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Clinical predictors of unstable cervical spinal injury in multiply injured patients
Injury (1992) 23, (5), 317-319
Printed in Great Britain
317
Clinical predictors of unstable cervical spinal injury in multiply injured patients S. E. Ross’, K. F. O’Malleyl, W. G. DeLong’, C. T. Born’ and C. W. Schwab2 ‘Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School at Camden, Cooper Hospital/University Medical Center, Camden, New Jersey, USA and 2Department of Surgery, University of Pennsylavania, Philadelphia, Pennsylvania, USA
All victims of wzajorblunt trauma have been said fo be at risk of cervical spinal injuy. In a prospective study of 410 such pafienfs at our institution, we ideniffied 13 patients (6.12 per cenf) wifh unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological defi0.t consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervicalspine. Immediafe radiographic investigation of the cervical spine is mandafo y in such patients, but may not be required in patients without these signs.
Introduction The identification of unstable cervical spine injury (UCSI) is essential in the initial evaluation of blunt multiply injured patients. A high index of suspicion is justified by the commonness of neck injury following major motor vehicle accidents (Huelke et al., 1981). The reported 3 per cent incidence of delayed onset of neurological deficit following ‘incorrect’ management (Geisler et al., 1966) mandates careful spinal immobilization and radiographic investigation in victims of blunt injury. The identification of a subgroup of injured patients at no risk of spinal injury, however, remains problematical. In order to evaluate specific clinical indications of CSI and develop a protocol for selective use of immediate radiography, an g-month prospective study of the evaluation of the cervical spine in blunt multiply injured patients admitted to our Level I trauma centre was undertaken. The clinical identification of unstable cervical spinal injury was based on the criteria of White et al., (1976).
Patients and methods During the study period, 15 April 1985 to 15 December 1985, all patients over 12 years of age admitted to the Southern New Jersey Regional Trauma Centre, following non-penetrating trauma were evaluated for the presence of unstable cervical spinal injury using the criteria of White et al. (1976). Five clinical factors: (1) loss or defect of consciousPresented, in part, at the 17th Annual for Emergency Medicine, Philadelphia, 1987.
Meeting, University Association Pennsylvania, USA, 19-21 May,
0 1992 Butteworth-Heinemann 0020-1383/92/050317-03
Ltd
ness at any fime following injury; (2) bony injury above the clavicle; (3) soft tissue injury above the clavicle; (4) neck pain or tenderness; and (5) neurological deficit consistent with injury to the cervical cord or nerve root, were selected for examination as warning signs of cervical spinal injury. Patients with loss of consciousness were further divided into those suffering severe head injury (AIS 2 3) and lesser head injury (Committee on Injury Scaling, American Association of Automotive Medicine, 1980). These factors, as well as mechanism of injury, were recorded for each patient. Initial radiological evaluation included three-view cervical spine series performed in the resuscitation area. Computed tomography, thin-section tomography, flexionextension stress views, tine mobility studies and radionuelide bone scan were performed as required clinically to exclude or diagnose injury. The diagnosis of cervical spinal injury was recorded following complete clinical and radiographic evaluation. All patients were followed by clinical outpatient examination for a minimum of 2 weeks after discharge. The significance of the mechanism of injury and clinical factors as predictors of unstable injury were determined using Fisher’s exact test.
Results A total of 410 adult victims of major blunt trauma were included in the study. There were 294 men and 116 women, and the average age was 31.4 years (range 13-80 years). Of the patients, 206 were motor vehicle occupants, 56 victims of assault, 51 pedestrians struck by motor vehicles, 43 victims of falls from heights, 31 motorcyclists, 15 pedal cyclists and 8 injured in industrial accidents. The distribution of clinical signs and symptoms is shown in Table I. In 89 patients there was one warning sign only, 91 presented with two warning signs, 32 with three signs and 2 with four signs. No patient had all five clinical signs. Unstable injuries were sustained by 13 (3 per cent) of patients. All patients with injury demonstrated at least one of the clinical indications. There were no late signs of injury or missed injuries during the study period. No mechanism of injury was helpful in identifying patients at risk of unstable injury (Table II).
