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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Hawkins SC, Williams J, Bennett BL, Islas A, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update. Wilderness Environ Med 2024; 35:78S-93S. [PMID: 38379496 DOI: 10.1177/10806032241227232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.
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Affiliation(s)
- Seth C Hawkins
- Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC
| | - Jason Williams
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Arthur Islas
- Department of Family and Community Medicine, University of Nevada, Reno School of Medicine, Reno, NV
| | - Robert Quinn
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX
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Muacevic A, Adler JR. Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review. Cureus 2022; 14:e30065. [PMID: 36238421 PMCID: PMC9547612 DOI: 10.7759/cureus.30065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Since its introduction in 1992, the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been used in trauma to decide whether a patient requires radiographic imaging. The tool is important in reducing radiation exposure. However, applying the NEXUS criteria for cervical spine imaging in pediatric patients is poorly supported compared to their use in adults. The objective of this review was to examine the effectiveness of using the NEXUS criteria in the diagnostic management of pediatric cervical spine injuries (CSI). The following databases were searched for studies focused on applying the NEXUS criteria for CSI in pediatric patients: Cochrane, PubMed, Google Scholar, EMBASE, ELSEVIER, and ScienceDirect. Additional studies were found through reference lists of primary sources and previous systematic and meta-analyses. The search focused on randomized controlled trials (RCTs), cohort studies, retrospective studies, prospective studies, and other uncontrolled trials published from 2000 to 2022. There were seven included studies with a total of 4502 pediatric patients. Five of the included studies were retrospective studies, while the remaining were prospective and case studies. Our results show that the sensitivity ranged from 43% to 100%, while the specificity ranged from 12.93% to 96%. The sensitivity increased with age, with those under the age of two or under the age of eight reporting poorer outcomes than the older pediatric patients. One study also shows that the proportion of patients undergoing cervical spine CT increased from 18% to 61% in the initial period before the implementation of clearance guidelines. The implementation of guidelines led to a 23% decrease in CT scans clearable by NEXUS criteria after 12 months. One of the studies reported that NEXUS criteria were a cost-effective option when used along with X-rays and CT. Overall, the studies do not strongly support the application of the NEXUS criteria to image pediatric patients for CSI. In conclusion, there is weak support in the literature for applying the NEXUS criteria in determining the need for cervical spine imaging in pediatric trauma patients. The practice and research implications of the findings are also discussed.
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Benchetrit S, Blackham J, Braude P, Halliday R, Shipway D, Williams A, Carlton E. Emergency management of older people with cervical spine injuries: an expert practice review. Emerg Med J 2021; 39:331-336. [PMID: 34344732 DOI: 10.1136/emermed-2020-211002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/26/2021] [Indexed: 11/03/2022]
Abstract
Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.
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Affiliation(s)
| | | | - Philip Braude
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Ruth Halliday
- Trauma & Orthopaedic Research Team, Southmead Hospital, Bristol, UK
| | - David Shipway
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Adam Williams
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
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Hawkins SC, Williams J, Bennett BL, Islas A, Kayser DW, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection. Wilderness Environ Med 2019; 30:S87-S99. [DOI: 10.1016/j.wem.2019.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/25/2019] [Accepted: 08/01/2019] [Indexed: 11/30/2022]
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Ngatchou W, Beirnaert J, Lemogoum D, Bouland C, Youatou P, Ramadan AS, Sontou R, Alima MB, Plumaker A, Guimfacq V, Bika C, Mols P. Application of the Canadian C-Spine rule and nexus low criteria and results of cervical spine radiography in emergency condition. Pan Afr Med J 2018; 30:157. [PMID: 30455786 PMCID: PMC6235470 DOI: 10.11604/pamj.2018.30.157.13256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 06/15/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction The Canadian C Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (Nexus) low criteria are well accepted as guide to help physician in case of cervical blunt trauma. Methods We aimed to evaluate retrospectively the application of these recommendations in our emergency department. Secondly we analyzed the quality of cervical spine radiography (CSR) in an emergency setting. Results 281 patients with cervical blunt trauma were analyzed retrospectively. The CCR and the NEXUS rules were respected in 91.2% and 96.8% of cases respectively. No lesions were found in 96.4% of patient. A lesion was present in 1.1% of patient and suspected in 2.5% of patient. The quality of CSR was adequate in only 37.7% of patient. The poor quality of CSR was due either to the lack of C7 vertebrae visualization in 64.6% or other lower vertebrae in 28%. Other causes included the absence of open mouth view (8%), the absence C1 vertebrae visualization (3.4%), artifact in 2.3% and the absence of lateral view in 0.6% of patient. Conclusion CCR and NEXUS are widely used in our emergency department. The high rate of inadequate CSR reinforces the debate about it’s utility in emergency condition.
