Head, facial, and clavicular trauma as a predictor of cervical-spine injury

Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use

PURPOSE

To develop a method to use clinically apparent factors to determine cervical spine fracture risk to guide selection of optimal imaging strategies.

MATERIALS AND METHODS

Records from 472 patients with trauma (168 with fractures, 304 control patients) who visited the emergency department in 1994 and 1995 were reviewed for 20 potential predictors of cervical spine fracture in this retrospective case-control study. Simple logistic regression was used to determine predictors of cervical spine fracture. Prediction rules were formulated by using multiple logistic regression and recursive partitioning with bootstrap validation. Posttest fracture probabilities were calculated from base prevalence and likelihood ratios derived for predictors by using Bayes theorem.

RESULTS

Predictors of cervical spine fracture included severe head injury (adjusted odds ratio [OR] = 8.5, 95% CI: 4.0, 17.0), high-energy cause (OR = 11.6, 95% CI: 5.4, 25.0), and focal neurologic deficit (OR = 58, 95% CI: 12, 283). The prediction rule was used to stratify patients into groups with fracture probabilities of 0.04%-19.70%. After adjusting for overfitting, the area under the receiver operating characteristic curve was 0.87.

CONCLUSION

Clinically apparent factors, including cause of injury, associated injuries, and age, can be used to determine the probability of cervical spine fracture. Development of evidence-based imaging guidelines should incorporate knowledge of fracture probability.

Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting

OBJECTIVE

To determine whether paramedics can safely use a spinal clearance algorithm to reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting.

METHODS

Paramedics were instructed in the use of a spinal clearance algorithm that prompted assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm indicated that if any of the above were present, the patient should receive full SI, and if all of the above were negative, then SI could be withheld. Paramedics completed a tracking form that included the above and followed the patient to the emergency department (ED). Data were then gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the two. To compare the trends for SI, a retrospective medical incident report (MIR) review was conducted from the previous year. MIRs were selected based on the same criteria as those used for study inclusion.

RESULTS

Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in utilization of SI (95% confidence interval: 27.2%- 38.8%).

CONCLUSION

An out-of-hospital spinal clearance algorithm administered by paramedics can reduce SI by one-third. Any application of a spinal clearance algorithm should be accompanied by rigorous medical supervision.

Epidemiologic features of facial injuries among motorcyclists

STUDY OBJECTIVE

To describe the extent, nature, and severity of facial injuries among motorcyclists injured in a crash requiring hospital treatment.

METHODS

The study population consisted of 5,790 motorcycle riders who sustained a nonfatal crash injury during 1991, 1992, or 1993 in 10 California counties. The injured riders were identified in 28 hospitals during 1991 and 1992 and in 18 of these 28 hospitals in 1993. Information was collected from crash reports and hospital records. All injuries were coded according to the 1990 Abbreviated Injury Scale.

RESULTS

Facial injury was present in 24.3% of injured riders, a high proportion of them young men. Among riders wearing helmets, 36.8% had facial injuries, compared with 53.8% of those not wearing helmets. Soft tissue injuries and facial fractures were present in 72% and 22% of the injured, respectively. The maxilla (22%), orbit (16%), and nasal (16%) bones were the most frequently fractured facial bones. The frequency of multiple facial injuries, severity of facial injuries, and incidence of high-severity facial fractures was greater among nonhelmeted riders compared with helmeted riders. Upper facial fractures were more common among riders without helmets compared with those wearing helmets.

CONCLUSION

This study provides evidence of the protective value of helmets to reduce risk of facial injury. Information on the positive effect of facial injury sparing provided by helmet use should be incorporated into helmet promotion programs.

How effective is the Newport/Aspen collar? A prospective radiographic evaluation in healthy adult volunteers

BACKGROUND

Cervical extrication collars are used in the evacuation of the injured to minimize secondary injury. These collars were designed for extrication and evacuation, not for longterm use, and complications have been reported when they have been used in the rehabilitation phase. The Newport/Aspen collar was designed specifically for long-term use.