318
Injury: the British Journal of Accident Surgery (1992)
Table I. Distribution of clinical signs and symptoms No. of patients (%)
Clinical indicator Loss of consciousness Major head injury Facial soft tissue injury Facial fracture Neck tenderness Cervical neurological deficit No clinical signs
166 59 99 43 48 11 196
Total patients
410 (100)
(40) (14) (24) (10) (12) (03) (48)
Table II. Mechanism of injury as a predictor No. of patients
Unstable spinal injuries
206 56 51 43 31 15 8
8 (N-3 1 (NS) 1 (W
Motor vehcile Assault Pedestrian Fall Motorcycle Bicycle Crush
3 0 0 0
(NS) (NS) (NS) (NS)
Significance * NS NS NS NS NS NS NS
‘Fisher’s exact test (NS = P> 0.05)
Table III. Significance of clinical indicators in the prediction of
unstable cervical spinal injury
Indicator Loss of consciousness Major injury Minor injury Soft tissue injury Fracture Tenderness Neurological deficit No indicators
No. of patients
Unstable injury
165 59 106 99 43 48 11 196
10 (6.0%) 4 (6.8%) 6 (5.7%) 1 (1 .O%) 1 (2.3%) 5 (10.4%) 5 (45.5%) 0 (0%)
Significance* P< 0.01
NS NS P< 0.01 p<10p<10-3
*Fisher’s exact test (NS= P> 0.05)
Several of the clinical signs were found to be significant in the identification of unstable spinal injury (Table III). Loss of consciousness, neck tenderness and neural deficit were all statistically significant indications of the risk of a neck injury. There was no difference in predictive value for minor versus major head injury. No significant difference in risk could be demonstrated in patients having one or more signs present.
Discussion Modem trauma care systems demand identification of unstable cervical spinal injuries in the absence of neural deficit and in patients who could not be reliably examined for signs of neck injury (Maul1 and Sachatello, 1977); therefore, the identification of patients at risk of objective signs is vital. Conversely, the rational selection of those patients who do not require radiographic evaluation of the cervical spine may increase the efficiency and costeffectiveness of treatment. The conservative approach adopted by American trauma authorities, includes neck radiographs in all blunt trauma
Vol. 23/No.
5
patients with injury above the clavicle, or involved in high-velocity accidents (Cowley and Dunham, 1982; American College of Surgeons Committee on Trauma, 1985). Accurate prediction of the risk of neck injury in patients without clinically apparent injury is vital to a selective approach to spinal radiography. Certain mechanisms of injury have been identified as risk factors for unstable cervical spinal injury. The studies used to suppport this concept are based largely upon retrospective reviews of patients with documented cervical spinal injury (Huelke et al., 1981; Walter et al., 1984). In retrospective and prospective studies of cohorts of blunt trauma patients, including the present study, however, the mechanism of injury has not been shown to be a significant risk identifier (Dula, 1979; Rischer, 1984; Jacobs and Schwartz, 1986). The use of clinical factors, such as a history of head and neck trauma or signs and symptoms of neck injury, have also been advocated in the screening of patients to justify neck radiographs. While our data support radiological evaluation for patients with neck tenderness or neurological deficit, the usefulness of head and facial injuries as screening tools remains in question (Wales et al., 1980; Fischer, 1984; Jacobs and Schwartz, 1986). Head injury has been reported to have an associated 10-20 per cent incidence of neck injury (Roberts, 1979; Rockswold, 1981), and mandatory radiography of the cervical spine has been advised in these patients (Maul1 and Sachatello, 1977; Roberts, 1979). More recent clinical reports demonstrate a significantly lower incidence of CSI in head injury patients surviving to reach hospital (O’Malley and Ross, 1988). Some authors advocate omission of radiography of the cervical spine in the awake, alert patient without specific cervical symptoms (Wales et al., 1980; Fischer, 1984) despite prior loss of consciousness. The present series demonstrates a 6 per cent incidence of unstable CSI with either severe or minor head injury. The severity of head injury does not influence the significance of this association. Even alert, awake, asymptomatic patients who have sustained simple concussion should have radiography of the cervical spine. Facial and mandibular injuries have also been advocated as screening factors (Maul1 and Sachatello, 1977; American College of Surgeons Committee on Trauma, 1985). No unstable injuries occurred with facial injury alone in our series. Despite continued reports of ‘occult’ cervical spinal injury in awake, alert patients (Thambyrajah 1972; Bressler and Rich, 1982; Walter et al., 1984) there remains controversy about the real nature of these injuries (Cadoux and White, 1986). The concern about unrecognized unstable neck injury must primarily be directed towards those patients unable to give any history of related symptoms. Any patient with alteration of consciousness must, therefore, be radiographed. Abnormalities or inadequacies in initial radiographs must have repeat films once the patient has been determined to be at risk (Ross et al., 1987).
