Cervical Spine Clearance Protocols

Transcription

1 Cervical Spine Clearance Protocols Spinal Interest Group rd March, 2018 Dr Helen Ackland, PhD Senior Clinical Trauma Research Fellow, National Trauma Research Institute, The Alfred Senior Lecturer, Department of Epidemiology and Preventive Medicine, Monash University

2 Today: Victorian State Trauma System Cervical spine clearance issues: Clearing alert patients with CT NAD for acute injuries, persistent midline cervical tenderness Clearing unconscious/obtunded patients +/- TBI, skull or facial fractures Elderly low falls Current international protocols Spinal injuries in ladder falls Ionising radiation in trauma imaging

3 Trauma in Victoria Trauma: Leading cause of death in Victoria Accounted for 50% of childhood deaths Accounted for 75% of deaths in young adults (18-25 years) High preventable death and potentially preventable death rates widely variable depending on the size and expertise of treating hospital For every death, there were 31 hospital admissions and 144 ED presentations (++ morbidity) Ministerial taskforce and working parties: Review of trauma and emergency services in Victoria

4 Taskforce Parliamentary Secretary to Minister for Health and representatives from: Dept Health Ambulance Service ICU, anaesthetics, emergency Trauma, orthopaedics and neurosurgery Nursing Consultative Committee on Road Trauma Geriatrics Disability Services TAC General practice General medical (general physician) Regional health workforce representatives Consumers representatives Ministerial Taskforce on Emergency and Trauma Services Report Of The Ministerial Taskforce on Trauma and Emergency Services and the Department Of Human Services Working Party on Emergency And Trauma Services, 1999

5 Working party Multiple members Sub-committees: Retrieval subgroup Neurosurgical subgroup Education subgroup System monitoring subgroup Role delineation subgroup Paediatric subgroup Ambulance communication subgroup Working Party on Emergency and Trauma Services Report Of The Ministerial Taskforce on Trauma and Emergency Services and the Department Of Human Services Working Party on Emergency And Trauma Services, 1999

6 Trauma in Victoria Key areas identified for improvement in major trauma: Reduction in emergency time to the accident scene Refinement of triage to appropriate hospital Improvement in the inter-hospital transfer process Process culminated in publication of the ROTES Report, 1999 > 100 recommendations : Right patient to right hospital in the shortest time

7 Trauma in Victoria Major proposals Development of 1 paediatric and 2 adult major trauma centres/services (MTS) gross infrastructure already in place Ambulance transfer of major trauma to MTS within 30 minutes of leaving accident scene (now 45 mins), otherwise transfer to nearest trauma service for stabilisation first

8 Major trauma Additional screening criteria Victorian State Trauma System and Registry Annual Report: July 2015-June 2016, published July 2017

9 Current major trauma profile Victorian State Trauma System and Registry Annual Report: July 2015-June 2016, published July 2017

10 Current major trauma profile 3244 major trauma patients 92% blunt trauma, 5% penetrating, 2% burns Increase in patients 85 years of age and older Increase in low falls, and trauma in motorcyclists and pedal cyclists Increase in injuries occurring at home 1568 trauma deaths in in-hospital deaths Alfred Hospital helipad, 2017

11 Trauma deaths Victorian State Trauma System and Registry Annual Report: July 2015-June 2016, published July 2017

12 Major trauma service Alfred: ~ 14,500 trauma presentations to ED annually, 11% major trauma 3600 admitted per year 1150 treated for traumatic spinal injuries: fractures, or intervertebral disc, ligamentous or cord injury, frequently with associated injuries eg. TBI

13 Clinical decision rules Yes No No National Emergency X-radiography Utilisation Study: Hoffman et al, NEJM, 2000 Yes Yes No Canadian C-spine Rule (CCR) Stiell et al, JAMA, 2001

14 Problematic Group No. 1: Alert patients with focal midline tenderness

15 Ackland HM, Cameron PA. Cervical spine assessment following trauma. Aust Fam Phys, 2012

16 Alert patients Prospective observational cohort study Primary aim: Determine the incidence of MRIdetected injury when CT is negative Outcome measures: Presence and extent of ligamentous, disc, cord and soft tissue injuries Association of clinical and radiographic factors with the extent of injury according to the number of spinal columns injured

