A Pain In The Neck - Dr. Irish

Leon Irish, M.D. Lakeridge Health CorporationEmergency Medicine and Family Practice

This is notGood!!!I sure am gladWe did anX-ray

1. Anatomy review2. Acute Trauma Issues: Deciding when imaging is necessary How to proceed Evaluating radiographs Distinguishing between stable and unstable injuries Some fracture types.

 Radiculopathy Spondylosis and CDDD Spinal stenosis Cancer and infections. Increased role of MRI

 ATLAS Axis C3 to C7

 C3 to C7

 If 2 of 3 columns are disrupted it is probably an unstable injury Can be boney injury in one column and ligament in another

 Upper C-spine has more mobility, more space for the cord but the structures are more fragile Lower C-spine has less mobility, more strength but less space for the cord when there is a fracture

 Whom to image? Can we clear a patient without imaging? Clearing a patient with radiography only  Only 1% of neurologically intact trauma victims have a cervical spine injury  These issues are not easy to resolve; there are no universal standards or protocols

NEXUS criteria for NO C-spine x-ray:  Fully alert patient  No midline posterior C-spine tenderness  No intoxication  No distracting, painful injury elsewhere  No neurological deficits (by patient report or exam) *If patient meets these criteria, they will not have an unstable fracture. *Highly sensitive=poor specificity (~12%)

NEXUS CCR National X-Radiography Utilization  Canadian C-spine decision rules Study Group in USA  Question 1: Is there any high-risk factor No tenderness at the posterior midline that mandates radiography (i.e., age >=65 of the cervical spine years, dangerous mechanism, or No focal neurologic deficit paresthesias in extremities)? Normal level of alertness  Question 2: Is there any low-risk factor No evidence of intoxicaion present that allows safe assessment of No clinically apparent, painful injury range of motion (i.e., simple rear-end to distract from the pain of a cervical- motor vehicle collision, sitting position spine injury in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)?  Question 3: Is the patient able to actively rotate neck 45° to the left and right?  If the answer is “yes” to Question 1, or “no” to Questions 2 and 3 then cervical spine radiography is required. CCR has been proven to be better than NEXUS

For stable patients with GCS 15 and possible neck injury:

Dangerous mechanism:  Fall from elevation 3 feet+/5 stairs  Axial load to head, e.g. diving  MVC high speed (>100km/hr), rollover  Motorized recreational vehicles  Bicycle struck or collision

 100% sensitive for significant fractures Saves health care dollars Avoids lots of unnecessary imaging and radiation. Applied in ER setting would improve flow through of patients by avoiding time in x-ray Safe for patients, no missed fractures

 17 year old boy walks in to ER with bathing suit on and holding head straight ahead and will not let anyone touch him yelling “I broke my neck” No question he needs full imaging and CT and likely a halo for a few months

 21 year old girl walks in to ER 12 hours after rolling her car with neck pain that started one hour after the accident. She was wearing a seat belt and did not lose consciousness Mechanism is severe but presentation is mild

 A NP friend of yours is over for a party and decides it would be fun to jump out of the hot tub and roll in the snow. Getting back in the hot tub she complains that she really hurt her neck. She thinks her chin bounced off the patio under the snow. Alcohol is a factor. It moves ok so she goes home to sleep it off, declines your suggestion to get an x-ray that night.

 You are the triage nurse in a local hospital and a 45 year old healthy male comes in walking 3 hours after a rear end collision in town with symptoms of whiplash and neck pain. He did not lose consciousness. The neck was fine for the first hour and he was walking fine at the scene. Do you ask him to move his neck 45 degrees to RT and LT? Do you x-ray him?

