karamanos E et al. Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study. JAMA Surg 2014; 149: 934–9. 13. Chew BG, Swartz C, Quigley MR, Altman DT, Daffner RH, Wilberger JE. Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? J. Neurosurg. Spine 2013; 19: 576–81. 14. Soult MC, Weireter LJ, Britt RC et al. MRI as an adjunct to cervical spine clearance: a utility analysis. Am. Surg. 2012; 78: 741–4. 15. Ackland HM, Cameron PA, Varma DK et al. Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann. Emerg. Med. 2011; 58: 521–30. 16. Pollack CV, Hendey GW, Martin DR, Hoffman JR, Mower WR, Group NEXUS. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann. Emerg. Med. 2001; 38: 8–11. 17. Insko EK, Gracias VH, Gupta R, Goettler CE, Gaieski DF, Dalinka MK. Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J. Trauma 2002; 53: 426–9. 18. Tran B, Saxe JM, Ekeh AP. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan? J. Surg. Res. 2013; 184: 411–3. 19. McCracken B, Klineberg E, Pickard B, Wisner DH. Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. Eur. Spine J. 2013l; 22: 1467–73. 20. Khan SN, Erickson G, Sena MJ, Gupta MC. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J. Orthop. Trauma 2011; 25: 51–6. 21. Taylor M, Hipp JA, Gertzbein SD, Gopinath S, Reitman CA. Observer agreement in assessing flexion-extension X-rays of the cervical spine, with and without the use of quantitative measurements of intervertebral motion. Spine J. 2007; 7: 654–8. 22. Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic

922

23.

24.

25.

26.

27.

28.

Lukins et al.

scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am. J. Surg. 2013; 206: 987–93, discussion 993-4. Russin JJ, Attenello FJ, Amar AP, Liu CY, Apuzzo MLJ, Hsieh PC. Computed tomography for clearance of cervical spine injury in the unevaluable patient. World Neurosurg. 2013; 80: 405–13. Kaiser ML, Whealon MD, Barrios C, Kong AP, Lekawa ME, Dolich MO. The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan. Am. Surg. 2012; 78: 1156–60. Raza M, Elkhodair S, Zaheer A, Yousaf S. Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan–a meta-analysis and cohort study. Injury 2013; 44: 1589–95. Khanna P, Chau C, Dublin A, Kim K, Wisner D. The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J Trauma Acute Care Surg. 2012; 72: 699–702. Como JJ, Leukhardt WH, Anderson JS, Wilczewski PA, Samia H, Claridge JA. Computed tomography alone may clear the cervical spine in obtunded blunt trauma patients: a prospective evaluation of a revised protocol. J. Trauma 2011; 70: 345–9, discussion 349-51. Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J. Neurosurg. 2011; 115: 541–9.

29. Hussein D, Kanji MD. Sixty-four–slice computed tomographic scanner to clear traumatic cervical spine injury: Systematic review of the literature. J. Crit. Care 2014; 29: 314.e9–13. 30. Duane TM, Cross J, Scarcella N et al. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am. Surg. 2010; 76: 595–8. 31. MacDonald RL, Schwartz ML, Mirich D, Sharkey PW, Nelson WR. Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough? J. Trauma 1990; 30: 392–7. 32. Banit DM, Grau G, Fisher JR. Evaluation of the acute cervical spine: a management algorithm. J. Trauma 2000; 49: 450–6. 33. Lewis LM, Docherty M, Ruoff BE, Fortney JP, Keltner RA, Britton P. Flexion-extension views in the evaluation of cervical-spine injuries. Ann. Emerg. Med. 1991; 20: 117–21. 34. Sanchez B, Waxman K, Jones T, Conner S, Chung R, Becerra S. Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol. J. Trauma 2005; 59: 179–83. 35. Stelfox HT, Velmahos GC, Gettings E, Bigatello LM, Schmidt U. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J. Trauma 2007; 63: 630–6. 36. Berne JD, Velmahos GC, El-Tawil Q et al. Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J. Trauma 1999; 47: 896–902, discussion 902-3. 37. Daffner RH, Hackney DB. ACR Appropriateness Criteria on suspected spine trauma. J. Am. Coll. Radiol. 2007; 4: 762–75.

© 2015 Royal Australasian College of Surgeons

Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm.

Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Cong...
376KB Sizes 0 Downloads 10 Views