Cervical Spine ============== þ Distracting Injuries - Injuries considered distracting: + Fractures: 58% + Lacerations/soft tissue injuries: 16% + Visceral injuries: 2% - Three patients with cervical spine injury who had “distracting” injury as sole reason for cervical imaging: + Ankle fracture + Clavicle fracture + Unknown in the 3rd patient [Ullrich, A., G. W. Hendey, et al. (2001). "Distracting painful injuries associated with cervical spinal injuries in blunt trauma." Acad Emerg Med 8(1): 25-29.] Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography. OBJECTIVE: To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography. METHODS: This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries. RESULTS: Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34%) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6%) additional cases. Fractures accounted for a majority of DPIs (154, or 58%), 42 (16%) were soft-tissue injuries or lacerations, and 86 (34%) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5%) patients with an acute cervical spinal injury, 20 (54%) had a DPI, including three (8%) who had DPI as the only indication for cervical radiography. CONCLUSIONS: A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI. - Chang: + 336 patients with distracting injury as sole indication for spine imaging + 8 patients had vertebral injury + One cervical spine injury (rotatory subluxation) + 7 with thoracolumbar injuries (compression fractures & transverse process fractures) + All 8 had bony fractures as their distracting injuries + No other type of “distracting injury” associated with vertebral fracture [Chang, C. H., J. F. Holmes, et al. (2005). "Distracting injuries in patients with vertebral injuries." J Emerg Med 28(2): 147-152.] To describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. A prospective cohort study was conducted at an urban Level I trauma center. All patients undergoing radiographic evaluation of the cervical, thoracic, or lumbar vertebrae after blunt trauma were enrolled. Patients had a data collection form completed by the treating physician before radiographic imaging and were evaluated for the following upon initial presentation: tenderness to the cervical, thoracic, or lumbar spine, distracting injuries, altered mental status, alcohol or drug intoxication, or neurological deficits. Patients with distracting injuries as the sole documented indication for vertebral radiographs were reviewed for the types of injuries present. A total of 4698 patients were enrolled in the study. There were 336 (7.2%) patients who had distracting injuries as the sole documented indication for obtaining radiographic studies of the vertebrae. Eight (2.4%, 95% CI 1.0-4.6%) of the 336 patients had 14 acute vertebral injuries including compression fractures (5), transverse process fractures (7), spinous process fracture (1), and cervical spine rotatory subluxation (1). There were 13 thoracolumbar injuries and one cervical spine injury. Distracting injuries in the eight patients with acute vertebral injuries included 13 bony fractures. Distracting injuries in those patients without vertebral injuries included bony fractures (333), lacerations (63), soft tissue contusions (62), head injuries (15), bony dislocations (12), abrasions (11), visceral injuries (8), dental injuries (5), burns (3), ligamentous injuries (3), amputation (1), and compartment syndrome (1). In conclusion, in patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries. - Heffernan + Prospective study of 406 patients + 40 with cervical spine fractures + 7 patients with non-tender necks and c-spine injuries: + All had at least one bony fracture: Ribs, humerus, scapula, pelvis, or femur + Conclusion: upper torso injuries are most worrisome but be especially concerned when there is a fractured bone [Heffernan, D. S., C. R. Schermer, et al. (2005). "What defines a distracting injury in cervical spine assessment?" J Trauma 59(6): 1396-1399.] BACKGROUND: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment. METHODS: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture. RESULTS: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33). CONCLUSIONS: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging. þ New rule for pediatric xrays (add-on to NEXUS rules) - ...our study focuses solely on clearing the cervical spine after trauma in patients younger than 3 years. ... three points to GCS <=14, 2 points to GCSeye=1 and to MVC, and 1 point to age 2 years or older. (Discussion of sensitivity and risks of imaging which came to this break point.) So, no imaging if: (GCS >=14?)*3 + (GCS: No eye opening?)*2 + (MVA)*2 + (age >2 <3?)*1 is <2 Pediatric GCS: Best eye response: (E) 4 Eyes opening spontaneously 3 Eye opening to speech 2 Eye opening to pain 1 No eye opening Best verbal response: (V) 5 Smiles, oriented to sounds, follows objects, interacts. 4 Cries but consolable, inappropriate interactions. 3 Inconsistently inconsolable, moaning. 2 Inconsolable, agitated. 