17 Methodology Inclusions: GCS 15 No acute injury on CT Persistent focal midline cervical tenderness ie. not patient-reported pain Exclusions: BOS or high thoracic fractures Painful distracting injury or persistent focal neurologic deficit (NEXUS) History of cervical spine surgery History of chronic neck pain MRI > 96 hours post presentation

18 Imaging CT imaging: 64 slice GE LightSpeed VCT scanner Helical image acquisition at mm interval Skull base T5 MR imaging: 1.5T GE Signa Excite scanner Sagittal T1, T2 FSE, Axial T2 Blinded, independent MR reporting (Austin and Alfred) Interrater reliability at 100 patients 1, 2 or 3 column injury (Denis) 1,2 1. Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine

19 CT-detected spondylosis Category Disc space narrowing Osteophytes Canal stenosis Mild None < 2mm Not significant Moderate Visible > 2mm Visible centrally or laterally Severe Complete loss of disc height > 2mm Significant Early = mild Advanced = moderate or severe Peterson et al. A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United Kingdom patients. Spine. 2003;28: Yu et al. Criteria for classifying normal and degenerated lumbar intervertebral discs. Radiology. 1989;170:

20 Findings 178 patients recruited: Males 56%, Age median 34 years (range18-83) Road trauma 63%, Falls 19%, Sport 12%, Assaults 6% MR imaging: Median 37.5 hours (IQR: 22-51) 89% within 72 hours

21 Analyses Multivariate logistic regression: Association with injury extent according to number of columns injured Factors OR 95% CI p value Advanced cervical spondylosis Cervical spine protocol change: MRI for advanced cervical spondylosis in alert patients with persisting focal midline tenderness Ackland, Cameron, Varma et al. Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative CT. Annals Emerg Med. 2011;58:

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23 Current international protocols: Alert patients

24 American Association of Neurological Surgeons (AANS) Last protocol update: 2013 (evidence to 2010 included) Alert, symptomatic patient: High quality CT as first line imaging modality (or 3-view plain film if CT unavailable) Normal CT and neck pain or tenderness: 1. Continue collar until asymptomatic 2. Clear after adequate F/E views 3. Clear after normal MRI obtained within 48 hours 4. Clear at discretion of treating physician AANS and Congress of Neurological Surgeons. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery, 2013:72, issue suppl 3.

25 Eastern Association for the Surgery of Trauma (EAST) Last protocol update: 2009 (evidence to 2007 included) Alert, symptomatic patient: Axial CT occiput T1 as primary imaging modality Normal CT and neck pain or tenderness: 1. Continue cervical collar 2. Clear after negative MRI 3. Clear after adequate F/E views Como et al. Practice management guidelines for identification of cervical spine injuries following trauma: Update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma, 2009

26 American College of Radiology Last protocol update: 2012 (evidence to 2011 included) Suspected acute c spine trauma: imaging indicated by NEXUS or CCR: CT as primary imaging modality - sagittal and coronal reformats Entire spine should be examined due to high incidence of non-contiguous injuries No recommendation for normal CT and neck pain or tenderness Follow-up in patient kept in collar for pain, returning for evaluation: 5 view plain films American College of Radiology. ACR Appropriateness Criteria: Suspected spine trauma. ACR, 2012

27 National Institute for Health and Care Excellence (NICE), UK Last protocol update: 2016 (evidence to March, 2015 included) Suspected acute c spine trauma: imaging indicated by CCR: CT as primary imaging modality No recommendation in the case of normal CT and neck pain or tenderness NICE: Spinal injury: assessment and initial management full guideline:

28 RANZCR Last protocol update: 2014 (evidence to 2013 included) Suspected acute cervical spine trauma: imaging indicated by NEXUS or CCR: CT as primary imaging modality Persistent neck pain or midline bony tenderness are not absolute indications for MRI in the presence of a normal CT scan (no other recommendations) RANZCR: Education modules for appropriate imaging referrals,

29 Problematic Group No. 2 Obtunded patients

30 C5-6 disc extrusion causing acute cord compression. Partial tear ALL, high signal PLL, interspinous ligamentous tears C-6. ACDF

