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Re: C-spine Trauma
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Re: C-spine Trauma - January 25, 2005 10:06:00 AM
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nari
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Thanks, Army.
While many are looking for fractures, there are other ways that movement of one segment on another can occur without fracture; there is also rotation between C1 and C2- maybe normal -but ligament disruption seems the most likely culprit here, given the circumstances of the fall....
Nari
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Re: C-spine Trauma - January 25, 2005 10:52:00 AM
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OrthoSam
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A few questions, as don't think I am even close.
Does the left C2 transverse process look okay to you?
Also, C2 looks as though there is a small side glide to the right, confirmed by the spinous process rotated out to the left and a closer position of the dens relative to the right lateral mass of C1. But, the front teeth are not "perfectly" aligned with the dens, so I'm not sure if the head is just tipped right. The left C1 facet is also elevated on the left, indicating positioning from the side-bending right, and/or pull from the right alar ligament?
I'm going with a "cock-robin" positioning of the upper cervical spine in right side-bending and rotation left,due to left upper cervical instability. Is that a small change to the countour of the left C1-2 facet medially?
....deep breath
Sam
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Re: C-spine Trauma - January 25, 2005 2:23:00 PM
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Dr.Wagner
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I will say one thing only...this man NEEDS A C-COLLAR ON (I cringe when I look at this and hear the history and see no c-collar)
In this setting, don't get a flexion or extension view...jump straight to CT. This is a trauma.
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Dr. Wagner DO
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Re: C-spine Trauma - January 26, 2005 1:48:00 AM
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tr6454
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Dr. Wagner are you referring to a soft collar (the ER special), or immobilization until instability can be ruled out?
I'm leaning with Jeff and Greg, can't visualize anything dramatic. physical exam would dictate additional imaging. There are people with worse DJD walking thru the mall. I'll bet after the fall he got up and went on his way. The 'rest of the story' will be interesting.
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Terry
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Re: C-spine Trauma - January 26, 2005 5:18:00 AM
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Dr.Wagner
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ER special?...never used or seen a soft collar used in the ED.
In a patient with a traumatic c spine injury which you cannot clear clinically (this case because of neurological complaints AND midline tenderness) they need to have a Philly collar or other hard collar placed until cleared radiographically. This is a NEED. Even if this is a day later, they NEED the collar prior to radiographs. If radiographs are inconclusive (3 views are all that are needed, but if you want obliques are also ok) then a CT is your next line. Many centers go straight to CT as its sensitivity for clinically significant injury is higher than radiographs (in trauma).
Hope that helps clarify.
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Dr. Wagner DO
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Re: C-spine Trauma - January 26, 2005 8:12:00 AM
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tr6454
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Dr. Wagner,
That's what I assumed you were meaning. Your lack of experience with soft collars speaks well to the quality of your services. It is not uncommon for me to see patients, often MVA, who have been given a soft collar, in the ED and then I have a heck of a time trying to convince them that their head won't fall off if they remove it.
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Terry
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Re: C-spine Trauma - January 26, 2005 9:06:00 AM
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chiroortho
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I tell patients to make a planter out of it.
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 26, 2005 10:08:00 AM
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Alex Brenner PT MPT OCS
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Sometimes I have to use my military rank and "order" the soldier to remove the collar.
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Alex Brenner, PT, MPT, OCS
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Re: C-spine Trauma - January 26, 2005 12:31:00 PM
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Jeep
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Collars may be very beneficial- IF used appropriately.
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Re: C-spine Trauma - January 26, 2005 1:55:00 PM
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chiroortho
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[QUOTE]If radiographs are inconclusive[/QUOTE]By inconclusive do you mean normal? If this is what you're saying then it would seem to make plain films unnecessary, because if they're normal and the ED gets a CT, and if they're abnormal and the ED gets a CT, then why bother with plain films?
And you seem to be referring to the Canadian C-spine rule. Is that the current standard that you use?
The Canadians come up with some good rules. Ottawa Ankle Rule, for example.