1 No verbal response. Best motor responses: (M) 6 Infant moves spontaneously or purposefully 5 Infant withdraws from touch 4 Infant withdraws from pain 3 Abnormal flexion to pain for an infant (decorticate response) 2 Extension to pain (decerebrate response) 1 No motor response [Pieretti-Vanmarcke, R., G. C. Velmahos, et al. (2009). "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." The Journal of trauma 67(3): 543-549; discussion 549-550.] BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population. þ Distribution of Blunt Cervical Spine Injury - 1/3 insignificant, C2 most common. [Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med 2001; 38:17-21. STUDY OBJECTIVE: Previous studies of cervical spine injury involve individual institutions or special populations. There is currently little reliable information regarding natural cervical spine injury patterns after blunt trauma. This substudy of the National Emergency X-Radiography Utilization Study project was designed to accurately assess the prevalence, spectrum, and distribution of cervical spine injury after blunt trauma. METHODS: We prospectively enrolled all patients with blunt trauma undergoing cervical spine radiography at 21 diverse institutions. Injury status was determined by review of all radiographic studies obtained on each patient. For each individual injury, we recorded which specific films revealed the injury, the level and location of injury on each vertebra, and the age and sex of the patient. RESULTS: Of 34,069 enrolled patients with blunt trauma, 818 (2.4%) individuals had a total of 1,496 distinct cervical spine injuries to 1,285 different cervical spine structures. The second cervical vertebra was the most common level of injury (286 [24.0%] fractures, including 92 odontoid fractures), and 470 (39.3%) fractures occurred in the 2 lowest cervical vertebrae (C6 and C7). The vertebral body, injured in 235 patients, was the most frequent site of fracture. Nearly one third of all injuries (29.3%) were considered clinically insignificant. CONCLUSION: Cervical spine injuries occur in a small minority of patients with blunt trauma who undergo imaging. The atlantoaxial region is the most common site of injury, and the sixth and seventh vertebrae are involved in over one third of all injuries. Other spine levels are much more commonly involved than has previously been appreciated. A substantial minority of radiographically defined cervical spine injuries are of little clinical importance.] þ Canadian Spine Rules (Dec 2003) - High risk factor (get radiograph): + Age > 65 years + Dangerous mechanism (fall, axial load to head, bad MVC) + Paresthesias - Low risk factor (no need for radiographs): + Simple rear-end MVC + Sitting in ED or ambulatory + Delayed onset of neck pain + Absence of midline neck tenderness - Ability to rotate neck to 45º to left and right - Sensitivity: derivation set: 100% Journal Club discussion: - Age > 65, dangerous mech, paresthesia - rotate 45 degrees left and right - misapplication due to complexity? - GCS normal - physicians had 1-hour training on rules - did NOT x-ray all patients - smaller than NEXUS - CCR had better specificity, only missed 1 injury. - NEXUS missed 15 injuries; but, all had dangerous mechanisms - non-blinded - complex - Abby Wolfson, Don Yealy: misapplied NEXUS in several patients, big difference, ignore NEXUS comparison; "Neither one of these rules were actually used by the physicians. You simply can't use this study to compare the two criteria. The Canadian rule actually works well, if you can remember it!" [Stiell, I. G., C. M. Clement, et al. (2003). "The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma." N Engl J Med 349(26): 2510-2518.] BACKGROUND: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance. METHODS: We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography. RESULTS: Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries. CONCLUSIONS: For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography. [Stiell, I. G., G. H. Greenberg, et al. (1993). "Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation." Jama 269(9): 1127-1132. OBJECTIVE--To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries. DESIGN-- Survey prospectively administered in two stages: validation and refinement of the original rules (first stage) and validation of the refined rules (second stage). SETTING--Emergency departments of two university hospitals. PATIENTS- -Convenience sample of adults with acute ankle injuries: 1032 of 1130 eligible patients in the first stage and 453 of 530 eligible patients in the second stage. MAIN OUTCOME MEASURES--Attending emergency physicians assessed each patient for standardized clinical variables and classified the need for radiography according to the original (first stage) and the refined (second stage) decision rules. The decision rules were assessed for their ability to correctly identify the criterion standard of fractures on ankle and foot radiographic series. The original decision rules were refined by univariate and recursive partitioning analyses. MAIN RESULTS--In the first stage, the original decision rules were found to have sensitivities of 1.0 (95% confidence interval [CI], 0.97 to 1.0) for detecting 121 maleolar zone fractures, and 0.98 (95% CI, 0.88 to 1.0) for