31 Alfred cervical spine clearance: history Protocol history for unconscious patients: 1992: 3 view plain films, passive bedside flexion/extension 1995: Dynamic flexion/extension in radiology department (Ajani et al, Anaes Int Care, 1998) 1998: CT 3mm cuts C1-C3 added 2000: CT 3mm cuts C2-C6 added 2001: Dynamic flexion/extension removed from protocol (Padayachee et al, J Trauma, 2006) 2002: CT cuts extended to T4/ detection of occult ligamentous injury MRI for high risk patients (TBI, facial fractures, T/L spinal injuries 2006: MRI associated with increased complications eg. collar-related ulcers 66% increase in risk for every 1 day (Ackland et al, Spine, 2007) 2011: MRI when advanced cervical spondylosis evident on CT (Ackland et al, Ann Emerg Med, 2011) 2013: CT 0.625mm cuts C0-T4/5 CT technology Ackland et al, The Alfred Cervical Spine Clearance Protocol

32 International protocols: Obtunded patients Lower quality of evidence The majority of protocols recommend high quality CT imaging only MRI only if indicated on CT imaging

33 Problematic Group No. 3 Elderly low falls

34 Elderly patients 65 years Low falls are 1 metre (VSTR) Most common low falls are ground level falls Risk factors for spinal injury: cervical spondylosis, degenerative osteoarthritis, rheumatoid arthritis, osteoporosis Spinal precautions at scene Stifneck collar Most common injuries: C1 and C2 fractures, including odontoid Risk factors associated with operative management and halo Fracture stability on active flexion/extension - bony vs fibrous union Peck et al. Cervical spine immobilisation in the elderly. Br J Neurosurg, 2018 Koech et al. Non-operative management of Type II odontoid fractures in the elderly. Spine, 2008

35 Elderly patients 65 years Difficulty with spinal clearance eg. cognitive decline, distracting injury etc NEXUS criteria sensitivity reduced 1 Controversy regarding morbidity associated with collars Queensland Ambulance Service no longer fitting cervical collars routinely as a precaution in this age group Ambulance Victoria RCT Paykin, O Reilly, Ackland, Mitra. The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury. 2017;48(5):

36 Ladder-related injuries

37 Background ~ 1600 presentations to EDs in Victoria - underestimate Males 50 years and older falling at home are the most common demographic 9-10 deaths per year TBI Of the more seriously injured survivors, < 50% are home and able to self-care at 12 months post injury. Recommendation: bicycle helmet Serious spinal injuries Ackland et al. Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma. Injury, 2016.

38 Monash University Injury Research Institute analysis of 14 years of data, 2014 Oxley et al. Report on the reduction of major trauma and injury from ladder falls, Monash Injury Research Institute, 2014

39 240 Ladder Fall Admissions to The Alfred: Admissions (n) Total ladder falls Minor trauma ladder falls Major trauma ladder falls Linear (Total ladder falls) 0 July 2006 June 2007 July 2007 June 2008 July 2008 June 2009 July 2009 June 2010 July 2010 June 2011 July 2011 June 2012 Admission period July 2012 June 2013 July 2013 June 2014 July June 2015 July June 2016

40 Case study 23F 1.5m fall: L1 chance fracture, 8mm retropulsion, multiple comminuted fragments, unstable 3 column injury Anterior fusion T12-L2 with L1 corpectomy & cage insertion into residual vertebral body. Brace for 3 months

41 Case study 37M 2.5m fall: T6-7 fracture dislocation with anterior translation of T6 by 50%. Bifacet dislocation. Similar changes at T9-10. Complete posterior ligamentous disruption at each level. Complete cord transection at T6-7 with oedema and haemorrhage in the cord ends. At T9-10 the cord is compressed, angulated and virtually transected.

