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Chapter 3. Neurotrauma

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An 85-year-old woman with past medical history of hypertension and diabetes mellitus, not on insulin, suffered a witnessed fall. She tripped down a few stairs and struck her face against a concrete floor. She was brought in by her daughter who reported no loss of consciousness. The patient complained of some left hip pain on movement and had no other complaints. The emergency department (ED) attending physician would like to clear her spine clinically and is wondering if he should get a computed tomography (CT) of the cervical spine in this patient. Which of the following clinical characteristics should prompt cervical spine imaging for this patient?

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A. Age >65; dangerous mechanism or paresthesias in the extremities

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B. Age >65; dangerous mechanism or neck pain

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C. Age >80; dangerous mechanism or paresthesias in the extremities

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D. Regardless of age, dangerous mechanism or neck pain

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A. The question of cervical spine imaging versus clinical clearance needs to be answered early in triaging trauma patients. Patients with a depressed level of consciousness or an unclear mechanism of injury should be maintained in a hard cervical collar until formal imaging can be obtained. However, many low-risk patients can be cleared clinically without the need for cervical imaging.

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The Canadian Cervical Spine Rules are extremely sensitive (correctly identifying cervical spine injury in 161 of 162 cases with 99% sensitivity) for identifying low-risk cases in awake patients with a normal mental status who do not require radiography (Table 3-1). In addition to the above criteria, patients must also have a low-risk factor, including a low-risk rear-end car accident, being comfortably seated in the ED, absence of midline cervical spine tenderness, or delayed onset of neck pain. The patient must then have a range of motion of 45° horizontally in both directions. If a high-risk factor is present, a low-risk factor is absent, or there is limited range of motion, an x-ray of the cervical spine is indicated.

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Table 3-1. NEXUS Criteria and the Canadian Cervical Spine (C-Spine) Rules
NEXUS Criteria Canadian C-Spine Rules

No posterior midline C-spine tenderness

No evidence of intoxication

Normal level of alertness

No focal neurologic deficit

No painful distracting injuries

No evidence of intoxication

Normal level of alertness

No focal neurologic deficit

No painful distracting injury

Step 1

Any high-risk factor that mandates radiography?

  • Age ≥65

  • Dangerous mechanism

  • Paresthesias in extremities

Step 2

Any low-risk factor that allows safe assessment of range of motion?

  • Simple rear-end motor vehicle collision

  • Being comfortably seated in the emergency department

  • Ambulatory at any time

  • Absence of midline C-spine tenderness or delayed-onset neck pain

Step 3

Able to rotate neck ...

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