Conclusions From these data, we conclude that radiography of the cervical spine should be considered for all patients sustaining blunt trauma involving the head and neck and is mandatory in those with: (1) closed head injury (including concussion) or alteration of consciousness; (2) neurological deficit consistent with cervical cord or nerve root injury; or (3) neck tenderness. Conversely, radiography will not be helpful, and may not be required, in patients without these findings.
Ross et al.: Predictors of unstable cervical spinal injury
References American College of Surgeons
Committee on Trauma (1985) Initial Assessment and Management. In: Advanced Trauma Life Support Co~.~for Physicians.Chicago, Illinois; American College of Surgeons, 139. Bressler M. J. and Rich G. H. (1982) Occult cervical spine fracture in an ambulatory patient. Ann. Emerg. Med. II, 440. Cadoux C. G. and White J. D. (1986) High-yield radiographic considerations for cervical spine injuries. Ann. Emerg. MeA. 15, 236. Committee on Injury Scaling, American Association for Automotive Medicine (1980) AbbreviatedInjury Scule: 1980 Revision. Arlington Heights, Illinois: American Association for Automotive Medicine. Cowley R. A. and Dunham C. M. (1982) Initial assessment and management. In: Cowley R. A. and Dunham C. M. (eds). Shuck Trauma/Crifical Care Manuul. Baltimore: University Park Press, 31. Dula D. J. (1979) Trauma to the cervical spine. ]ACEP 8, 504. Fischer R. P. (1984) Cervical radiographic evaluation of alert patients following blunt trauma. Ann. Emerg. Med. 13, 905. Geisler W. C., Wynne-Jones M. and Jousse A. T. (1966) Early management of the patient with trauma to the spinal cord. Med. Serv. ]. Canada 23,512. HueIke D. F., O’Day J. and Mendelsohn R. A. (1981) Cervical injuries suffered in automobile crashes. J. Netrrosqg. 54,316. Jacobs L. M. and Schwartz R. (1986) Prospective analysis of acute cervical spine injury: a methodology to predict injury. Ann. Emerg. Med. 15, 44.
319 MauII K. I. and Sachatello C. R. (1977) Avoiding a pitfall in resuscitation: the painless cervical fracture. Soafk. Med. J 70, 477. O’Malley K. F. and Ross S. E. (1988) The incidence of injury to the cervical spine in patients with craniocerebral injury. 1. Trauma 28, 1476. Roberts J. R. (1979) Trauma of the cervical spine. Top. Emerg. Med. 1,63. Rockswold G. L. (1981) Evaluation and resuscitation in head trauma. Minn. Med 64, 81. Ross S. E., Schwab C. W., David E. T. et al. (1987) Clearing the cervical spine: initial radiologic evaluation. J. Trauma 27, 1055. Thambyrajah K. (1972) Fractures of the cervical spine with minimal or no symptoms. Med. 1. Malaya 26,244. Wales L. R., Knopp R. K. and Morishima M. S. (1980) Recommendations for evaluation of the acutely injured cervical spine: a clinical radiologic algorithm. Ann. Emerg. Med. 9, 422. Walter J., Doris P. E. and Shaffer M. A. (1984) Clinical presentation of patients with acute cervical spine injury. Ann. berg. Med. 13, 512. White A. A., Southwick W. 0. and Panjabi M. M. (1976) Clinical instability of the lower cervical spine. Spine 1, 15.
Paper accepted 4 November
19%.
Requests for reprinfsshould be addressedto: Steven E. Ross MD FACS, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA.