METHODS

Using a radiographic method, the effectiveness of the collar in restricting motion was evaluated for the cervical spine as a whole and for constituent segments, occiput to C7, in 15 normal volunteers.

RESULTS

Combined flexion-extension was reduced from mean 98.8 to 31.1 degrees (31.5% of normal; p = 0.000000002), lateral bending was reduced from mean 31.1 to 15.9 degrees (51.1% of normal; p = 0.0000001), and overhead rotation was reduced from mean 64.6 to 26.8 degrees (41% of normal; p = 0.000000002). The cervical spine, however, does not move as one unit; paradoxical motion, the phenomenon of "snaking," occurs. Goniometric techniques do not demonstrate this effect. Data are provided for motion by segmental level.

CONCLUSION

Full cervical immobilization is a myth. It would seem logical to match the level-specific efficacy of the device to the level of injury. Data are provided for the Aspen collar.

Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation

OBJECTIVE

The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head.

METHODS

A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded.

RESULTS

A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008).

CONCLUSIONS

Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

The management of severe traumatic brain injury

An approach to the initial evaluation, resuscitation, and treatment of the patient with severe traumatic brain injury is presented in terms of the underlying physiology and literature support. The primary importance of rapid and complete systemic resuscitation in terms of the "ABCs" is stressed, with the goal of optimizing cerebral perfusion and preventing secondary insults to the injured brain. The integration of brain-specific treatments and diagnostic maneuvers into resuscitation protocols is discussed, including the role of mannitol and hyperventilation as well as the prioritization of CT imaging of the brain.

Cervical spine injury in maxillofacial trauma

OBJECTIVE

To find out the incidence of associated facial injuries and injuries to the cervical spine.

DESIGN

Retrospective study.

SETTING

Teaching hospital, India.

SUBJECTS

536 patients treated for maxillofacial injuries between January 1992 and November 1993.

INTERVENTIONS

Review of hospital case notes and radiographs.

MAIN OUTCOME MEASURES

Coexisting facial and cervical spine injuries, morbidity and mortality.

RESULTS

16 patients (3%) had sustained both facial and cervical spine injuries. There were 14 men (median age 40, range 21-64) and 2 women (aged 19 and 30). In 10 of the 16 patients the cause of the injury was a road traffic accident. In 11 patients the facial injury was to the soft tissue only, in 4 it was to both hard and soft tissue, and in 1 it was to hard tissue only. Soft tissue damage to the midface was more likely to be associated with injuries in the area of C5-7 and that to the lower third of the face was more likely to be associated with damage to the upper cervical spine. 11 patients had neurological deficits as a result of their injuries and 2 died.

CONCLUSION

If diagnosis and treatment of simultaneous facial and cervical spine injuries are to be improved, further study of the biomechanics of injury is necessary.

Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing

OBJECTIVE

To evaluate the hypothesis that alert nonintoxicated trauma patients with negative clinical examinations are at no risk of cervical spine injury and do not need any radiographic investigation.

DESIGN

Prospective study.

SETTING

A university-affiliated teaching county hospital.

PATIENTS

Five hundred and forty-nine consecutive alert, oriented, and clinically nonintoxicated blunt trauma victims with no neck symptoms.

RESULTS

All patients had negative clinical neck examinations. After radiographic assessment, no cervical spine injuries were identified. Less than half the patients could be evaluated adequately with the three standard initial views (anteroposterior, lateral, and odontoid). All the rest needed more radiographs and/or computed tomographic scans. A total of 2,27 cervical spine radiographs, 78 computed tomographic scans and magnetic resonance imagings were performed. Seventeen patients stayed one day in the hospital for no other reason but radiographic clearance of an asymptomatic neck. The total cost for x-rays and extra hospital days was $242,000. These patients stayed in the collar for an average of 3.3 hours (range, 0.5-72 hours). There was never an injury missed.

CONCLUSIONS

Clinical examination alone can reliably assess all blunt trauma patients who are alert, nonintoxicated, and report no neck symptoms. In the absence of any palpation or motion neck tenderness during examination, the patient may be released from cervical spine precautions without any radiographic investigations.