C-Spine Injury - Shawn Safford: Update Course 2014

So, uh, Sean's gonna be talking about, uh, C-Spine because, uh, I've been trying to shove, put this into our trauma symposiums that we do, and it never really hit what I see very common but controversial questions. So, uh, we're gonna hit on hopefully some of these controversies. So, uh, there's kind of the cases have gone so far, just go through some kind of basic, um, concepts of, of different presentations. Uh, an 18 month old arrives in the emergency room, uh, from the scene of NBC where he's unrestrained and ejected from the car. His GPS is 15, however, has no neurologic deficits, and what would be the next evaluation for this child? So what does the faculty think here? So, uh, 18 month old. Um, he's normal GCS, no deficit. So, can I, before we get into this cause I'm trying to see here, we have. Can you tell if he's tender? I'm sorry, say again. Is, is he, does he have any C-spine tenderness? No, so he's, he's presenting. He's got no, no tenderness. He's 18 months old, so of course he's not going to necessarily, uh, tell you, but, uh, he seems to be neurologically intact and, and is a normal infant GCS. Did he come in with a C collar? He's coming in with a towel wrapped around his neck and, and he had, so you say he was ejected. Was he a fighter pilot ejected in his car seat or ejected out of his car seat? He hit the eject button. OK, so you're saying if he was in his car seat, it would make a difference to you. It might, yeah, because if, if he was in a car seat and he looks like perfect when I went and saw him, I might just, uh, clear him clinically. Yeah, OK, so mechanism alone, that's the question. Mechanism in an 18 month old, how, what would you guys do? Would you get a study? Could you clear him clinically? Steve mechanism alone. I think you got to study him. OK, yeah, I'd be concerned based on his age and the reliability of your exam, uh, and as well as the mechanism would probably push me more toward getting a. Another option, let's add E is if he's staying, well, he's GCS 15, but if he was staying overnight, maybe examine him again in the morning, in the morning, yeah, you could also use time. You don't think you a time. Leave the towel around him. a collar on. No, you put a real sea collar on. You put a real sea collar on him and check in the morning when he's he'll definitely be tender then because he's had a sea collar on. I do think, you know, the only thing I'll say is that, you know, I mean, medical legally, I don't think anyone will get away, you know, everyone's gonna feel like they have to get C-spine films on this kid and because he's 18 months, I think. Because of the because of the mechanism and and these 18 months, you can't talk to him. The Nexus trial doesn't cover kids, but if you look at the Nexus trial, the mechanism of injury isn't really, no, I know it, and you should be able to clear him clinically, right, by the Nexus trial, but it's his age that I think calls that for me it's, it's the age in 18, but the, but the other piece is that has any, you know, I, the only C-spine injuries that, you know, when you see a C-spine injury in a kid this age. You know, it takes significant force and I've, you know, they almost, to come in with no head injury sitting there, you know, if the kid looks totally normal sucking on his pacifier jibber jabbering with mom or whatever, you know, but it's also going to be high. A high injury, right in a kid this age, so I think that potentially you might miss that on physical exam. And the kid would be able to. Have you ever seen a C-spine in a kid where the kid could move their neck around and like wasn't tender and was just like, you know, what the problem is they come in with the towel wrapped around them. They're, they're wigging out because you're poking and prodding it. I, I just think it's hard in an 18 month old to get an exam that would make me say I'm not gonna worry about this kid's neck, which after he was injected. But would you get plain films or would you go straight to a CT for this kid, CT or MR or MR. I would not get an MRI because it requires anesthesia, so I would get a CT. So, so I just want to clarify this kid, you would get a lateral C-spine film. Right, is that what you're saying? You might or might not. I mean, it depends if you're gonna scan them for anything else. Let's say you're just scanning. So, so the scanning anything else. So we, we, we actually did a study in our institution looking at the radiation from neck CTs. I know, I know you don't believe this stuff, Todd, but the, but no one knows. Well, no one knows the effects of it, but what I can tell you is that it takes 600 plane films to equal one neck CT and radiation. But the question is, does it really, is it 600 times such a small number in terms of the radiation exposure that it's, that's the answer nobody knows, and everyone tells me if it's 1 in 1000, you know, maybe that is pretty significant because we do, we do thousands of CTs in our institution. So, but Dan, back to my question, so if you get, you, you would just get a lateral C-spine film. If you don't know, if you didn't need a CT, but if you, I mean you could try that. The problem with that is if you get a lateral and it's inadequate, then you're going to get a CT and then you're giving them the exposure