42 Case study 65M 2m fall: Plastering ladder feet slipped out at base 10 level spinal fusion for # T 2,3,6,8,9,10,11 and L1 TBI

43 Ionising radiation in trauma imaging With acknowledgement to: Dr Zoe Brady, Medical Physicist, Department of Radiology, The Alfred

44 ANZJPH 2014 vol. 38 no MJA 2010; 193:

45 Annual Background Radiation Terrestrial (soil, rocks etc) 49% 15% 13% Internal (food & water etc) Radon gas (seepage from ground) 23% Cosmic Rays Australia: Total msv/year = chest X-rays Australian Radiation Protection and Nuclear Safety Agency, 2015 National Research Council, Health effects from exposure to low levels of ionising radiation, BEIR VII, 2006

46 Sources of Radiation 1980s 2006 National Council on Radiation Protection and Measurements, Report 160, 2009

47 Sources of Radiation 2015 Source: Australian Radiation Protection and Nuclear Safety Agency, 2015

48 Ionising radiation levels Relative Radiation Levels (American College of Radiology) 1 None: 0 msv Minimal: <0.1 msv Low: msv Medium: 1-10 msv High: msv Very high: msv ACR Appropriateness Criteria: Suspected spine trauma. American College of Radiology, 2012

49 Ionising radiation levels in trauma imaging Imaging Estimated Dose (msv) Equivalent number of chest X-rays Equivalent background radiation in Australia Chest X-ray (AP) days (0.01 years) C-Spine Series (AP and Lat) days Pelvis X-ray (AP) days T-Spine Series (AP and Lat) days L-Spine Series (AP and Lat) days CT Brain days CT C-Spine years CT T-Spine years CT L-Spine years Ackland et al. Occult morbidity: The effects of ionising radiation levels in spinal imaging. Emerg Med Australas. 2011;23(Supp 1): 7-8. RANZCR: Education modules for appropriate imaging referrals, 2014

50 Cancer risk Primary Risk = cancer (solid or leukaemia) 1 in 2000 will develop cancer with exposure of 10 msv 1 in 200 will develop cancer with exposure of 100 msv year latency period Risks are not hypothetical: Life Span Study conducted in 1965, 69, 79, 91, and Recommendations of the International Commission on Radiological Protection, ICRC Pub 103, Ann ICRP, 2007 ICRP, Managing Patient Dose in Multi-Detector Computed Tomography (MDCT). ICRP Pub 102. Ann ICRP 37 Hall & Brenner. Solid cancer mortality, BJR, 2008 Richardson et al. Risk of cancer from exposure to ionizing radiation, BMJ, 2015

51 35,000 patients with 5,000 cases of cancer received low dose exposures of msv at km from the hypocentre Of the million-plus atomic bomb survivors, only about 183,000 are still alive - average age 80 years

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53 Major trauma example 54 year old motor vehicle driver, ICU admission 147 plain x-rays 10 CT scans: brain, C spine, T/L spine, chest, abdomen, pelvis 2 nuclear medicine procedures: bone scan, gallium whole body scan 6 fluoroscopy procedures: nephrostomy, PICC insertion, theatre image intensification Estimated dose: 213 msv Risk of neoplasm from this exposure: 1 in 95

54 Reducing risk The Australian Radiation Protection & Nuclear Safety Agency with the RANZCR is working to reduce equipment and protocol-related radiation dose levels. Also developing benchmark minimum dose rates for procedures The RANZCR is also lobbying federal govt for changes to govt policy of requiring pts to have referrals to MRI from consultants rather than GPs (Medicare restrictions), and preventing radiologists from substituting more appropriate modalities where possible Avoid repeating foreign images (rural issues of transfer/major trauma service repeating scans) Consider risk in multiple/serial CTs often lack of communication Avoid ordering CT for T/L spine when reformats are possible

55 Thank you

56 Injury severity score Region Injury Description AIS Square of top 3 body regions Head & Neck Cerebral contusion 3 9 Face No Injury 0 Chest Flail chest 4 16 Abdomen Minor contusion of liver Complex rupture spleen Extremity Fractured femur 3 External No injury Injury Severity Score: (Range 0 75) 50 AIS = Abbreviated Injury Scale score ISS > 15 = 10% mortality rate Table Source: Trauma.org 56

57 Cohort assembly Trauma cervical spine CT n=9152 Persistent midline tenderness, Negative CT, MRI conducted n=741 n=9 Refused consent n=338 Fractures Included n=178 n=554 Excluded n=113 Distracting injury n=17 Persistent deficit Single column: n=48 Two columns: n=15 Three columns: n= 5 n=68 (38%) n=20 History pain /surgery n=66 MRI > 96 hours 38 (21% ) clinically managed: 33 (18.5%) cervical collar 5 (2.8%) ACDF