Authors: Ian T. McGraw, MS, MSIII and Margaret Strecker-McGraw, MD, FACEP, FAAEM, Texas A&M Health Science Center School of Medicine

Editor: Julianna Jung, MD, Johns Hopkins Medical School

Last Update: 2016

Objectives

1. Discuss the purpose of traditional spinal immobilization and its effect on neurological outcomes in trauma
2. Recognize when spinal immobilization is indicated or not indicated
3. Identify the two decision rules that can be safely used to rule out clinically significant cervical spine injury
4. Discuss how to clear a C-spine in the Emergency department
5. Describe what imaging may be necessary in patients who complain of neck pain after trauma
   

Introduction

Spinal immobilization is one of the most common prehospital procedures in the setting of trauma.1 Early use of spinal immobilization was inadequate, resulting in the recommendation for a standardized practice of spinal immobilization in nearly all patients with the possibility of a spinal cord injury.2 Early outcomes research associated development of improved spinal immobilization techniques with better neurological outcomes in spinal cord injuries, and decreased development of complete lesions.1 However, this was merely an association, not backed by rigorous scientific research. Currently there is no high level evidence (Class I) demonstrating that spinal immobilization contributes to improved neurologic outcomes, as current evidence is limited to Class II and III, and future high-quality trials are unlikely to occur due to obvious ethical considerations.1,2

Rigid spinal immobilization is not without risk to the patient. It has been shown to decrease forced vital capacity in both the adult and pediatric populations,2 compromise vascular function and increase risk of pressure ulcers,3-4 and can confound emergency department assessment of traumatic injuries by causing pain. Utilization of spinal immobilization when not indicated can lead to moderate to severe pain.5 Due to the potentially injurious nature of spinal immobilization, judicious use has become the standard recommendation.

In 2013 the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma released a position paper on emergency medical services (EMS) spinal precautions and use of the long backboard, addressing proper use and precautions of spinal immobilization. Patients may be evaluated on scene to determine whether spinal immobilization is indicated. Possible indications and situations in which immobilization is contraindicated are listed below:6

Spinal Immobilization Indicated

• Blunt trauma
• Altered mental status
• Midline spinal pain or tenderness
• Neurologic complaints or findings
• Anatomic deformity of spine

High-energy mechanism of injury and any of the following:

• Drug or alcohol intoxication
• Inability to communicate
• Distracting injury

Spinal Immobilization NOT Indicated (ALL must be present)

• Normal level of consciousness (e.g. Glasgow Coma Score of 15)
• No spine tenderness or anatomic abnormality
• No neurologic findings or complaints
• No distracting injuries
• No intoxication

Relative Contraindications

• Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury

Maintaining spinal precautions (which means attempting to limit movement while maintaining alignment of the vertebral bodies), rigid cervical collar (stiff c-collar) without the use of a backboard may be appropriate for patients who are ambulatory at the scene, must be transported for a protracted time, or for whom a backboard is not otherwise indicated.6

Special Considerations

The numerous concerns regarding collars in adult patients are mostly transferable to the pediatric population.7 Most of the foundation for prehospital treatment of children with CSIs (cervical spine injuries) is based on adult studies, and the evidence favoring current management strategies is therefore even weaker than in adults.7

Currently, there are no randomized clinical trials that compare spinal immobilization in children with and without collars. However, there have been several observational studies and protocol algorithms to address pediatric cervical spine clearance. Most are based upon the NEXUS and Canadian C-Spine Rules with some additional considerations, and are institution dependent.8,9

How to Implement Spinal Motion Immobilization

1. Grasp the patient’s head and shoulders from a position at the head of the bed, physically keeping the spine aligned with the head.
2. While maintaining spinal alignment, have an assistant apply a cervical collar without lifting the head off the bed.
3. Prepare to roll the patient by having one or two assistants place hands on the far side of the patient across their shoulder, hip and knee, crossing their arms at the waist.
4. While maintaining cervical alignment from the head of the bed, the individual maintaining spinal alignment should count to three, at which time the assistant(s) roll the patient toward themselves, while another assistant quickly examines the back and then places the backboard under the patient. The patient is then rolled back onto the backboard.
5. Center the patient on the board while maintaining cervical alignment.
6. Secure the upper torso with straps first.
7. Secure the chest, pelvis, and upper legs with straps.
8. Secure the patient’s head by using a commercial immobilization device or rolled towels.
9. Place tape across the patient’s forehead and fasten the edges to the edges of the board.
10. Check all straps and readjust as needed. Reassess distal functions in all extremities.
    