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Affiliation(s)
- William Ngatchou
- Department of Emergency and Cardiac Surgery, St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Jeanne Beirnaert
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Daniel Lemogoum
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - Cyril Bouland
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Pierre Youatou
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Ahmed Sabry Ramadan
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Regis Sontou
- Department of Radiology, St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Maimouna Bol Alima
- Department of Cardiac Surgery, St Luc University Hospital, Université Catholique de Louvain, Belgium
| | - Alain Plumaker
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
| | - Virginie Guimfacq
- Department of Cardiology, Ixelles University Hospital, Université Libre de Bruxelles, Belgium
| | | | - Pierre Mols
- Department of Emergency St Pierre University Hospital, Université Libre de Bruxelles, Belgium
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7
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Stiebel-Kalish H, Amitai A, Mimouni M, Bach M, Saban T, Cahn M, Gantz L. The Discrepancy between Subjective and Objective Measures of Convergence Insufficiency in Whiplash-Associated Disorder versus Control Participants. Ophthalmology 2018; 125:924-928. [DOI: 10.1016/j.ophtha.2017.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 11/24/2022] Open
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev 2017; 12:CD011686. [PMID: 29215711 PMCID: PMC6486014 DOI: 10.1002/14651858.cd011686.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population. OBJECTIVES To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma. SEARCH METHODS We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility. SELECTION CRITERIA We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy. MAIN RESULTS Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity. AUTHORS' CONCLUSIONS There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.
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Affiliation(s)
- Annelie Slaar
- WestfriesgasthuisDepartment of RadiologyMaelsonstraat 3HoornNoord HollandNetherlands1624 NP
| | - M M Fockens
- University of AmsterdamAcademic Medical CenterAmsterdamNetherlands
| | - Junfeng Wang
- Academic Medical CenterDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mario Maas
- Academic Medical CenterDepartment of RadiologyUniversity of AmsterdamMeibergdreefAmsterdamNetherlands
| | - David J Wilson
- St Lukes HospitalDepartment of RadiologyLatimer RoadHeadingtonOxfordUKOX3 7PF
| | - J Carel Goslings
- Academic Medical CenterTrauma Unit, Department of SurgeryMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Niels WL Schep
- Academic Medical CenterDepartment of Surgery/Trauma UnitMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Rick R van Rijn
- Academic Medical Center AmsterdamDepartment of RadiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Jones Rhodes W, Steinbruner D, Finck L, Flarity K. Community Implementation of a Prehospital Spinal Immobilization Guideline. PREHOSP EMERG CARE 2016; 20:792-797. [DOI: 10.1080/10903127.2016.1194932] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Guarnieri G, Izzo R, Muto M. The role of emergency radiology in spinal trauma. Br J Radiol 2016; 89:20150833. [PMID: 26612468 DOI: 10.1259/bjr.20150833] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low-energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.
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Affiliation(s)
| | - Roberto Izzo
- Neuroradiology Unit, Cardarelli Hospital, Naples, Italy
| | - Mario Muto
- Neuroradiology Unit, Cardarelli Hospital, Naples, Italy
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Finnerty NM, Rodriguez RM, Carpenter CR, Sun BC, Theyyunni N, Ohle R, Dodd KW, Schoenfeld EM, Elm KD, Kline JA, Holmes JF, Kuppermann N. Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda. Acad Emerg Med 2015; 22:1406-16. [PMID: 26567885 DOI: 10.1111/acem.12828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.