 Most ER MDs do not use the CCR or NEXUS routinely, I am among them “complicated, hard to remember, too time consuming” ER MDs- “Worry about medical-legal” and “patients demand and expect an x-ray” Learning the tool in training/residency correlates with use later on It is not too late to learn the tools

 Radiography Three Views: AP, lateral, and open mouth Radiographs are often suboptimal - see C7-T1? Using only a lateral view may miss 15% or more of fractures visible on three views Insensitive: More than 50% of fractures may be missed Consider adding active flexion and extension lateral views to “clear” the spine

 3 view trauma series: 1. Lateral 2. AP 3. Odontoid (OMO) 5 view full series-add the obliques Flexion and extension views

Examine the following: Alignment: Occiput to T1 Vertebral body height Prevertebral soft tissues: 7at 2”, And 2 at 7”, smooth contour Interspinous spaces Facet “shingling” Atlanto-odontoid interval: No more than 3mm in adult, 5mm In child Occipital-C1 distance

Normal Abnormal

Look for alignment of: •Anterior longitudinal ligament •Posterior longitudinal ligament •Spinolaminar line

Physiologicalsubluxation

AP view AP view

AP view

 Spinous processes aligned Undulating smooth flow to lateral masses No unusual gaps between intraspinous process Check to see the first rib

 Inspect the entire odontoid Spaces between odontoid and lateral masses of C1 Spaces can be asymmetric if there is head tilt or rotation Alignment of lateral masses Shadows of teeth on odontoid mimic fracture

 Check for ligament injury, integrity The patient always does it on own, do not assist Often has a role in follow up clinics after fractures. Limited in ER due to muscle spasms and other injuries to be dealt with Consider when x-ray normal and midline pain is severe.

 Jefferson fracture of C1--burst of the ring Unstable

Look at atlantodentaldistance

 Now 7 subtypes

 Easy to see here---not always!!! hyperextension

 Teardrop Flexion teardrop fracture fracture -unstable -flexion extension mechanism -usually lower C-spine -some compression of body -the presence of teardrop fragment -wide space in posterior interspinous ligament -all three columns can be affected

 Role of CT: Supplement to non-normal or incomplete X-rays Routine CT of entire C-spine Flexion/extension radiographs Moving to MRI-immediately, late for whom? The protocol varies depending on the clinical picture

 Thin section (1-3mm) Multiplanar reconstructions important (computer will generate coronal and sagittal images) Very high sensitivity for bony injury (99%) May miss isolated soft tissue injuries but a patient with normal CT has very low risk of missed unstable ligamentous injury.

 Not as good as CT to look at bones Excellent for imaging longitudinal ligaments, discs, interspinous ligaments, spinal cord, epidural space and prevertebral space Can be used in initial evaluation of trauma for patients with cord symptoms or unstable fractures. MRI useful in work up of spinal stenosis, CDDD, herniated discs, tumors, infections

 22 year old girl out with boyfriend in 4x4 truck “four wheeling” and they roll over in the gravel pits near Burketon. Seatbelted but bangs head on ceiling of cab Crawls out of upside down truck cab, then cannot walk any more. No LOC. Arrives in ER on backboard, signs of motor weakness. Has mild neck pain.

 C-spine x-ray is normal CT ordered as neurological exam abnormal No signs of fracture Sent to Sunnybrook, work up included urgent MRI, spinal cord contusion Outcome not known

 Disc protrusion Degenerative boney disease Infection Tumor

 X-ray as screening Less role for CT MRI very helpful to see discs, ligaments, cord compressions and cord signal changes to suggest myelopathy

 Rely on the history, the progression, the history of injuries, the clinical exam Look out for red flags Start with plain films (with obliques) Proceed to MRI if there are signs of myelopathy or radiculopathy or suspicion of tumor or infection

 Narrow ds Osteophyteral bars Narrow foramens

 Muscle spasm, tension Arthritis of facet joints Disc degeneration and protrusion Whiplash – ligament and other soft tissue Combination of above Aging population of ex-athletes= looming and booming problem in boomers and older.

A Pain In The Neck - Dr. Irish

by Nurse Practitioners' Association of Ontario on Aug 03, 2011

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A Pain In The Neck - Dr. Irish — Presentation Transcript