The Patient Arrives in the Emergency Department

Once the patient arrives in the Emergency Department, the question then becomes, can we take the patient out of the C-collar and off the backboard, and which patients need to have c-spine imaging done as part of their workup?

There are over a million visits to US Emergency Departments annually for blunt trauma patients who present with a concern for possible cervical spine injury. Most of these patients undergo imaging of their c-spine, and most (98%) of the studies come back negative for fractures. So, how does one sort out who really needs imaging and who doesn’t?

The Canadian C-Spine Rule and National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria were developed to help physicians determine whether cervical spine imaging could be safely avoided in appropriate patients, with the implication that if imaging was not necessary, then neither was the c-collar and backboard. Both the Nexus Criteria and the Canadian C-spine Rules are well-validated decision rules that can be used to safely rule out cervical spine injuries in alert, stable trauma patients without the need to obtain radiographic images.11,12,13

The NEXUS Criteria was a prospective, observational sample of 34,069 patients, aged 1 to 101 years, presenting to 21 US trauma centers. Of those studied, 1.7% had clinically significant cervical spine injuries (CSI). The NEXUS Criteria was found to have sensitivity of 99.6% for ruling out CSI (2/578). This rule also detected 99.0% (8/818) of all CSI (6 of which were injuries that didn’t require stabilization or specialized treatment). Subsequent studies have found a sensitivity of 83-100% for CSI with majority finding 90-100% sensitivity.11 Utilizing this rule could decrease imaging in the these patients by 12.6%.
The Canadian C-spine Rule (CCR) was a prospective, cohort study that had a convenience sample of 8924 adults who had blunt trauma to the head/neck, stable vital signs and a GCS of 15.11 CCR was found to be highly sensitive for CSI, with the majority of studies finding it catches 99-100% of these types of injuries. Subsequent studies have found a sensitivity of 90-100%, which is similar to NEXUS.12 CCR would allow healthcare providers to safely decrease the need for imaging among this patient population by over 40%.

In the only trial to undertake a prospective head to head comparison of NEXUS to the CCR, the CCR was found to have superior sensitivity (99.4 vs. 90.7).13 While the Canadian C-Spine Rule is more complex than the NEXUS Criteria, and more difficult to memorize, it is more sensitive and can potentially be used on patients who cannot be cleared via Nexus Criteria.13

Unlike the Canadian C-spine Rule (CCR), NEXUS Criteria does not have age cut-offs and is theoretically applicable to all patients > 1 year of age.13 However, there is literature to suggest caution applying NEXUS to patients > 65 years of age, as the sensitivity may be as low as 66-84%.

So, who can be cleared in the emergency department with low risk of an undetected c-spine injury?

The NEXUS rules are as follows:

•  No midline tenderness: you must put your fingers on the c-spine and palpate all the way down
•  No evidence of intoxication
•  The patient has a normal level of alertness
•  No neurological deficit is detected
•  No distracting injury is present (a painful injury that would so occupy the patient that they may not notice pain in their neck)
  

The Canadian C-Spine rules are as follows:

•  The patient cannot be > 65 years old
  
•  The patient must be alert (GCS 15)
  
•  The patient cannot be intoxicated
  
• The patient cannot have a distracting injury
  
• The patient is not high risk (age >65 y or dangerous mechanism or paresthesias in extremities)
  
• A low risk factor that allows safe assessment of range of motion exists. This includes simple rear end motor vehicle collision, seated position in the ED, ambulation at any time post trauma, delayed onset of neck pain, and the absence of midline cervical spine tenderness.
• The patient is able to actively rotate their neck 45 degrees left and right.