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Affiliation(s)
- Nathan M. Finnerty
- Department of Emergency Medicine; The Ohio State University College of Medicine; Columbus OH
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California San Francisco School of Medicine; San Francisco CA
| | - Christopher R. Carpenter
- Department of Emergency Medicine; Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
| | - Nik Theyyunni
- Department of Emergency Medicine; University of Michigan Medical School; Ann Arbor MI
| | - Robert Ohle
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
- Department of Internal Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Kendra D. Elm
- Department of Emergency Medicine; University of Minnesota Medical School; Minneapolis MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
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12
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Matteucci MJ, Moszyk D, Migliore SA. Agreement Between Resident and Faculty Emergency Physicians in the Application of NEXUS Criteria for Suspected Cervical Spine Injuries. J Emerg Med 2015; 48:445-9. [DOI: 10.1016/j.jemermed.2014.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/27/2014] [Accepted: 11/16/2014] [Indexed: 11/30/2022]
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13
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Quinn RH, Williams J, Bennett BL, Stiller G, Islas AA, McCord S. Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment: 2014 Update. Wilderness Environ Med 2014; 25:S105-17. [DOI: 10.1016/j.wem.2014.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 01/21/2023]
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Jubert P, Lonjon G, Garreau de Loubresse C. Complications of upper cervical spine trauma in elderly subjects. A systematic review of the literature. Orthop Traumatol Surg Res 2013; 99:S301-12. [PMID: 23973001 DOI: 10.1016/j.otsr.2013.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 02/02/2023]
Abstract
UNLABELLED The frequency of cervical spine trauma in elderly patients is increasing with most injuries occurring in the upper cervical spine. These fractures are associated with a risk of sometimes life-threatening complications, although very few studies have specifically analyzed this. The goal of this study was to identify the incidence of complications in the literature (mortality and morbidity) following upper cervical spine trauma in elderly patients. METHODS A systematic search was performed on the MEDLINE database without limiting the search by language or date to identify all studies reporting the rate of complications after upper cervical spine trauma in patients over the age of 60. RESULTS Twenty-four observational studies were included, four were comparative. These studies included a total of 857 patients, mean age 76. Nearly all traumas were odontoid process fractures, and most were treated surgically (57%). The median mortality rate was 9.2% (Q1-Q3: 2.5-19.6) and the median rate of short-term complications was 15.4% (Q1-Q3: 5.8-26.9). The main late stage complication was nonunion, which developed in a mean 10 to 12% depending on the type of treatment. CONCLUSION Complications following cervical spine trauma are frequent in elderly patients whatever the type of treatment. Knowledge of the rate of complications in the literature and the potential risk factors is essential for the clinician to improve the information provided to patients and to prevent complications. TYPE OF STUDY Systematic review of the literature. Level of evidence IV.
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Affiliation(s)
- P Jubert
- Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France
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Griffith B, Vallee P, Krupp S, Jung M, Slezak M, Nagarwala J, Loeckner CP, Schultz LR, Jain R. Screening cervical spine CT in the emergency department, phase 3: increasing effectiveness of imaging. J Am Coll Radiol 2013; 11:139-44. [PMID: 24035123 DOI: 10.1016/j.jacr.2013.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 05/28/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of this study was to determine the effect of a clinical education initiative on the appropriate utilization of screening cervical spine CT in the emergency department. The purpose was to assess if clinical education can produce stricter adherence to the ACR Appropriateness Criteria and improve the utilization of screening CT examinations in the emergency department. METHODS Institutional review board approval was obtained for this HIPAA-compliant study. All adult patients presenting to a level 1 trauma center with blunt trauma prompting screening cervical spine CT were eligible. For each study, the requesting clinician completed a survey selecting all clinical indications. CT examinations were evaluated by a board-certified radiologist blinded to survey data. Results were compared with retrospective and prospective studies performed before the institution of the education initiative. RESULTS Of the 388 cervical spine CT examinations performed, 12 (3.1%) were positive for acute cervical spine injury, compared to only 1.0% before the clinical education program (phase 2). Of the 376 examinations without injury, 13% met all 5 National Emergency X-Radiography Utilization Study criteria for nonimaging (down from 16.1% in phase 2), and 15 (4%) required no imaging when both National Emergency X-Radiography Utilization Study and abbreviated Canadian cervical spine rule criteria were applied. CONCLUSIONS Implementation of a clinical education initiative resulted in improved adherence to ACR Appropriateness Criteria and improved clinical effectiveness of the studies by increasing fracture detection rate. Initiatives such as these could potentially influence imaging overutilization without burdening emergency department clinicians with excessive roadblocks to image ordering.