detecting 49 midfoot zone fractures. For interpretation of the rules in 116 patients, kappa values were 0.56 for the ankle series rule and 0.69 for the foot series rule. Recursive partitioning of 20 predictor variables yielded refined decision rules for ankle and foot radiographic series. In the second stage, the refined rules proved to have sensitivities of 1.0 (95% CI, 0.93 to 1.0) for 50 malleolar zone fractures, and 1.0 (95% CI, 0.83 to 1.0) for 19 midfoot zone fractures. The potential reduction in radiography is estimated to be 34% for the ankle series and 30% for the foot series. The probability of fracture, if the corresponding decision rule were "negative," is estimated to be 0% (95% CI, 0% to 0.8%) in the ankle series, and 0% (95% CI, 0% to 0.4%) in the foot series. CONCLUSION--Refinement and validation have shown the Ottawa ankle rules to be 100% sensitive for fractures, to be reliable, and to have the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one third. Field trials will assess the feasibility of implementing these rules into clinical practice. þ Effects of Prehospital Immobilization þ NEXUS Study: - [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. National Emergency X- Radiography Utilization Study Group [see comments]. N Engl J Med 2000; 343:94-9.] BACKGROUND: Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies. METHODS: We conducted a prospective, observational study of such a decision instrument at 21 centers across the United States. The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury. We examined the performance of the decision rule in 34,069 patients who underwent radiography of the cervical spine after blunt trauma. RESULTS: The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury (sensitivity, 99.0 percent [95 percent confidence interval, 98.0 to 99.6 percent]). The negative predictive value was 99.8 percent (95 percent confidence interval, 99.6 to 100 percent), the specificity was 12.9 percent, and the positive predictive value was 2.7 percent. Only two of the patients classified as unlikely to have an injury according to the decision instrument met the preset definition of a clinically significant injury (sensitivity, 99.6 percent [95 percent confidence interval, 98.6 to 100 percent]; negative predictive value, 99.9 percent [95 percent confidence interval, 99.8 to 100 percent]; specificity, 12.9 percent; positive predictive value, 1.9 percent), and only one of these two patients received surgical treatment. According to the results of assessment with the decision instrument, radiographic imaging could have been avoided in the cases of 4309 (12.6 percent) of the 34,069 evaluated patients. CONCLUSIONS: A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients. Panacek EA. Mower WR. Holmes JF. Hoffman JR. NEXUS Group. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury. [Journal Article. Multicenter Study. Validation Studies] Annals of Emergency Medicine. 38(1):22-5, 2001 Jul. Abstract BACKGROUND: The National Emergency X-Radiography Utilization Study (NEXUS) recently validated the ability of a decision instrument to define a population with an extremely low risk of cervical spine injury (CSI) after blunt trauma. It is unclear whether each of the 5 individual criteria is necessary for the decision instrument to maintain its high ensitivity. METHODS: NEXUS was a prospective observational study at 21 emergency departments, which enrolled ll patients with blunt trauma for whom cervical spine radiographs were ordered. In this substudy, we examined the NEXUS database to determine the contribution of each of the 5 individual low-risk clinical criteria to the overall ensitivity of the decision instrument. RESULTS: All but 8 of 818 patients with CSI, and all but 2 of 578 patients with ignificant CSI, were identified by using the decision instrument. A substantial number of patients with CSI (236/818 [29%]) and patients with significant CSI (175/578 [30%]) met only 1 of the 5 non--low-risk criteria, and each of the 5 riteria was the only indicator of non--low-risk status in at least 8 patients with CSI and at least 5 patients with significant CSI. CONCLUSION: Because each of the 5 low-risk criteria was the only marker of non--low-risk status in at least a few patients with significant CSI, modification of the overall NEXUS decision instrument by eliminating any one of the criteria would markedly reduce sensitivity and make the instrument unacceptable for clinical use. Lowery DW. Wald MM. Browne BJ. Tigges S. Hoffman JR. Mower WR. NEXUS Group. Epidemiology of cervical spine injury victims. [Journal Article] Annals of Emergency Medicine. 