If the criteria above are applied, there will be a significant number of patients who can be cleared without imaging. However, all patients with a suspected CSI who cannot be clinically cleared must have radiographic evaluation. This applies to patients with pain, tenderness, a neurologic deficit, altered mental status, a distracting injury, and obtunded patients.

Imaging and Follow Up

Computerized tomography (CT) of the cervical spine (CS) has supplanted plain radiography as the primary modality for screening suspected CS injury after trauma.15 Not only is CT CS is more accurate than plain radiography, but it is time effective, cost effective, and does not require additional plain films.15 If a CT CS demonstrates an injury or there is a neurologic deficit referable to a CS injury, a spine consultation should be obtained.8  Cervical spine imaging is discussed further in Cervical Spine Imaging in Trauma.

For patients who complain of neck pain but are awake, alert, have no neurologic deficit and a negative CT CS, there are several treatment options, but limited data.8 This may include continuing the cervical collar until follow up or negative imaging. There is current evidence that follow up films may actually be unnecessary with the use of new high resolution CT scanners.15,16 More research on this is still necessary.

References

1. Theodore N, Hadley MN, Aarabi B, et al. Prehospital Cervical Spinal Immobilization After Trauma: Neurosurgery. 2013; 72:22-34.
2. Domeier RM. Indications for prehospital spinal immobilization. National Association of EMS Physicians Standards and Clinical Practice Committee. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir. 1999; 3(3):251-253.
3. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988; 17(9):915-918.
4. Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991; 20(9):1017-1019.
5. McHugh TP, Taylor JP. Unnecessary Out-of-hospital Use of Full Spinal Immobilization. Acad Emerg Med. 1998; 5(3):278-280.
6. EMS spinal precautions and the use of the long backboard. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir. 2013; 17(3):392-393.
7. Blunt cervical spine injury in children. Tilt L, Babineau J, Fenster D, Ahmad F, Roskind CG. Curr Opin Pediatr. 2012 Jun; 24(3):301-6
8. http://www.east.org/education/practice-management-guidelines/cervical-spine- injuries-following-trauma
9. Anderson RC1, Scaife ER., et. al. Cervical spine clearance after trauma in children. J Neurosurg. 2006 Nov; 105(5 Suppl):361-4.
10. Foltin G.L., Dayan P., Tunik M., Marr M., Leonard J., Brown K., Hoyle J., and Lerner E.B.; Prehospital Working Group of the Pediatric Emergency Care Applied Research Network. (2010). Priorities for pediatric prehospital research. Pediatr. Emerg. Care 26, 773–777
11. Ian G. Stiell, MD, et. al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA. 2001; 286(15):1841-1848.
12. Jerome R. Hoffman, M.D., et. al., for the National Emergency X-Radiography Utilization Study Group. Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma. N Engl J Med 2000; 343:94-99July 13, 2000
13. Ian G. Stiell, M.D., et.al; The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003; 349:2510-2518December 25, 2003
14. Pieretti-Vanmarcke, Rafael MD; Velmahos, George C. MD; Clinical Clearance of the Cervical Spine in Blunt Trauma Patients Younger Than 3 Years: A Multi-Center Study of the American Association for the Surgery of Trauma. Journal of Trauma-Injury Infection & Critical Care: September 2009 – Volume 67 – Issue 3 – pp 543-550
15. Lisa Bush, PA-C1; Robert Brookshire, PA-C1; Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma ONLINE FIRSTJAMA Surg. Published online June 15, 2016. Original Investigation | June 15, 2016
16. Olubode A. Olufajo, MD, MPH, et. al. Does the Computed Tomographic Scan Tell the Whole Story for Cervical Spine Clearance? ONLINE FIRSTJAMA Surg. Published online June 15, 2016. Invited Commentary | June 15, 2016