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 26, 2005 7:49:00 PM
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Dr.Wagner
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I use a combination of NEXUS criteria and Canadian C spine...canadian c spine didn't include children and gets a bit archaic.
Hard collar stays on until cleared by a doc (at time of trauma eval)...usually me.
And yep a recent article in the journal TRAUMA made the assertion that sensitivity is much higher with CT alone than with 3 or 5 view radiographs...creating an interesting dilemma. Are Xrays good enough in trauma (such as this). Until then I use the NEXUS criteria for cervical spine clearance, find it easier to utilize than the candadian cspine rules.
Here is a good example of how to clear a c spine in trauma
http://www.anastomosis.net/Trauma/1-C-Cervical_spine_clearance_1-C-Cervical_spine_clearance.html
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Dr. Wagner DO
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Re: C-spine Trauma - January 28, 2005 4:05:00 AM
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Alex Brenner PT MPT OCS
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This was a tough case due to the obvious barriers of trying to read a complicated radiograph off a computer monitor.
Other than all the degenerative changes noted at the various cervical levels this is a normal radiograph. There are no fractures.
[IMG]http://img.photobucket.com/albums/v85/brennerak/c-spinelat2.jpg[/IMG]
The calcification of the ligamentum nuchae is sometimes mistaken as a fracture or pathology, however, this is just a normal variant that is found. It is believed by some to be caused by previous trauma to the c-spine. I tend to believe it is just a normal variant because it is seen so often in almost nearly the same location.
[IMG]http://img.photobucket.com/albums/v85/brennerak/densview2.jpg[/IMG]
There is no fracture through the Dens. The "mach band" is highlighted here which can also be confused as a fracture.
Good job to the Greg, Jeff, and Terry for their correct interpretations of the radiograph.
A special star goes to Chiroortho for recognizing the importance of good early dental hygeine.
And finally, Pablo's streak ends. He was on fire.
This was a good thread. Thank you everyone who contributed and were willing to go out on a limb and make a judgment call.
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Alex Brenner, PT, MPT, OCS
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Re: C-spine Trauma - January 28, 2005 5:11:00 AM
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Dr.Wagner
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If I may, let me add a touch.
So lets approach this from a trauma standpoint.
57 year old gentleman arrives in the ED from an accident just moments earlier.
A fall from standing onto the face onto concrete.
Pt should arrive (if by EMS) in a hard collar and backboard as he complains of neurological findings and pain.
If he arrives without a collar, a collar should be placed upon the patient (standard of care).
Since the patient has both pain and neurological complaints he keeps the collar on and should recieve a minimum of 3 view radiographs prior to clearance. (standard of care)
If the patient had LOC or needs a head CT, a neck CT likely would occur rather than radiographs. (new trends in emergency medicine and trauma)
So now you have the radiographs as pictured below, significant arthritic findings but no defined fracture and no subluxation.
Correlate neurological exam with history to decided if the patient needs emergent CT of a segmental level.
One of the top 5 reasons for lawsuits of EM physicians or those in first contact of fractures (usually the ED) is missed fracture (usually peripheral joints). Missed fracture with morbidity means potential lawsuit for malpractice from 1 year from the FINDING of the fracture or pathology, NOT from the incident.
In this case the history is of utmost importance...if it is significant he gets a neck CT regardless of radiograph findings...if the neuro complaints are significant enough, he goes straight to CT.
In my mind I think bad things. I think everyone should as well. Being OVERcautious is never wrong from an initial standpoint.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: C-spine Trauma - January 28, 2005 5:21:00 AM
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gerry
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Army,
Thanks so much for the time and effort you put in posting these. Good stuff!
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Re: C-spine Trauma - January 28, 2005 9:58:00 AM
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Alex Brenner PT MPT OCS
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Dr. Wagner,
Thank you very much for your input and knowledge from an ER physician point of view. Very helpful and informative.
Thanks.
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Alex Brenner, PT, MPT, OCS
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Re: C-spine Trauma - January 28, 2005 10:02:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Chiros,
Thank you for your input and additions to these threads. Your knowledge and expertise is obvious and has been a great addition.
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Alex Brenner, PT, MPT, OCS
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