to both. Let's say you get a CT or, or if it takes you 10 laterals to get the right one, that's OK. That's what, that's my point. It's better than, it's better than this. It's less than the CT. A CT doesn't add anything above an adequate X-ray and. In an 18 month old, you should be able to get an adequate. You should. So I agree. I mean, I would, I would, I'm an anti-CT person, so I would be more inclined to get a lateral film. I mean less 2 years and younger. I don't know in any case what a CT would ever add. Well, I think in most places. Places this kid would come into an institution that had a protocolized system. This kid would be a level 2 trauma coming into your trauma program, and you would automatically go bam bam bam, yeah, and they get there. That's right, they get there. It's not like you're there scratching your head trying to decide what to do, right. But, but I would say that anybody ever seen a C spine injury in this age group that wasn't either dead or paralyzed? Well, that's, that was my point. That was my point. Yes. Yeah. And it was unbelievably scary that you could miss something that horrible on an MRI and it was an MRI that caught it, but was it an a dislocation or? No, I mean, it was a, uh, uh, it was a, a, uh, contusion to the uh spinal cord, and there was some high highlighting of the muscles. Soywara, not, not exactly, exactly. And we got good, uh, they got a CT scan elsewhere, which didn't add anything again, but, uh, the X-ray kind of looked OK. And the kid was immobilized and didn't have any deficit. So what made you get to see the MR, uh, the MRI. Once he, once he cooled down and, and cause he was screaming, um, he wouldn't move what mom said. He wasn't acting normal. Uh. Even like 6 to 8 hours after. So he had some symptoms. Sean, OK, go ahead, Sean. Go on. So how old, how old was that child, because again, I think that's the key, the key point here, right, which is the age of the child. Uh, you're really trying to evaluate the aurora versus, um, having some other unknown finding, and again the aura can, can be seen up to hours afterwards, and those initial findings may not have been seen initially and only being found later on. Don't you want to know the severity of the accident? I mean, uh, you know, if he got ejected unrestrained, it had to be a pretty significant accident. So, uh, I, I'd wanna get almost on that basis alone, I'd want to get some C spines. Keep going. So Sean, what would you do in the first? What would you do? That's what hit the button. Somebody, Sean, what would you do? Uh, so at that point, given his age and having no findings, he, he potentially could be qualify for a 2DC fine to see if there's any gross abnormalities given the fact that he's got a significant, uh, mechanism. Um, the second child at the scene is found to have distracting injuries, a femur fracture, otherwise normal, otherwise it's exacts a twin brother, but has the femur fracture involved with it as well. Uh, same question, which is, do you see spine range of motion, MRI or CT? On that one, I'd, I'd do a two view C-spine and then, and then leave them in a collar until things calm down and you can examine them the next morning. Put them in Miami or in Aspen or something. I said 2 views C-spine and observe them for a few hours at least 6 hours. I do the 22, To view uh CT uh spine film. So these kind of, so then, then you've got the, the previous knee exam is normal, but would not have a normal range of motion. How, what would be your next step in your clearance of the child's uh C spine? Do you CT it, MR, Flexex films, or repeat an exam in 8 to 12 hours? Well, there's another option, E, but I guess he's, this is still an 18 month old. Yeah, In an older child, I would leave the collar on. I wouldn't do that to him. You're gonna leave the collar on for how long? A week or two, more, sometimes a week or two is what I would do. And then we reevaluate. But if you get an MRI and it's negative, you can take it off. Yeah, I would get an MRI, and that collar is kind of, you know, uncomfortable. Yeah, yeah, and you get 2 weeks. 3 weeks, sometimes 4. I, I wouldn't. Oh, because you mean they still have pain or the resident is seeing him in clinic. I mean, you, we have followed up patients where 6 weeks later, they still have a caller because they got followed up in clinic and stuff happens, right? I mean, oh, you just leave it, just leave it. That's the easy answer. You get an MRI. If it's negative, you're done. I mean, maybe not in if you need the sedation, but If you don't need the sedation, you can get the MRI for sure. It's, I mean, it's well worth everybody's time, right? So I again, I think someone said here, most of these hospitals have very nice protocols for these patients, and we certainly have a great, beautiful algorithm and institution dependent is how that last step goes. And, uh, but I think most would say collar or MRI, right, on the algorithms because both are reasonable options, uh, then the person clearing it, whether it's ortho, you or neurosurgeon makes that decision, right, right. I, I think both are reasonable options. We just usually, that's usually what we do here. Steve Stiligianos is on the phone. Do you have any comments, Steve, about this issue? Uh, Steve. All right, can you ask Amanda because it says his name, he's on the phone, maybe