Printed in Great Britain
317
Clinical predictors of unstable cervical spinal injury in multiply injured patients S. E. Ross’, K. F. O’Malleyl, W. G. DeLong’, C. T. Born’ and C. W. Schwab2 ‘Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School at Camden, Cooper Hospital/University Medical Center, Camden, New Jersey, USA and 2Department of Surgery, University of Pennsylavania, Philadelphia, Pennsylvania, USA
All victims of wzajorblunt trauma have been said fo be at risk of cervical spinal injuy. In a prospective study of 410 such pafienfs at our institution, we ideniffied 13 patients (6.12 per cenf) wifh unstable cervical spines. Loss or defect of consciousness following injury (regardless of duration), neurological defi0.t consistent with cervical cord or nerve root injury and neck tenderness were significantly predictive of an unstable cervicalspine. Immediafe radiographic investigation of the cervical spine is mandafo y in such patients, but may not be required in patients without these signs.
Introduction The identification of unstable cervical spine injury (UCSI) is essential in the initial evaluation of blunt multiply injured patients. A high index of suspicion is justified by the commonness of neck injury following major motor vehicle accidents (Huelke et al., 1981). The reported 3 per cent incidence of delayed onset of neurological deficit following ‘incorrect’ management (Geisler et al., 1966) mandates careful spinal immobilization and radiographic investigation in victims of blunt injury. The identification of a subgroup of injured patients at no risk of spinal injury, however, remains problematical. In order to evaluate specific clinical indications of CSI and develop a protocol for selective use of immediate radiography, an g-month prospective study of the evaluation of the cervical spine in blunt multiply injured patients admitted to our Level I trauma centre was undertaken. The clinical identification of unstable cervical spinal injury was based on the criteria of White et al., (1976).
Patients and methods During the study period, 15 April 1985 to 15 December 1985, all patients over 12 years of age admitted to the Southern New Jersey Regional Trauma Centre, following non-penetrating trauma were evaluated for the presence of unstable cervical spinal injury using the criteria of White et al. (1976). Five clinical factors: (1) loss or defect of consciousPresented, in part, at the 17th Annual for Emergency Medicine, Philadelphia, 1987.
Meeting, University Association Pennsylvania, USA, 19-21 May,
0 1992 Butteworth-Heinemann 0020-1383/92/050317-03
Ltd
ness at any fime following injury; (2) bony injury above the clavicle; (3) soft tissue injury above the clavicle; (4) neck pain or tenderness; and (5) neurological deficit consistent with injury to the cervical cord or nerve root, were selected for examination as warning signs of cervical spinal injury. Patients with loss of consciousness were further divided into those suffering severe head injury (AIS 2 3) and lesser head injury (Committee on Injury Scaling, American Association of Automotive Medicine, 1980). These factors, as well as mechanism of injury, were recorded for each patient. Initial radiological evaluation included three-view cervical spine series performed in the resuscitation area. Computed tomography, thin-section tomography, flexionextension stress views, tine mobility studies and radionuelide bone scan were performed as required clinically to exclude or diagnose injury. The diagnosis of cervical spinal injury was recorded following complete clinical and radiographic evaluation. All patients were followed by clinical outpatient examination for a minimum of 2 weeks after discharge. The significance of the mechanism of injury and clinical factors as predictors of unstable injury were determined using Fisher’s exact test.
Results A total of 410 adult victims of major blunt trauma were included in the study. There were 294 men and 116 women, and the average age was 31.4 years (range 13-80 years). Of the patients, 206 were motor vehicle occupants, 56 victims of assault, 51 pedestrians struck by motor vehicles, 43 victims of falls from heights, 31 motorcyclists, 15 pedal cyclists and 8 injured in industrial accidents. The distribution of clinical signs and symptoms is shown in Table I. In 89 patients there was one warning sign only, 91 presented with two warning signs, 32 with three signs and 2 with four signs. No patient had all five clinical signs. Unstable injuries were sustained by 13 (3 per cent) of patients. All patients with injury demonstrated at least one of the clinical indications. There were no late signs of injury or missed injuries during the study period. No mechanism of injury was helpful in identifying patients at risk of unstable injury (Table II).
