Distracting Injury and C-Spine Clearance

Written by Clay Smith

Spoon Feed
Clinical clearance of the c-spine missed an equal number of c-spine injuries (CSI) on CT (10-13%) whether distracting injury (DI) was present or not.

Why does this matter?
Distracting injury is part of the clinical assessment for CSI when using NEXUS criteria. It was vaguely defined in that study on purpose but is generally thought to include severe extremity fractures, degloving injuries, severe burns, etc. But does a DI actually detract from a patient’s ability to focus on the examiner and preclude clinical assessment? Single-center studies in 2011, 2012, and 2013 seemed to suggest physical exam alone, even with DI, was adequate to rule out c-spine fracture without imaging. This was a large, multi-center look at this question.

Limb hanging off? Clear the c-spine.
This was a multi-center prospective study of 2,929 adult patients with blunt trauma who were awake and alert. All patients had clinical exam of the c-spine with assessment of neck pain, tenderness, and pain on range of motion. Of these patients, 70% had DI; 7.6% (222/2929) had CSI on CT. Clinical exam was performed whether DI was present or not, and all patients underwent c-spine CT. There were 25 CSI missed on clinical exam alone. Of the 222 patients with CSI on CT, clinical exam missed an equal number with or without DI, 10.4% vs 12.6% (p=0.601), respectively. Sensitivity and NPV for clinical exam with DI were 89.6% and 99.2%; for exam without DI, sensitivity and NPV were 87.4% and 98.2%, respectively. The rate of missed c-spine injury was unusually high in this study. That may have been due, in part, to the fact that the stakes were low for the examiner. All patients had subsequent CT. One wonders if they got a little sloppy or cavalier, knowing that they were putting the collar back on and getting a CT regardless. Either way, this study shows that DI didn’t impact the sensitivity or NPV of clinical c-spine assessment, which is the key take home point. Darn Canadians are right again…

Source
Clearing the Cervical Spine in Patients with Distracting Injuries: An AAST Multi-Institutional Trial. J Trauma Acute Care Surg. 2018 Sep 4. doi: 10.1097/TA.0000000000002063. [Epub ahead of print]

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