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Affiliation(s)
- Brent Griffith
- Department of Radiology, Henry Ford Health System, Detroit, Michigan.
| | - Phyllis Vallee
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Seth Krupp
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Melissa Jung
- Department of Radiology, Henry Ford Health System, Detroit, Michigan
| | - Michelle Slezak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jumana Nagarwala
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - C Patrick Loeckner
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Lonni R Schultz
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Rajan Jain
- Department of Radiology, Henry Ford Health System, Detroit, Michigan; Department of Radiology, NYU Langone Medical Center, New York, New York
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Wilderness Medical Society practice guidelines for spine immobilization in the austere environment. Wilderness Environ Med 2013; 24:241-52. [PMID: 23827829 DOI: 10.1016/j.wem.2013.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 03/03/2013] [Accepted: 03/07/2013] [Indexed: 11/22/2022]
Abstract
In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.
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Taneja A, Berry CA, Rao RD. Initial Management of the Patient With Cervical Spine Injury. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.semss.2012.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1467-73. [PMID: 23404352 DOI: 10.1007/s00586-012-2598-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 10/31/2012] [Accepted: 11/15/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. METHODS We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30° of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed. RESULTS One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80% of the films either did not adequately demonstrate the C7/T1 junction or had less than 30° range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. CONCLUSION Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.
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Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CWC. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ 2012; 184:E867-76. [PMID: 23048086 PMCID: PMC3494329 DOI: 10.1503/cmaj.120675] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is uncertainty about the optimal approach to screen for clinically important cervical spine (C-spine) injury following blunt trauma. We conducted a systematic review to investigate the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria, 2 rules that are available to assist emergency physicians to assess the need for cervical spine imaging. METHODS We identified studies by an electronic search of CINAHL, Embase and MEDLINE. We included articles that reported on a cohort of patients who experienced blunt trauma and for whom clinically important cervical spine injury detectable by diagnostic imaging was the differential diagnosis; evaluated the diagnostic accuracy of the Canadian C-spine rule or NEXUS or both; and used an adequate reference standard. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies criteria. We used the extracted data to calculate sensitivity, specificity, likelihood ratios and post-test probabilities. RESULTS We included 15 studies of modest methodologic quality. For the Canadian C-spine rule, sensitivity ranged from 0.90 to 1.00 and specificity ranged from 0.01 to 0.77. For NEXUS, sensitivity ranged from 0.83 to 1.00 and specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. For both rules, a negative test was more informative for reducing the probability of a clinically important cervical spine injury. INTERPRETATION Based on studies with modest methodologic quality and only one direct comparison, we found that the Canadian C-spine rule appears to have better diagnostic accuracy than the NEXUS criteria. Future studies need to follow rigorous methodologic procedures to ensure that the findings are as free of bias as possible.
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Griffith B, Kelly M, Vallee P, Slezak M, Nagarwala J, Krupp S, Loeckner CP, Schultz LR, Jain R. Screening cervical spine CT in the emergency department, Phase 2: A prospective assessment of use. AJNR Am J Neuroradiol 2012; 34:899-903. [PMID: 23042928 DOI: 10.3174/ajnr.a3306] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The National Emergency X-Radiography Utilization Study Low-Risk Criteria were established to identify patients with a low probability of cervical spine injury in whom imaging of the cervical spine was unnecessary. The purpose of this study was to ascertain the number of unnecessary cervical spine CT studies on the basis of proper application of established clinical guidelines and, secondarily, to determine indications for ordering studies in the absence of guideline criteria. MATERIALS AND METHODS All patients presenting to a level I trauma center for whom a screening cervical spine CT was ordered in the setting of blunt trauma were eligible for enrollment. For each study, the requesting clinician completed a survey regarding study indications. CT examinations were evaluated by a board-certified radiologist blinded to survey data to determine the presence or absence of cervical spine injury. RESULTS Of 507 CT examinations, 5 (1%) were positive and 497 (98.0%) were negative for acute cervical spine injury. Five studies (1%) were indeterminate for acute injury but demonstrated no abnormality on subsequent imaging and clinical follow-up. Of the 502 studies without cervical spine injury, 81 (16.1%) were imaged despite meeting all 5 NEXUS criteria for nonimaging. Of these, the most common study indication was dangerous mechanism of injury (48.1%) followed by subjective neck pain (40.7%). CONCLUSIONS Strict application of NEXUS criteria could potentially reduce the number of screening cervical spine CT scans in the setting of blunt trauma; this change would avoid a considerable amount of unnecessary radiation and cost.