318
Injury: the British Journal of Accident Surgery (1992)
Table I. Distribution of clinical signs and symptoms No. of patients (%)
Clinical indicator Loss of consciousness Major head injury Facial soft tissue injury Facial fracture Neck tenderness Cervical neurological deficit No clinical signs
166 59 99 43 48 11 196
Total patients
410 (100)
(40) (14) (24) (10) (12) (03) (48)
Table II. Mechanism of injury as a predictor No. of patients
Unstable spinal injuries
206 56 51 43 31 15 8
8 (N-3 1 (NS) 1 (W
Motor vehcile Assault Pedestrian Fall Motorcycle Bicycle Crush
3 0 0 0
(NS) (NS) (NS) (NS)
Significance * NS NS NS NS NS NS NS
‘Fisher’s exact test (NS = P> 0.05)
Table III. Significance of clinical indicators in the prediction of
unstable cervical spinal injury
Indicator Loss of consciousness Major injury Minor injury Soft tissue injury Fracture Tenderness Neurological deficit No indicators
No. of patients
Unstable injury
165 59 106 99 43 48 11 196
10 (6.0%) 4 (6.8%) 6 (5.7%) 1 (1 .O%) 1 (2.3%) 5 (10.4%) 5 (45.5%) 0 (0%)
Significance* P< 0.01
NS NS P< 0.01 p<10p<10-3
*Fisher’s exact test (NS= P> 0.05)
Several of the clinical signs were found to be significant in the identification of unstable spinal injury (Table III). Loss of consciousness, neck tenderness and neural deficit were all statistically significant indications of the risk of a neck injury. There was no difference in predictive value for minor versus major head injury. No significant difference in risk could be demonstrated in patients having one or more signs present.
Discussion Modem trauma care systems demand identification of unstable cervical spinal injuries in the absence of neural deficit and in patients who could not be reliably examined for signs of neck injury (Maul1 and Sachatello, 1977); therefore, the identification of patients at risk of objective signs is vital. Conversely, the rational selection of those patients who do not require radiographic evaluation of the cervical spine may increase the efficiency and costeffectiveness of treatment. The conservative approach adopted by American trauma authorities, includes neck radiographs in all blunt trauma
Vol. 23/No.
5
patients with injury above the clavicle, or involved in high-velocity accidents (Cowley and Dunham, 1982; American College of Surgeons Committee on Trauma, 1985). Accurate prediction of the risk of neck injury in patients without clinically apparent injury is vital to a selective approach to spinal radiography. Certain mechanisms of injury have been identified as risk factors for unstable cervical spinal injury. The studies used to suppport this concept are based largely upon retrospective reviews of patients with documented cervical spinal injury (Huelke et al., 1981; Walter et al., 1984). In retrospective and prospective studies of cohorts of blunt trauma patients, including the present study, however, the mechanism of injury has not been shown to be a significant risk identifier (Dula, 1979; Rischer, 1984; Jacobs and Schwartz, 1986). The use of clinical factors, such as a history of head and neck trauma or signs and symptoms of neck injury, have also been advocated in the screening of patients to justify neck radiographs. While our data support radiological evaluation for patients with neck tenderness or neurological deficit, the usefulness of head and facial injuries as screening tools remains in question (Wales et al., 1980; Fischer, 1984; Jacobs and Schwartz, 1986). Head injury has been reported to have an associated 10-20 per cent incidence of neck injury (Roberts, 1979; Rockswold, 1981), and mandatory radiography of the cervical spine has been advised in these patients (Maul1 and Sachatello, 1977; Roberts, 1979). More recent clinical reports demonstrate a significantly lower incidence of CSI in head injury patients surviving to reach hospital (O’Malley and Ross, 1988). Some authors advocate omission of radiography of the cervical spine in the awake, alert patient without specific cervical symptoms (Wales et al., 1980; Fischer, 1984) despite prior loss of consciousness. The present series demonstrates a 6 per cent incidence of unstable CSI with either severe or minor head injury. The severity of head injury does not influence the significance of this association. Even alert, awake, asymptomatic patients who have sustained simple concussion should have radiography of the cervical spine. Facial and mandibular injuries have also been advocated as screening factors (Maul1 and Sachatello, 1977; American College of Surgeons Committee on Trauma, 1985). No unstable injuries occurred with facial injury alone in our series. Despite continued reports of ‘occult’ cervical spinal injury in awake, alert patients (Thambyrajah 1972; Bressler and Rich, 1982; Walter et al., 1984) there remains controversy about the real nature of these injuries (Cadoux and White, 1986). The concern about unrecognized unstable neck injury must primarily be directed towards those patients unable to give any history of related symptoms. Any patient with alteration of consciousness must, therefore, be radiographed. Abnormalities or inadequacies in initial radiographs must have repeat films once the patient has been determined to be at risk (Ross et al., 1987).