38(1):12-6, 2001 Jul. Abstract STUDY OBJECTIVE: We sought to characterize demographics and injury patterns among patients undergoing emergency department cervical spine radiography for blunt traumatic injury. METHODS: All patients with blunt trauma undergoing cervical spine radiography at 21 centers were enrolled in this prospective, observational study. Patients' date of birth, age, sex, and ethnicity were noted before cervical spine radiography. RESULTS: Demographic factors associated with cervical spine injury, present in 818 of 33,922 patients, included the following: age of 65 years or older (relative risk [RR] 2.09; 95% confidence interval [CI] 1.77 to 2.59); "other" ethnicity (RR 1.79, 95% CI 1.46 to 2.19); male sex (RR 1.72, 95% CI 1.48 to 2.00); and white ethnicity (RR 1.50, 95% CI 1.31 to 1.72). Hispanic ethnicity (RR 0.64, 95% CI 0.51 to 0.79), female sex (RR 0.58, 95% CI 0.50 to 0.67), black ethnicity (RR 0.55, 95% CI 0.45 to 0.66), and age of less than 18 years (RR 0.39, 95% CI 0.27 to 0.55) were associated with reduced risk of cervical spine injury. CONCLUSION: Among patients undergoing ED cervical spine radiography, cervical spine injury is more common among the elderly, male subjects, and patients of white or "other" ethnicity. Because cervical spine injury occurs in patients in all demographic categories, however, this information cannot be used to select individual patients who should or should not undergo imaging. Goldberg W. Mueller C. Panacek E. Tigges S. Hoffman JR. Mower WR. NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. [Journal Article] Annals of Emergency Medicine. 38(1):17-21, 2001 Jul. Abstract STUDY OBJECTIVE: Previous studies of cervical spine injury involve individual institutions or special populations. here is currently little reliable information regarding natural cervical spine injury patterns after blunt trauma. This ubstudy of the National Emergency X-Radiography Utilization Study project was designed to accurately assess the revalence, spectrum, and distribution of cervical spine injury after blunt trauma. METHODS: We prospectively enrolled ll patients with blunt trauma undergoing cervical spine radiography at 21 diverse institutions. Injury status was etermined by review of all radiographic studies obtained on each patient. For each individual injury, we recorded which specific films revealed the injury, the level and location of injury on each vertebra, and the age and sex of the atient. RESULTS: Of 34,069 enrolled patients with blunt trauma, 818 (2.4%) individuals had a total of 1,496 distinct ervical spine injuries to 1,285 different cervical spine structures. The second cervical vertebra was the most common level of injury (286 [24.0%] fractures, including 92 odontoid fractures), and 470 (39.3%) fractures occurred in the 2 lowest cervical vertebrae (C6 and C7). The vertebral body, injured in 235 patients, was the most frequent site of fracture. Nearly one third of all injuries (29.3%) were considered clinically insignificant. CONCLUSION: Cervical spine injuries occur in a small minority of patients with blunt trauma who undergo imaging. The atlantoaxial region is the most common site of injury, and the sixth and seventh vertebrae are involved in over one third of all injuries. Other spine levels are much more commonly involved than has previously been appreciated. A substantial minority of radiographically defined cervical spine injuries are of little clinical importance. Mower WR. Hoffman JR. Pollack CV Jr. Zucker MI. Browne BJ. Wolfson AB. NEXUS Group. Use of plain radiography to screen for cervical spine injuries. [Journal Article. Multicenter Study. Validation Studies] Annals of Emergency Medicine. 38(1):1-7, 2001 Jul. Abstract STUDY OBJECTIVE: Standard radiographic screening may fail to reveal any evidence of injury in some patients with spinal injury. The purposes of this investigation were to document the efficacy of standard radiographic views and to categorize the frequencies and types of injuries missed on plain radiographic screening of the cervical spine. METHODS: All patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions underwent a standard 3-view series (cross-table lateral, anteroposterior, and odontoid views), as well as any other imaging deemed necessary by their physicians. Injuries detected with screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies. RESULTS: The study enrolled 34,069 patients with blunt trauma, including 818 patients (2.40% of all patients; 95% confidence interval [CI] 2.40% to 2.40%) having a total of 1,496 distinct cervical spine injuries. Plain radiographs revealed 932 injuries in 498 patients (1.46% of all patients; 95% CI 1.46% to 1.46%) but missed 564 injuries in 320 patients (0.94% of all patients; 95% CI 0.94% to 0.94%). The majority of missed injuries (436 injuries in 237 patients [representing 0.80% of all patients]; 95% CI 0.80% to 0.80%) occurred in cases in which plain radiographs were interpreted as abnormal (but not diagnostic of injury) or inadequate. However, 23 patients (0.07% of all patients; 95% CI 0.05% to 0.09%) had 35 injuries (including 3 potentially unstable injuries) that were not visualized on adequate plain film imaging. These patients represent 2.81% (95% CI 1.89% to 3.63%) of all injured patients with blunt trauma undergoing radiographicevaluation. CONCLUSION: Standard 3-view imaging provides reliable screening for most patients with blunt trauma. However, on rare occasions, such imaging may fail to detect significant unstable injuries. In addition, it is difficult to obtain adequate plain radiographic imaging in a substantial minority of patients. þ Official criteria: 2 mm