we'll figure that out, let us know, OK. So this goes to the uh kind of the algorithm that that we have locally uh regarding 6 C spine clearance in our uh in our kind of less than 2 years of age group um it goes up to about 7 to 8 years of age that we kind of are a little bit uh marginal, but you know, looking at the nexus criteria they're saying these are not applying to, uh, children, uh, however, midline tenderness, altered LOT and not many 8 year olds intoxicated, but distracting injury and focal deficit. Um, as well as potentially having age greater than 2 GPS, whether to kind of proceed with this, this algorithm. Um, with these risk factors identified above, you know, you can look at the, uh, if they have those risk factors. In other words, they've got distracting injury, high mechanisms, uh, getting a two view C spine. It was interesting. Some people were talking about just lateral versus two view. I'd be interested in hearing kind of people's thoughts on that from, uh, our experience, um, we require two view, not the three view. We're not looking at thedontoid views, but we do require two views to C spine in, in, in the children. So, um, I just have a question. I don't. One last thing is I just want to make sure because this will again will be probably the 4th thing in this half a day that I've changed my practice. So everybody here gets an MRI to rule out ligamentous injury. I just want to make sure that that's a uniform. So if we have a kid in, in this age group, you get an MRI. If they were older and could voluntarily follow commands, we would get flex X films. We, we. So funny. This is, you know, this is incredible to me because I got flex sex films until I was told, oh, that's like the worst thing. And then I stopped getting flex sex films because you could piss or piss someone, you know, under you do it under, yeah, under flora, and, and they do. So there's someone responsible in the room, yeah, there's two different kinds of flex sex films. So there's the kid that has a little paraspinal tenderness, you know, you think it's probably just muscular, um. Or, or maybe you have some, maybe they do have some midline tenderness, but they're, it's not, it's, you know, the plain films are stone cold normal, so you're pretty sure they don't have a fracture and they're an older kid that can follow commands. We'll do, we'll do the flex X films where they're moving their neck back and forth and then the, then the others are the ones that we require either someone from neurosurgery or pediatric, you know, trauma, the trauma team to be there where you're actually moving their head. Under flora to make sure that you don't fit them. OK, so just curious, two different things, right? So you get MRI in the little ones and you do voluntary or or assisted. Yeah, one or the other and the older kids, um, is that, is that we get MRIs on everybody. You do MRI, everyone. Is there anyone here that, that, so it sounds like nobody leaves them in collars except for what we do here. We'll, we'll leave them in a collar. You can. They're, they're just not nice, and I would say they're they're, I just want to know what people are doing. Well, I know you can. So there are times that we have patients that have normal films, normal MRI. They have persistent midline tenderness. They're usually evaluated by the neurosurgeons, and they typically discharge the patient. Home with a collar in place. So why did you get, but it's a soft collar for comfort. It's, but they know that the patient will take the thing off after about a week because they get sick of wearing the thing. I heard that. And, and, but that's typically the way that how accurate, and I know Steve, you're on the phone now, Stilanos, you're here. Yes, yes, I'm here. We're going to have you comment in a second. How accurate? I just don't know how accurate is MRI for ligamentous injury. I think it's extremely accurate. It's just the, the hoops you have to pass through to get it, uh, when you need it, and if there are other organ systems involved, then it's really a, a, a struggle, but it's, uh, what I have found is that it's fantastic for when the kid has it, you see it. Uh, any comments about what you've heard so far, Steve? Um anything you disagree with one thing, the one thing that we can always count on is how, how often this target changes, but I think that with the work done by many of our colleagues over the last 5 to 10 years, we've been able to kind of drill down to certain high risk age groups, you know, we, we don't treat a 13-year-old like we treat a 2-year-old, and It's just going to be going forward we're going to have to figure out who does not need any imaging at all, and that's going to be quite a challenge, but there's a lot of work out of Pecan that is going to help us see who does or doesn't need imaging. But right now if you're, if you're in doubt, an MRI is brilliant if you can get it. Great. All right, Sean. Well, first, Skiora, just to comment, just kind of continue that comment for Skiwara as well as ligaments is in you, MRI is definitely the gold standard for for for evaluating them. So this is an encounter kind of going along with Doctor Celiano about to say, which now you got a 10-year-old skateboarding accident, no specific neuro symptoms, has midline tenderness with no distracting injuries, and a