A new study is about to be published which questions the use of current cervical spine clearance criteria in the elderly(1). It goes further, recommending “liberal c-spine imaging for older trauma patients with significant mechanism of trauma”.
Here is a typical case:
74 year old patient from home, has had a mechanical fall from a standing height. He has fractured 2 ribs and his clavicle. It is not certain if there has been a head strike but the patient states he broke his fall with his hands. On examination, the patient is GCS 15 with pain over the right lower ribs and clavicle on movement and palpation, but with no neck pain on palpation. You apply NEXUS criteria and there is no neck pain and clear the neck. Is it clear?
NEXUS and The Canadian C-Spine Rule
The idea of a distracting injury is difficult to protocolise. NEXUS states that a precise definition of a distracting injury is not possible. “This condition includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second(neck) injury” They include some examples such as long bone fractures, visceral injuries, lacerations, degloving or crash injuries.
The Canadian C Spine Rule automatically includes those that are older than 65 years as higher risk and mandates imaging.
The current approach by most practitioners would be to apply the NEXUS rule, to most cases, because for the most part it’s simple to remember. In a patient like this a percentage of physicians would clear the neck clinically. It is their judgement call about the level of distraction. The NEXUS rule is well validated and accepted, however there are potential issues with it. It relies very much on the clinical criteria of neck pain and on our interpretation of what may be distracting. If you take the collar off, please document your findings and impressions carefully.
What is emerging in the literature, is that in the elderly, ther response to neck pain post trauma, may reflect what we see in other areas, such as chest pain, or abdominal pain, it can be misleading. In fact there may be no neck tenderness on examination, even in the presence of a clinically significant fracture. (2)
The study at the centre of this discussion, is a retrospective study of 2390 patients who were 55 years or older. 1071 patients had a CT cervical spine, where it was found that 183 had a cervical spine fracture. 36 of these patients with a fracture had no neck pain. Of those with a fracture 19% required surgical intervention.
What this means is that 3.7% of patients with a clinically significant fracture had no neck pain.
Those with no neck pain and a fracture had a higher severity score and a longer hospitalisation. Their injury severity score was between 9 and 15(moderate injury) and there was a higher rate of another body region being injured in the asymptomatic group. This may be a masking phenomenon.
So who do we image? There certainly are a larger number of CT cervical spines being done in the elderly. This is because we see those getting CT brains also getting CT cervical spines.
Recommendations have been made that (3,4)
- All elderly patients with a ‘trauma call’ should have a CT cervical spine
- All elderly that have a CT brain or CT chest should also have a CT cervical spine.
Will this study change my practice? Not necessarily. I currently have a low threshold for CT cervical spine in the elderly, especially if I’m imaging the brain, or chest. I’m very vigilant when I consider those above 65 years of age.
- Healy C et al. Asymptomatic cervical fracture: Current Guidelines can Fail Older Patients. Journal of Trauma and Acute Care Surgery, 2017- Published ahead of schedule.
- Schrag S et al. Cervical Spine Fractures in Geriatric Blunt Trauma Patients with Low-Energy Mechanism: Are the Predictors Adequate? Am J of Surg 195(2008)170-173
- Duane TM et al Defining the Cervical Spine Clearance Algorithm: A Single Institution Prospective Study of More than 9000 patients. J Trauma Acute Care Surg. 2016; 81:541-547
- Duane TM et al. Clinical Examination and its Reliability in Identifying Cervical Spine Fracture. J trauma. 2007;62:1405-1410