The Management of Low Risk Blunt Trauma to the NeckA Standardized Approach for Clinicians to Rule Out Cervical Spine InjuryThe investigation of neck pain in the low risk adult patients who have sustained blunt trauma to the cervical spine poses a diagnostic challenge even for the most astute clinician. The patient who slips on the ice or is hit from behind at low speed, only to present two days later with neck pain offers an investigative challenge. How we examine this group and what factors determine who gets radiography varies significantly accross the country.1 Our unfounded fears of the "silent, or occult" fracture with its intrinsic risk of litigation fuels the thinking.2 The reality however is that of the estimated 200,000 C-spines done in a given year in Canada, 98% are negative. This prompts the question of unnecessary health care expenditures and needless radiation exposure. Clinicians have expressed a desire to have access to clinical decision rules that could assist them in their day-to-day practice.3 The popularity and interest in the Ottawa ankle rules substantiate this.4 A recent paper published in the US and a soon to be released body of work from Canada have attempted to reliably, and with assurance identify clinical decision rules that clinicians could use when evaluating patients with blunt trauma to the neck. The study is the National Emergency X-Radiography Utilization Study (NEXUS). This is a well-designed, multicenter, prospective-observational research paper by Dr. JR Hoffman and his team, involving 34,069 patients, 818 of whom have radiographic evidence of C-spine injuries.5 (Level 3 Evidence) This group has developed a list of clinical criteria, derived from previous research that can be used to identify those patients who have an extremely low probability of injury and therefore do not require radiography of the cervical spine. This decision instrument requires patients to meet five criteria in order to be classified as having a low probability of injury:
The Nexus decision intrument appears to to be safe and reliable. It was able to identify 99.6% of clinically significant C-spine injuries. Although the authors admit that no tool can be 100% accurate, they estimate the odds of missing a cervical spine injury using this tool to be 1:4000. Putting this into clinical perspective, "physicians could expect to encounter a case of occult cervical spine injury perhaps one in every 125 years of practice". Clinically significant injuries would be even more infrequent. One question regarding this tool, is whether it can truly decrease x-ray utilization in Canada. The concerns that motivate clinicians to order radiography vary significantly. For instance, those clinicians who practice in the atmosphere of high litigation may order more X rays because of a heightened anxiety about being sued. You could predict therefore, that the benefit of a clinically sound decision instrument may self-assuredly allow them to reduce their utilization of X-ray. Canadian physicians however, who practice with a reduced fear of litigation may use more clinical judgement and consequently their utilization may already be low. This decision tool may actually result in an increase in the the use of X-ray for these individuals. Overall however, the decision instrument shows great promise, although it needs to undergo independent validation in Canada before it can be adopted as a standard of care. A second multicenter study called The Canadian C-spine/CT Head study (CCC study), confronts the same issues as Nexus with regards to blunt trauma to the neck, but uses slightly different clinical criteria and methodology.10,11 This soon to be released paper from a leading Canadian research authority, Dr. Ian Steill, involves a cohort of 8933 alert, stable patients of whom 148 had clinically important cervical spine injuries. The Candian C-spine rule, which was derived from 20 standardized clinical findings, is currently being prospectively validated and will soon hit the press.11 The CCC rule comprises 3 high-risk and 5 low risk variables which will assist clinicians in determining the safety of assessing range of motion of the neck.12 Dr. Steill predicts a 100% sensitivity (95% CI 98%-100%) in identifying clinically important cervical spine injuries when using this decision instrument. (Level 3 Evidence) The recent explosion of valid, skillfully researched decision rules have clinicians eager for more. These clinically relevant decision instruments appear to be straightforward and can be easily incorporated in our day-to-day practice, and when integrated with clinical judgement can ensure a consistent, reliable qulaity of care for our patients. It is hoped that these decision rules will minimize the extreme health care costs by eliminating unnecessary investigations. The accuracy and reliability that the clinician is afforded when using these tools may also provide confidence and a collective backing especially when physicians feel radiography is unnecessary. One such scenario could be with ensuing liability involving simple rear end motor vehicle collisions. Often practitioners feel compelled to X-ray despite the lack of compelling clinical need.. Perhaps these decision instruments will give us the confidence to redirect some of the unnecessary cost for doing radiography to the parties that have requested them, rather than shouldering the cost on the Canadian taxpayer. Thanks to Dr. Michael Silver, Director of Radiology Services at St. Martha's Regional Hospital in Antigonish Nova Scotia, for reviewing the draft copy of this article. References:
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