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Affiliation(s)
- B Griffith
- Department of Radiology, Henry Ford Health System, Detroit, MI 48202, USA.
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21
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Canadian Cervical Spine rule compared with computed tomography: a prospective analysis. ACTA ACUST UNITED AC 2011; 71:352-5; discussion 355-7. [PMID: 21825938 DOI: 10.1097/ta.0b013e318220a98c] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Canadian cervical spine rule (CCS) has been found to be an effective tool to determine the need for radiographic evaluation of the cervical spine (c-spine) incorporating both clinical findings and mechanism. Previously, it has been validated only through clinical follow-up or selective use of X-rays. The purpose of this study was to validate it using computed tomography (CT) as the gold standard to identify fractures. METHODS Prospective evaluation was performed on 3,201 blunt trauma patients who were screened by CCS and were compared with a complete c-spine CT. CSS positive indicated at least one positive clinical or mechanism finding, whereas CT positive indicated presence of a fracture. RESULTS There were 192 patients with c-spine fractures versus 3,009 without fracture on CT. The fracture group was older (42.7 ± 19.0 years vs. 37.8 ± 17.5 years, p = 0.0006), had a lower Glasgow Coma Scale score (13.8 ± 4.2 vs. 14.4 ± 4.3, p < 0.0001), and lower systolic blood pressure (133.3 ± 23.8 mm Hg vs. 139.5 ± 23.1 mm Hg, p = 0.0023). The sensitivity of CCS was 100% (192/192), specificity was 0.60% (18/3009), positive predictive value was 6.03% (192/3183), and negative predictive value was 100% (18/18). Logistic regression identified only 8 of the 19 factors included in the CCS to be independent predictors of c-spine fracture. CONCLUSIONS CCS is very sensitive but not very specific to determine the need for radiographic evaluation after blunt trauma. Based on this study, the rule should be streamlined to improve specificity while maintaining sensitivity.
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Abstract
OBJECTIVE The objective of our study was to analyze the use of screening cervical spine CT performed after trauma and establish the opportunity of potentially avoidable studies when evidence-based clinical criteria are applied before imaging. MATERIALS AND METHODS All cervical spine CT examinations performed in the emergency department of a level 1 trauma center between January and December 2008 on adult patients with trauma were analyzed; 1589 studies were evaluated. Radiology reports and clinical data were reviewed for the presence of fracture or ligamentous injury and for the mode of injury. We also looked for documentation of clinical criteria used to perform the CT study. In particular, we looked for mention of posterior midline cervical tenderness, focal neurologic deficit, level of alertness, evidence of intoxication, and clinically apparent distracting injury. These five criteria were established by the National Emergency X-Radiography Utilization Study (NEXUS) to identify patients with a low probability of cervical spine injury who consequently needed no cervical spine imaging. RESULTS Of the 1589 studies reviewed, 41 (2.6%) were positive for an acute cervical spine injury and 1524 (95.9%) were negative. The remaining 24 studies (1.5%) were indeterminate on the initial CT examination but subsequent imaging and clinical follow-up failed to show acute injury. Of the 1524 examinations with no acute injury, 364 (23.9%) had no documentation of any of the five NEXUS low-risk criteria. CONCLUSION The strict application of the NEXUS low-risk criteria could potentially reduce the number of screening cervical spine CT examinations in the setting of trauma in more than 20% of cases, thereby avoiding a significant amount of unnecessary radiation and significant cost.