pre-dens space 5 mm soft tissue anterior to bottom of C2 22 mm soft tissue anterior to bottom of C6 þ Clinically clearing the cervical spine þ Criteria for Instability: - anterior + all posterior elements disrupted - more than 3.5 mm overriding of one vertebral body on another - more than 11 degrees of angulation between two vertebral bodies þ Pediatrics - The younger the child, the higher the injury: ligamentous injuries at C1-2 much more likely in the very young. In Duke study, Jan 1987 Pediatric Radiology, 10 of 11 less than age 12 hand injury at C1, C2, or atlanto-occipital area. - Northwestern University, March 1987 Annals of Emergency Medicine: neck pain, neck tenderness, neuro findings, history of direct neck trauma, and limited range of motion associated with injury; other variables not associated. - Jefferson Fractures are rare prior to teen-age. A retrospective study demonstrated "pseudospread" of the atlas (C1) in most children aged 3 months to 4 years, including over 90% during the second year. Pseudospread results from a discrepancy between the "neural" growth pattern of the atlas and the "somatic" pattern of the axis. When an atlas fracture is suggested by apparent lateral spread of the lateral atlas masses, CT is useful to demonstrate an intact atlas ring. [Suss RA, Zimmerman RD, Leeds NE. Pseudospread of the atlas: false sign of Jefferson fracture in young children. Am J Roentgenol 1983;140:1079-1082.] - Spinal Cord Injury without Radiographic Abnormality (SCIWORA) + forms 20% of spinal injury in kids + absent lordosis, anterior wedging, pseudosubluxation, wide prevertebral soft tissue space can all be normal in children. + transient neurological symptoms at time of injury, gone when arrives in ED - CHOP protocol - try twice to get an open mouth view, and if can't at that point, get a helical CT of C1-C2. þ pseudosubluxation (usually C2 on C3): - line of the posterior aspect of the spinal canal from C3-C1 (Swisschuk's line) still normal. - 50% of those under age 16 have such pseudosubluxation þ Pre-dens space; - 4-5 mm in kids - may increase another 1-2 mm with flexion of neck þ Pseudo-fracture of base of dens - synchrondosis may persist until age 3-6 years - if synchrondosis rather than fracture, dens should always be in neutral or posterior position compared to base, never anterior. þ Anterior wedging of vertebral bodies - as verterbral bodies gradually ossify, they all tend to look wedged - may persist as rounding of the upper corner of C3 most typically, up to age 3 years þ Congenital defect of posterior arch of atlas: - generally a wide space between "fragments" Adults ------ þ Subluxation (Nontraumatic) - Patients with Rheumatoid Arthritis tend to develop subluxations, particularly at C1 and C2, with minimal or no trauma. þ Hyperflexion Sprains (Traumatic Anterior Subluxation) - from hyperflexion sprain - up to 4 mm of anterior subluxation is normal IF it is part of a generalized process of anterior subluxation at all levels - "Fanning" (spreading at one level) of the spinous process, which CAN be seen on AP or PA views - abrupt kyphosis at one level - _no_ soft tissue swelling as a rule - hyperflexion sprains may initially be stable, but over weeks may become unstable and cause cord compression; 21-50% incidence of delayed instability - flexion/extension view or MRI to diagnose þ Flexion/extension views: - suspicion of ligamentous injury - no bony abnormality - cooperative patient - subacute setting (acute spasm may cause problems; put patient in Philadelphia collar, send home, do flex/exten about 10-21 days later). þ Hyperextension sprains - soft tissue swelling - normal alignment - widened anterior space on flexion/extension views - "vacuum" sign: air in space between vertebrae - immobilize, MRI, ortho consult þ Posterior laminar line (C1-C2): normal is < 1-2 mm of instability þ Hangman's Fracture - Fracture of posterior elements of C2 - extension + distraction or extension + compression - if from extension, don't put in traction. - unstable þ Jefferson Fracture - Fracture of ring of C1 - Maximum spread is 1 mm in adults on odontoid view. þ Soft tissue criteria: - 5 mm at C3 - 22 mm at C5 þ Bone criteria: - anterior height 3 mm < posterior = compression fracture - oblique lucency = teardrop fracture - 25% displacement of one vertebral body on another = unilateral facet dislocation - 50% displacement of one vertebral body on another = bilateral facet dislocation - vertebral malalignment > 3 mm = dislocation - AP spinal canal space < 13 mm = cord compression - > 11 degree angulation of intervertebral space - atlas/axis + AP distance between anterior ring of C1 and odontoid more than ? = fracture/dislocation + > than 2 mm discrepancy between odontoid and lateral masses of C1 on odontoid view, or > 2 mm lateral displacement of C1 lateral mass lateral to C2 edge, = Jefferson fracture þ Number and type of radiological studies to get, especially with continued pain: Elderly ------- þ C1 and C2 fractures - are more common in the elderly than the general population. - This is due to a significant increase in the incidence of odontoid fractures. Ref: Tintinalli 4th ed. p 1137