Legal Update: Use of the Guides Down Under

Abstract Evaluations of the cervical and the lumbar spine are similar with the major exception that injury in the cervical spine may cause spinal cord damage that results in long-tract signs (weakness, numbness, or paralysis). The AMA Guides to the Evaluation of Permanent Impairment recognizes eight categories of cervical spine injury, and the first five are similar to those used for the lumbar spine. Category I involves no objective findings. Category II includes objective findings such as true muscle spasm, dysmetria, or nonverifiable radicular symptoms. Category III is radiculopathy and is assessed when the patient shows signs such as the loss of relevant reflexes or unilateral atrophy with a greater than 2-cm decrease in circumference compared with the unaffected side. Category IV is loss of motion segment integrity or multilevel neurologic compromise and indicates 3.5 mm or more translation of one vertebra on another on flexion and extension x-rays. Category V is severe upper extremity neurologic compromise that requires the use of upper extremity external functional or adaptive devices. Categories VI, VII, and VIII reflect a significant change in evaluating method and include long-tract signs in addition to upper extremity involvement. Category VI includes cauda equina–like symptoms without bowel or bladder involvement. Category VII is the same as Category VI but with bowel or bladder involvement. Category VIII is paraplegia, defined as complete or near-complete loss of function in the lower extremities.

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CT Better Than X-Rays for Diagnosis Of High-Risk Cervical Spine Injury

Family Practice News ◽

10.1016/s0300-7073(07)70381-x ◽

2007 ◽

Vol 37 (6) ◽

pp. 31

Author(s):

MICHELE G. SULLIVAN

Keyword(s):

Cervical Spine ◽

High Risk ◽

Cervical Spine Injury ◽

Spine Injury ◽

X Rays ◽

Better Than

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Management of cervical spine injuries in patients with ankylosing spondylitis

Journal of Neurosurgery ◽

10.3171/jns.1990.72.2.0210 ◽

1990 ◽

Vol 72 (2) ◽

pp. 210-215 ◽

Cited By ~ 78

Author(s):

Karl N. Detwiler ◽

Christopher M. Loftus ◽

John C. Godersky ◽

Arnold H. Menezes

Keyword(s):

Cervical Spine ◽

Ankylosing Spondylitis ◽

Motor Vehicle ◽

Motor Vehicle Accident ◽

Fracture Dislocation ◽

Spine Injury ◽

Minor Trauma ◽

Loss Of Function ◽

Traumatic Fracture ◽

Axial Traction

✓ Eleven patients with ankylosing spondylitis and traumatic fracture/dislocation of the spine were identified in a retrospective review of all cases of cervical spine injury treated on the neurosurgical service over a 10-year period. Injury was most often secondary to minor trauma or a motor-vehicle accident, and the level of vertebral involvement was most frequently between C-5 and T-1. Neurological symptoms at presentation ranged from neck pain alone to complete loss of function distal to the level of injury. Initial routine treatment consisted of axial traction for realignment with the minimal weight needed to accomplish this, taking into account the flexion deformity. All patients underwent pluridirectional tomography and/or computerized tomography to delineate the exact sites of injury. Three patients died shortly after admission due to pulmonary complications. The remaining eight patients underwent early posterior stabilization and mobilization in a halo or cervicothoracic brace to achieve fusion. Neurological improvement was achieved in six of these eight cases. The experience described here supports the initiation of axial traction as initial therapy for cervical injuries followed by early surgical stabilization in patients with ankylosing spondylitis. The difficulty of maintaining spinal alignment and the devastating pulmonary problems attendant on conservative management may be obviated by early fusion.

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DETECTION OF PEDIATRIC CERVICAL SPINE INJURY

Neurosurgery ◽

10.1227/01.neu.0000311348.43207.b7 ◽

2008 ◽

Vol 62 (3) ◽

pp. 700-708 ◽

Cited By ~ 47

Author(s):

Hugh J.L. Garton ◽

Matthew R. Hammer

Keyword(s):

Cervical Spine ◽

Young Children ◽

Cervical Spine Injury ◽

Diagnostic Yield ◽

Plain Film ◽

Spine Injury ◽

Lower Sensitivity ◽

X Rays ◽

Flexion Extension ◽

National Emergency

Abstract OBJECTIVE In evaluating the pediatric cervical spine for injury, the use of adult protocols without sufficient sensitivity to pediatric injury patterns may lead to excessive radiation doses. Data on injury location and means of detection can inform pediatric-specific guideline development. METHODS We retrospectively identified pediatric patients with codes from the International Classification of Diseases, 9th Revision, for cervical spine injury treated between 1980 and 2000. Collected data included physical findings, radiographic means of detection, and location of injury. Sensitivity of plain x-rays and diagnostic yield from additional radiographic studies were calculated. RESULTS Of 239 patients, 190 had true injuries and adequate medical records; of these, 187 had adequate radiology records. Patients without radiographic abnormality were excluded. In 34 children younger than 8 years, National Emergency X-Radiography Utilization Study criteria missed two injuries (sensitivity, 94%), with 76% of injuries occurring from occiput–C2. In 158 children older than 8 years, National Emergency X-Radiography Utilization Study criteria identified all injured patients (sensitivity, 100%), with 25% of injuries occurring from occiput–C2. For children younger than 8 years, plain-film sensitivity was 75% and combination plain-film/occiput–C3 computed tomographic scan had a sensitivity of 94%, whereas combination plain-film and flexion-extension views had 81% sensitivity. In patients older than 8 years, the sensitivities were 93%, 97%, and 94%, respectively. CONCLUSION Younger children tend to have more rostral (occiput–C2) injuries compared with older children. The National Emergency X-Radiography Utilization Study protocol may have lower sensitivity in young children than in adults. Limited computed tomography from occiput–C3 may increase diagnostic yield appreciably in young children compared with flexion-extension views. Further prospective studies, especially of young children, are needed to develop reliable pediatric protocols.

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Five criteria can identify pediatric blunt trauma victims who are unlikely to need x-rays to exclude cervical spine injury

PsycEXTRA Dataset ◽

10.1037/e556662006-009 ◽

2001 ◽

Keyword(s):

Cervical Spine ◽

Blunt Trauma ◽

Cervical Spine Injury ◽

Spine Injury ◽

X Rays ◽

Trauma Victims

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Gunshot Wound of the Lumbar Spine; Injury to the Cauda Equina; Destruction of the Pelvic Autonomic Nerves; Paralysis of the Large Intestine and Rectum; Recurrent Attacks of “Intestinal Obstruction.”

Proceedings of the Royal Society of Medicine ◽

10.1177/003591571600900905 ◽

1916 ◽

Vol 9 (Neurol_Sect) ◽

pp. 32-37

Author(s):

E. G. Fearnsides

Keyword(s):

Lumbar Spine ◽

Intestinal Obstruction ◽

Large Intestine ◽

Gunshot Wound ◽

Cauda Equina ◽

Spine Injury ◽

Autonomic Nerves ◽

Pelvic Autonomic Nerves

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Quantifying Cervical-Spine Curvature Using Bézier Splines

Journal of Biomechanical Engineering ◽

10.1115/1.4007749 ◽

2012 ◽

Vol 134 (11) ◽

Cited By ~ 3

Author(s):

Kathleen D. Klinich ◽

Sheila M. Ebert ◽

Matthew P. Reed

Keyword(s):

Cervical Spine ◽

Quantitative Method ◽

Advanced Technology ◽

Spinal Curvature ◽

Qualitative Assessment ◽

Spine Injury ◽

X Rays ◽

Gender And Age ◽

Spine Curvature ◽

Two Parameters

Knowledge of the distributions of cervical-spine curvature is needed for computational studies of cervical-spine injury in motor-vehicle crashes. Many methods of specifying spinal curvature have been proposed, but they often involve qualitative assessment or a large number of parameters. The objective of this study was to develop a quantitative method of characterizing cervical-spine curvature using a small number of parameters. 180 sagittal X-rays of subjects seated in automotive posture with their necks in neutral, flexed, and extended postures were collected in the early 1970s. Subjects were selected to represent a range of statures and ages for each gender. X-rays were reanalyzed using advanced technology and statistical methods. Coordinates of the posterior margins of the vertebral bodies and dens were digitized. Bézier splines were fit through the coordinates of these points. The interior control points that define the spline curvature were parameterized as a vector angle and length. By defining the length as a function of the angle, cervical-spine curvature was defined with just two parameters: superior and inferior Bézier angles. A classification scheme was derived to sort each curvature by magnitude and type of curvature (lordosis versus S-shaped versus kyphosis; inferior or superior location). Cervical-spine curvature in an automotive seated posture varies with gender and age but not stature. Average values of superior and inferior Bézier angles for cervical spines in flexion, neutral, and extension automotive postures are presented for each gender and age group. Use of Bézier splines fit through posterior margins offers a quantitative method of characterizing cervical-spine curvature using two parameters: superior and inferior Bézier angles.