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Bond MC, Lemkin DL, Brady W. The orthopedic literature 2009. Am J Emerg Med 2010; 29:943-53. [PMID: 20934830 DOI: 10.1016/j.ajem.2010.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 06/27/2010] [Indexed: 10/19/2022] Open
Affiliation(s)
- Michael C Bond
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Theocharopoulos N, Chatzakis G, Karantanas A, Chlapoutakis K, Damilakis J. CT evaluation of the low severity cervical spine trauma: When is the scout view enough? Eur J Radiol 2010; 75:82-6. [DOI: 10.1016/j.ejrad.2009.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 03/16/2009] [Indexed: 11/24/2022]
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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. ACTA ACUST UNITED AC 2009; 67:543-9; discussion 549-50. [DOI: 10.1097/ta.0b013e3181b57aa1] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
This is a systematic review of published evidence regarding management of the cervical spine in conscious and co-operative trauma patients. We examine the literature in the following sections: clinical evaluation of the cervical spine; use of plain radiography; use of additional radiographic views; use of computed tomography; use of magnetic resonance imaging. Finally we consider the elderly and paediatric populations, particularly where there are significant differences compared to the general adult population. This paper also reviews the literature regarding non-medical assessment of the cervical spine. We conclude that there are well-validated decision rules available to guide the clinician, and that each imaging strategy has distinct advantages and disadvantages. Familiarity with these issues provides a sound basis for safe and effective decision-making.
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Affiliation(s)
- Julian Blackham
- Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jonathan Benger
- Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK,
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Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol 2009; 39:447-56. [PMID: 19002679 DOI: 10.1007/s00247-008-1043-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 10/04/2008] [Accepted: 10/06/2008] [Indexed: 10/21/2022]
Abstract
Cervical spine trauma in children is rare and the diagnosis can be challenging due to anatomical and biomechanical differences as compared to adults. A variety of algorithms have been used in adults to accurately diagnose injuries, but have not been fully studied in pediatric patients. In this article we review suggested imaging protocols and the general characteristics, types of injuries, and measurements used to diagnose cervical spine injuries in children.
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28
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Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, Guzman J, van der Velde G, Carroll LJ, Holm LW, Côté P, Cassidy JD, Haldeman S. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther 2009; 32:S117-40. [PMID: 19251060 DOI: 10.1016/j.jmpt.2008.11.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Best evidence synthesis. OBJECTIVE To critically appraise and synthesize the literature on assessment of neck pain. SUMMARY OF BACKGROUND DATA The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature. METHODS The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain. RESULTS We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain. CONCLUSION The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.
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Affiliation(s)
- Margareta Nordin
- Department of Orthopaedics and Program of Ergonomics and Biomechanics, School of Medicine and Graduate School of Arts and Science, New York University, NY, USA.
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29
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Mathison DJ, Kadom N, Krug SE. Spinal Cord Injury in the Pediatric Patient. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2008. [DOI: 10.1016/j.cpem.2008.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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30
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Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, Guzman J, van der Velde G, Carroll LJ, Holm LW, Côté P, Cassidy JD, Haldeman S. Assessment of Neck Pain and Its Associated Disorders. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008. [DOI: 10.1007/s00586-008-0630-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008; 33:S101-22. [PMID: 18204385 DOI: 10.1097/brs.0b013e3181644ae8] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Best evidence synthesis. OBJECTIVE To critically appraise and synthesize the literature on assessment of neck pain. SUMMARY OF BACKGROUND DATA The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature. METHODS The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain. RESULTS We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain. CONCLUSION The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.