Conclusions From these data, we conclude that radiography of the cervical spine should be considered for all patients sustaining blunt trauma involving the head and neck and is mandatory in those with: (1) closed head injury (including concussion) or alteration of consciousness; (2) neurological deficit consistent with cervical cord or nerve root injury; or (3) neck tenderness. Conversely, radiography will not be helpful, and may not be required, in patients without these findings.
Ross et al.: Predictors of unstable cervical spinal injury
References American College of Surgeons
Committee on Trauma (1985) Initial Assessment and Management. In: Advanced Trauma Life Support Co~.~for Physicians.Chicago, Illinois; American College of Surgeons, 139. Bressler M. J. and Rich G. H. (1982) Occult cervical spine fracture in an ambulatory patient. Ann. Emerg. Med. II, 440. Cadoux C. G. and White J. D. (1986) High-yield radiographic considerations for cervical spine injuries. Ann. Emerg. MeA. 15, 236. Committee on Injury Scaling, American Association for Automotive Medicine (1980) AbbreviatedInjury Scule: 1980 Revision. Arlington Heights, Illinois: American Association for Automotive Medicine. Cowley R. A. and Dunham C. M. (1982) Initial assessment and management. In: Cowley R. A. and Dunham C. M. (eds). Shuck Trauma/Crifical Care Manuul. Baltimore: University Park Press, 31. Dula D. J. (1979) Trauma to the cervical spine. ]ACEP 8, 504. Fischer R. P. (1984) Cervical radiographic evaluation of alert patients following blunt trauma. Ann. Emerg. Med. 13, 905. Geisler W. C., Wynne-Jones M. and Jousse A. T. (1966) Early management of the patient with trauma to the spinal cord. Med. Serv. ]. Canada 23,512. HueIke D. F., O’Day J. and Mendelsohn R. A. (1981) Cervical injuries suffered in automobile crashes. J. Netrrosqg. 54,316. Jacobs L. M. and Schwartz R. (1986) Prospective analysis of acute cervical spine injury: a methodology to predict injury. Ann. Emerg. Med. 15, 44.
319 MauII K. I. and Sachatello C. R. (1977) Avoiding a pitfall in resuscitation: the painless cervical fracture. Soafk. Med. J 70, 477. O’Malley K. F. and Ross S. E. (1988) The incidence of injury to the cervical spine in patients with craniocerebral injury. 1. Trauma 28, 1476. Roberts J. R. (1979) Trauma of the cervical spine. Top. Emerg. Med. 1,63. Rockswold G. L. (1981) Evaluation and resuscitation in head trauma. Minn. Med 64, 81. Ross S. E., Schwab C. W., David E. T. et al. (1987) Clearing the cervical spine: initial radiologic evaluation. J. Trauma 27, 1055. Thambyrajah K. (1972) Fractures of the cervical spine with minimal or no symptoms. Med. 1. Malaya 26,244. Wales L. R., Knopp R. K. and Morishima M. S. (1980) Recommendations for evaluation of the acutely injured cervical spine: a clinical radiologic algorithm. Ann. Emerg. Med. 9, 422. Walter J., Doris P. E. and Shaffer M. A. (1984) Clinical presentation of patients with acute cervical spine injury. Ann. berg. Med. 13, 512. White A. A., Southwick W. 0. and Panjabi M. M. (1976) Clinical instability of the lower cervical spine. Spine 1, 15.
Paper accepted 4 November
19%.
Requests for reprinfsshould be addressedto: Steven E. Ross MD FACS, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA.