Cervical Spine Injury - Essay Example

Cervical Spine Injury Introduction: Injuries due to accidents from the field of sports to the roads and highways lead to many patients reaching the emergency department of hospitals all round the world. In countries of the United States of America and Canada alone the number of such trauma patients reaching the emergency departments of hospitals amount to more than thirteen million every year. Even though only a few of such patients are finally found to have cervical spine injuries, it remains essential to clear cervical spine injuries in such patients, where such a possibility is suspected. (1) The importance of clearing cervical spine injuries lies in the devastating effect that it could have on the patient in case it is missed. Advances in imaging technology assist the physicians in clearing cervical spine injuries, when it is suspected. For this purpose such patients are immobilized. (2). With so many patients annually the number of imaging requests for cervical spine clearance is mounting on one side and many of such patients unnecessarily go through the inconveniences involved in the use of imaging technology for clearing cervical spine injuries. Clearing cervical spine injuries is a challenge in the emergency department and meeting this challenge is assisted by imaging technology, however quite often there is over reliance on the assistance of imaging technology leading to unnecessary inconvenience, increased costs and delay in initiating treatment and management strategies. (3) According to Graber and Kathol, 1999, in trauma patients, “cervical spine injury is unlikely if the patient has no neck pain or tenderness, no neurologic signs or symptoms, no loss of consciousness, normal mental status and no distracting injury”. (4). Case Description: The patient was brought to the emergency department by ambulance and assisted to the emergency department by ambulance personnel on February 15, 2007 at eight in the night. The patient had fallen from a motor cycle after a skid. The patient had not worn a helmet. The patient had bleeding lacerations on the inside of the lower lip and on the outside the lower lip and underside of the chin. The patient was conscious and coherent. The patient was twenty years old. The patient complained of ringing pain in both the ears. Pupils of the eye reaction to light were normal. Heart rate was elevated at 92 per minute and blood pressure normal at 120/80. There was no smell of alcohol. Palms of the hand and soles of feet were sensitive to touch. There were no other injuries visible on the body. The patent could not tell if there was any pain in the head or neck areas. There was no feeling of tenderness in the posterior midline cervical spine area, as the pain in the ears was overwhelming. Movement of the neck was more than forty-five degrees on either side. The patient was immobilized on a backboard and radiological imaging done. Results of the radiological imaging cleared cervical spine injury and any other fracture of facial bone structures. Sutures were applied to the injuries inside and outside the lip. The wounds on the chin were cleaned and dressed. Injections of tetanus toxoid and amoxicillin were administered. The patient was kept in the emergency department overnight and discharged the next day morning with advice on oral amoxicillin anti-biotic regimen and follow-up advice was to see the dental department. Case Discussion: This case provides and opportunity to evaluate whether guidelines on the use of imaging technology in clearing cervical spine injuries in accident patients is adhered to in the emergency department. There are two guidelines that have been developed for clearing of cervical spine injuries in the emergency department for trauma patients. The first guideline is the nearly fifteen year old National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria (5). The second guideline is the recently developed Canadian C-Spine Rule (CCR). There remains debate on the superior ability of either of the guidelines in clearing cervical spine injuries, though there is emerging evidence that CCR is superior to the Nexus low-risk criteria in both sensitivity and specificity in the clearance of cervical spine injuries. (6). (Please see Appendix 1 for figure of CCR). The NEXUS low-risk criteria involve the use of five criteria to avoid unnecessary imaging of trauma patients to clear cervical spine injuries. “No tenderness at the posterior cervical spine midline. No focal neurological deficit. Normal levels of alertness. Normal Level of alertness. No evidence of intoxication. No painful injury that might distract from the pain of cervical spine injury”. (7). The CCR on the other hand identifies patients with a risk of cervical spine injury. The high risk factors wherein patients necessarily have to go through the imaging procedures are those over sixty-five years of age, or involved in a dangerous mechanism of accident, or having paresthiasis of the extremities. It also identifies patients with low risk, where it is possible to evaluate the active motion possible of the cervical spine, and then moves to ability of motion of the neck, through which the imaging technology is not required. See Appendix 1. Stiell et al, 2003, conducted a study comparing the NEXUS low-risk criteria and the CCR. The conclusion of this study that is extremely relevant in this case. The study concluded that for alert patients with trauma, who are stable, the CCR is superior to the NEXUS low-risk criteria in clearing patients for cervical spine injuries, and offers the advantage of reducing rates of radiographic imaging. (8). In this case it is obvious that the emergency department used the NEXUS low-risk criteria. The overwhelming pain in both the ears made it difficult for the patient to identify any other source of pain, and as such went against the fifth criterion of “no painful injury that might distract from the pain of cervical spine injury”. (7).This caused the advice for radiological imaging to clear cervical spine injury. On the other hand, if the CCR was used, there would have been no imaging required. The patient was below sixty-five years of age, not involved in a serious accident, had no paresthiasis of the extremities, and could turn the head more than forty-five degrees to either side. These factors would have rule out imaging requirement for clearing cervical spine injury in the case of CCR. (8) Though the emergency department adhered to a guideline in the form of the NEXUS low-risk criteria in clearing the patient of cervical spine injury, unfortunately it did not prevent the unnecessary use of radiographic imaging, which would have been the case had the emergency department used CCR instead. Works Cited 1. Zepf, Bill. “Which C-Spine Rule Works Best in Trauma Patients?” American Family Physician 69.12. 2004. American Academy of Family Physicians. 5 June 2007. . 2. Eubanks, J. D., Gilmore, A., Bess, S & Cooperman, D.R. “Clearing the pediatric cervical spine following injury”. The Journal of the American Academy of Orthopaedics 14.9. (2006): 552-564. 3. Platzer, P. et al. “Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis”. European spine journal 15.12. (2006): 1801-1810. 4. Graber, A. Mark & Kathol, Mary. “Cervical Spine Radiographs in the Trauma Patient”. American Family Physician. 1999. American Academy of Family Physicians. 5 June 2007. . 5. Hoffman, J. R., Wolfson, A. B., Todd, K. & Mower, W. R. “Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)”. Annals of Emergency Medicine. 32.4. (1998): 461-469. 6. Kerr, D., Bradshaw, L. & Kelly, A. M. “Implementation of the Canadian C-spine rule reduces cervical spine x-ray rate for alert patients with potential neck injury”. The Journal of emergency medicine. 28.2. (2005): 127-131. 7. Tins, B.J. & Cassar-Pullicino, V.N. “Imaging of acute cervical spine injuries: review and outlook”. Clinical radiology. 59.10. (2004): 865-880. 8. Stiell, G. Ian, et al. “The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma”. The NEW ENGLAND JOURNAL of MEDICINE. 349.26. (2003): 2510-2518. Appendix 1 Canadian C-Spine Rule (1) Read More