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Moser T, Dosch JC, Gangi A, Buy X, Dietemann JL. Le bilan d’imagerie dans les traumatismes récents du rachis. ACTA ACUST UNITED AC 2007; 93:653-65. [DOI: 10.1016/s0035-1040(07)73250-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Dosch JC, Moser T, Dupuis MG, Dietemann JL. [How to read radiography of the traumatic spine?]. JOURNAL DE RADIOLOGIE 2007; 88:802-16. [PMID: 17541376 DOI: 10.1016/s0221-0363(07)91349-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In this paper, the imaging features of traumatic injuries of the spine in an emergency department will be reviewed. Three themes are discussed. 1) Review of current indications for additional imaging work-up. Conventional radiographs are not always mandatory, especially at the cervical level since validated criteria are available from the literature. The low sensitivity of conventional radiographs often requires additional imaging by CT (bone lesions) or MRI (disk and ligamentous lesions). The degree of urgency in scheduling these different examinations will be defined by the clinical setting and risk level (low/intermediate/high) of the injury. 2) Review of imaging features associated with stable and unstable lesions. The analysis of conventional radiographs is based on biomechanical concepts. The features of the main lesions will be illustrated by clinical cases and diagrams. 3) Review of key points that must urgently be transmitted to clinicians. The preliminary radiology report is an essential document for the management of patients with traumatic injury to the spine. It will have an impact on the type of immediate management (medical, orthopedic or surgical). A final report validating the initial interpretation should, of course, soon follow.
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Affiliation(s)
- J C Dosch
- Service de radiologie 2, Hôpitaux Universitaires de Strasbourg, Centre de chirurgie orthopédique et de la main Illkirch, BP 49, 67098 Strasbourg cedex, France.
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34
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Imhof H. Imaging of Spinal Injuries. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Miller P, Coffey F, Reid AM, Stevenson K. Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation? ACTA ACUST UNITED AC 2006; 14:133-40. [PMID: 16730989 DOI: 10.1016/j.aaen.2006.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2005] [Revised: 01/31/2006] [Accepted: 03/05/2006] [Indexed: 10/24/2022]
Abstract
The Canadian c-spine rule (CCR) allows safe, reproducible use of radiography in alert, stable patients with potential c-spine injury in the emergency setting [Stiell, I., Clement, C., McKnight, R., Brison, R., Schull, M., Lowe, B., Worthington, J., Eisenhauer, M., Cass, D., Greenberg, G., MacPhail, I., Dreyer, J., Lee, J., Bandiera, G., Reardon, M., Holroyd, B., Lesiuk, H., G. Wells, 2003. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. The New England journal of medicine 349 (26), 2510-2518; Stiell, I., Wells, G., Vandemheen, K., Clement, C., 2001. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 286 (15), 1841]. This paper reports on a study of emergency nurses' ability to identify patients requiring immobilisation using the CCR. Emergency department triage nurses (N = 112) were trained in the use of the CCR and then asked to use the tool over the following 14 months in the assessment of 460 patients who presented with potential c-spine injury. Trained medical staff repeated 55% of the clinical assessments independently using the rule. The level of agreement between nurse and medical judgement was calculated. The inter-rater reliability using the kappa statistic was 0.6 (95% CI 0.50-0.62 N = 254) indicating a 'good' level of agreement. The majority of nurses indicated they were comfortable using the rule. The results suggest that UK emergency department nurses were able to use the Canadian c-spine rule to successfully guide selective immobilisation. A 25% reduction in immobilisation rates would have been achieved if the rule had been followed. Further studies are needed to test the reduction in levels of immobilisation that could be achieved in clinical practice.
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Affiliation(s)
- Phil Miller
- University Hospital Nottingham, Derby Road, Nottingham NG7 2UH, United Kingdom.
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36
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Barry TB, McNamara RM. Clinical decision rules and cervical spine injury in an elderly patient: a word of caution. J Emerg Med 2006; 29:433-6. [PMID: 16243202 DOI: 10.1016/j.jemermed.2005.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Revised: 03/21/2005] [Accepted: 05/24/2005] [Indexed: 11/21/2022]
Abstract
We report a case of a clinically significant cervical spine fracture in an elderly patient without midline cervical tenderness. Application of the NEXUS rule by the treating physicians ruled out the need for radiography. However, knowledge of the Canadian C-spine rule and clinical judgment prompted obtaining a three-view trauma series of the cervical spine and, when the patient's pain increased, a computed tomography scan of the cervical spine. A type III fracture of the dens was found. In review of the case it was recognized that application of the NEXUS rule for this patient was problematic regarding the assessment of mental status. Specifically, the treating physicians did not strictly adhere to the detailed explanations attached to the NEXUS criteria regarding mental status. Clinicians may wish to preferentially apply the Canadian rule for patients over the age of 64 years.