GCS of 15. What is the next step in the evaluation of his, uh, C spine? An MR, CT scan of C C spine, two BC spine, or physical scan to determine the range of motion. Comments from the group. Steve? And I mean you're gonna get plain films and uh may we may stop there. If do you think you can clear the C-spine just on two C-spine? Well, I think the tenderness is the key issue, and that's the one where it's hard on a, you know, on a multiple choice question. The degree of tenderness, the believability of the tenderness, the spasm of the neck muscles is really going to guide an astute clinician. And help them, you know, go down the path of of MR or not. But what we're going to try to get to is these children without distracting injuries, without neurologic symptoms, and the most minimal or no tenderness. We've over imaged those children. We know it for sure and slowly we'll get better at being able to show restraint in our imaging. But I think the question is next step, and I think the two of you C-spine as the next step, uh, I would be very standard. Yeah, absolutely. And then, and then you can either watch them in a collar overnight and reexamine or get the MRI. Hm wow. So that's, is that everyone agree on that? That's interesting. That's that's what CT scans. Oh no, no, no. So, so I thought that I just heard you say 22 view and I didn't mean CT if I said CT, I didn't mean 22 view C spine C spine. I'm sorry. At what age would you get, what if it was an 18 year old, would you go straight to CT? Is there anyone you don't, no, we don't, we don't do CT in anybody unless, you know, unless there's, if there's fractures we need to define. So if there's a positive plane film, if you're getting a head CT, do you just carry it on to the neck, or no, that's what we do. So we, we do plane films because of the whole radiation issue. Our, our, our radiologists and we get, you know, image safely and all that stuff. We are very paranoid about use of radiation. Image safely based on Hiroshima data. No, it's, it's more than, it's more than just Hiroshima data now. OK. No, I, I believe that I try to avoid it too, but I don't know how much we need to avoid it. All right, um. Any, uh, Sean, any last comments? Yeah, so to that, I mean, it's again kind of looking at the nexus risk factor for the greater than 8 year olds kind of correspond more with the adult literature, which um again this is our local protocols that we have. We do actually proceed with high risk, uh, midline tenderness, high, high worries for actual injury. We actually skip the two of these C-spine and generally they're going to be having a head injury as well, so usually they get they get the head and C-spine along with that. Um, and then MRIs with the prolonged intubations and, in spite of a clear CT in order to get, uh, the child, uh, cleared for either prolonged, uh, intubation, ICU space. I'd be interested in what people do for those for the, the neurologically devastated, uh, other things going on requiring what, what, what kind of, uh, protocols others are using to, to clear the C spine in this setting. So questions, neurological, I guess your question is neurologically devastated. Any other, is that your question? the collar off? How do you get the collar off in a in a neurologically devastated patient who's got a Train G2. At an elective time you get an MRI, yeah, yeah, at an elective time, because even if you're, OK, say it's an emergency, you got to open up the belly, but you want to scan the head because it's a really bad accident and you're, so you're going to scan the head and go, even then you still don't need to scan the neck because say you scan the neck, you spend an extra 30 seconds supposedly just going through the neck as well. What are you going to do? You're still going to put him in a column no matter what it shows, even if it's negative, and go to the operating room. Or if you have time and you're gonna scan the head and the belly and do everything else, you still don't need to scan the neck, but they'll eventually need imaging of their neck. So if you're there anyways, you just scan them right through if you're getting their head. No, you can get an X-ray if you're gonna put them in a collar. If it's an emergency, you're going to leave them in a column. No one's going to, no one should rightfully agree to moving that patient's neck if they're that devastated. But I would argue it will take a lot longer to get an X-ray than just to keep the scan going for another 10 centimeters through his neck. It's not going to change for 24 hours. I agree, but you said get a, get a CT of the head and then get neck films, and I would argue that would take a lot longer than just getting the CT while you're there. Yeah, but you don't need the neck films at all if you get the CT. And you're there in the CT scan, but it's a different amount of radiation for exactly the same, and we've argued whether that's a significant difference or not. Our radiologists would argue that it's a trivial amount of radiation, even if it's 100 times a plane fill. They say you get more radiation traveling in a plane from New York to LA or something like that. I, I think, uh, Steve or Sean, any final comments? Sean, I think I covered it pretty well. Thank you, Sean. I, I, again, another boring topic, no debate controversy at all. That's it.