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Postfixed Brachial Plexus Radiculopathy Due to Thoracic Disc Herniation in a Collegiate Wrestler: A Case Report

Journal of Athletic Training ◽

10.4085/1062-6050-48.5.03 ◽

2013 ◽

Vol 48 (5) ◽

pp. 710-715 ◽

Cited By ~ 4

Author(s):

Scott A. Kuzma ◽

Scott T. Doberstein ◽

David R. Rushlow

Keyword(s):

Cervical Spine ◽

Brachial Plexus ◽

Upper Extremity ◽

Health Care Providers ◽

Disc Herniation ◽

Substantial Contribution ◽

Spine Injury ◽

Intervertebral Disc Herniation ◽

Care Providers ◽

Cord Injury

Objective: To present the unique case of a collegiate wrestler with C7 neurologic symptoms due to T1–T2 disc herniation. Background: A 23-year-old male collegiate wrestler injured his neck in a wrestling tournament match and experienced pain, weakness, and numbness in his left upper extremity. He completed that match and 1 additional match that day with mild symptoms. Evaluation by a certified athletic trainer 6 days postinjury showed radiculopathy in the C7 distribution of his left upper extremity. He was evaluated further by the team physician, a primary care physician, and a neurosurgeon. Differential Diagnosis: Cervical spine injury, stinger/burner, peripheral nerve injury, spinal cord injury, thoracic outlet syndrome, brachial plexus radiculopathy. Treatment: The patient initially underwent nonoperative management with ice, heat, massage, electrical stimulation, shortwave diathermy, and nonsteroidal anti-inflammatory drugs without symptom resolution. Cervical spine radiographs were negative for bony pathologic conditions. Magnetic resonance imaging showed evidence of T1–T2 disc herniation. The patient underwent surgery to resolve the symptoms and enable him to participate for the remainder of the wrestling season. Uniqueness: Whereas brachial plexus radiculopathy commonly is seen in collision sports, a postfixed brachial plexus in which the T2 nerve root has substantial contribution to the innervation of the upper extremity is a rare anatomic variation with which many health care providers are unfamiliar. Conclusions: The injury sustained by the wrestler appeared to be C7 radiculopathy due to a brachial plexus traction injury. However, it ultimately was diagnosed as radiculopathy due to a T1–T2 thoracic intervertebral disc herniation causing impingement of a postfixed brachial plexus and required surgical intervention. Athletic trainers and physicians need to be aware of the anatomic variations of the brachial plexus when evaluating and caring for patients with suspected brachial plexus radiculopathies.

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Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

Emergency Medicine Journal ◽

10.1136/emermed-2020-210325 ◽

2021 ◽

Vol 38 (5) ◽

pp. 330-337

Author(s):

Natalie Phillips ◽

Katie Rasmussen ◽

Sally McGuire ◽

Kerrie-Ann Abel ◽

Jason Acworth ◽

...

Keyword(s):

Cervical Spine ◽

Decision Rules ◽

Clinical Decision ◽

Research Network ◽

Spine Injury ◽

X Rays ◽

Clinical Decision Rules ◽

Paediatric Emergency ◽

Spine Imaging ◽

Paediatric Emergency Care

BackgroundClinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population.MethodsA single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.Results1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%).ConclusionCSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

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Selection of Trauma Victims for Cervical Spine Radiological Examination

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00044460 ◽

1985 ◽

Vol 1 (S1) ◽

pp. 199-202

Author(s):

Betty L. Bryson ◽

Joseph P. Ornato ◽

Robert R. Farquharson ◽

Patrick J. Donovan ◽

Francis G. Palaio

Keyword(s):

Cervical Spine ◽

Neck Pain ◽

Medical Center ◽

Neurological Deficits ◽

Spine Injury ◽

Facial Trauma ◽

X Rays ◽

Facial Soft Tissue ◽

Cervical Spine Injuries ◽

Facial Injuries

Evaluation of the traumatized patient frequently involves consideration of possible cervical spine injury. When neurological deficits, unconsciousness, alcoholic intoxication, severe maxillofacial or head trauma, or local neck pain are present, it is an easy decision to obtain cervical spine x-rays. The dilemma arises in the patient without neck pain who has mild to moderate scalp or facial injuries. Such a patient usually arrives in the emergency department with a cervical collar placed by pre-hospital personnel because of the mechanism of injury and the associated head or facial soft tissue trauma. Due to the association of cervical spine fractures with “significant” facial trauma, neck x-rays have been recommended. What, however, constitutes “significant” facial trauma To delineate such facial injuries, a retrospective analysis of 30 patients with cervicalspine fractures hospitalizedin a five year period at the University of Nebraska Medical Center was performed. Seventeen patients had head, scalp or facial injuries ranging from skull fractures and scalp hematomas to minor abrasions and lacerations. To determine if cervical spine films are being over utilized, a current prospective study of patients undergoing this evaluation will be presented, detailing the facial and head injuries, location, degree of severity, and detection of cervical spine injuries.

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