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Affiliation(s)
- Thomas B Barry
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
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Abstract
OBJECTIVE To assess whether the introduction of the National Emergency X-ray Utilization Study guidelines in a UK emergency department reduced the number of patients having cervical spine radiographs and altered the accuracy of diagnosis of cervical spine injury. METHODS This was a prospective, observational study. The number of patients with recent neck injury who had cervical spine radiographs taken was assessed for 3 months before and three months after the introduction of the National Emergency X-ray Utilization Study guidelines to an urban emergency department in the UK. The number of injuries missed by emergency department doctors during the two 3-month periods was also recorded. RESULTS Prior to using the guidelines, 252 of 715 patients (35%) were X-rayed and when using the guidelines, 268 of 706 patients (38%) were X-rayed. No significant difference was observed between the rates of X-ray in the two groups (P=0.288). No injuries were missed by emergency department doctors either before or after the introduction of the guidelines. CONCLUSION Introduction of the National Emergency X-ray Utilization Study guidelines to a UK emergency department did not reduce the number of patients having cervical spine radiographs after neck trauma and had no effect on the pick-up rate for cervical spine injuries.
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Affiliation(s)
- Christine Dearden
- Accident and Emergency Department, Royal Victoria Hospital, Belfast, Northern Ireland.
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Van Goethem JWM, Maes M, Ozsarlak O, van den Hauwe L, Parizel PM. Imaging in spinal trauma. Eur Radiol 2005; 15:582-90. [PMID: 15696292 DOI: 10.1007/s00330-004-2625-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2004] [Accepted: 12/09/2004] [Indexed: 12/29/2022]
Abstract
Because it may cause paralysis, injury to the spine is one of the most feared traumas, and spinal cord injury is a major cause of disability. In the USA approximately 10,000 traumatic cervical spine fractures and 4000 traumatic thoracolumbar fractures are diagnosed each year. Although the number of individuals sustaining paralysis is far less than those with moderate or severe brain injury, the socioeconomic costs are significant. Since most of the spinal trauma patients survive their injuries, almost one out of 1000 inhabitants in the USA are currently being cared for partial or complete paralysis. Little controversy exists regarding the need for accurate and emergent imaging assessment of the traumatized spine in order to evaluate spinal stability and integrity of neural elements. Because clinicians fear missing occult spine injuries, they obtain radiographs for nearly all patients who present with blunt trauma. We are influenced on one side by fear of litigation and the possible devastating medical, psychologic and financial consequences of cervical spine injury, and on the other side by pressure to reduce health care costs. A set of clinical and/or anamnestic criteria, however, can be very useful in identifying patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Multidetector (or multislice) computed tomography (MDCT) is the preferred primary imaging modality in blunt spinal trauma patients who do need imaging. Not only is CT more accurate in diagnosing spinal injury, it also reduces imaging time and patient manipulation. Evidence-based research has established that MDCT improves patient outcome and saves money in comparison to plain film. This review discusses the use, advantages and disadvantages of the different imaging techniques used in spinal trauma patients and the criteria used in selecting patients who do not need imaging. Finally an overview of different types of spinal injuries is given.
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Affiliation(s)
- Johan W M Van Goethem
- Department of Radiology, Universitair Ziekenhuis Antwerpen, University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.
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In reply. Ann Emerg Med 2004. [DOI: 10.1016/j.annemergmed.2003.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mower WR, Hoffman J. Comparison of the Canadian C-Spine rule and NEXUS decision instrument in evaluating blunt trauma patients for cervical spine injury. Ann Emerg Med 2004; 43:515-7. [PMID: 15039696 DOI: 10.1016/j.annemergmed.2003.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Knopp R. Comparing NEXUS and Canadian C-Spine decision rules for determining the need for cervical spine radiography. Ann Emerg Med 2004; 43:518-20. [PMID: 15039697 DOI: 10.1016/j.annemergmed.2003.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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