removing collar after neg ct c/s

[Hamhock]

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The scenario is:
blunt trauma pt with collar in place after negative CT C-spine
palpation of the c/s is non-tender
active turn of head to left causes midline pain and/or tenderness at C6 with no neuro effects (no paresthesias or pain in extremities or elsewhere)

alternate scenario with same choices below: neg CT c/s and midline tenderness at c6 on exam

Now there are two choices:

#1 remove to collar as the CT is neg and there are no neuro deficits on exam (again, no paresthesias or distal pain)

#2 discharge the patient in the collar and him return for re-eval later in trauma clinic - if same exam, then MRI; if neg exam, remove collar and no furhter imaging

option #3 of MRI from ED for is does not exist (if you really would do flex-ex, I guess that's an OK response)

I have seen respected attendings do both. Is there literature to support one over the other? Expert advice to support one over the other?

In my mind, it has always been if midline pain or tenderness on exam, then ligamentous injury is possible and the collar must not be removed unless there is an MRI...but I have nothing to back this up. I was presented with a counter arguement today that if the pain and/or tenderness is caused by a significant ligamentous injury, then the cord would be compromised on c-spine exam as evidenced by distal pain or paresthesias (or altered spinous process spacing on CT).

Any thoughts? Please direct me to some evidence: literature, expert opinion, etc.

HH

 

[Apollyon]

Ligamentous injury = laxity =/= immediate neurologic dysfunction.

C-collar, and that day or delayed flex/ex. If concerned, MRI.

Put it this way: you don't want to be the hombre whose name is last on the chart when the pt comes back with a numb arm.

 

[Seaglass]

flex ex or collar and follow up.

 

[Rendar5]

Had a patient the other day with good story of forced extension, "heard crack", and lots of C6-7 tenderness. Neg CT, so we did a flex/ex c-spine which was negative before d/cing him with dx of cervical strain. Gave him a soft collar for comfort and pain meds. Anything more we decided could be done outpatient or on return to ED if new sx.

I'm told I was working with a fairly conservative attending, I'm curious about other ways to handle this.

 

[Apollyon]

Gave him a soft collar for comfort and pain meds.

Soft collar or Miami-J? If it's a soft collar, it's of no clinical use. Miami-J is a different story.

 

[lucky_deadman]

If it's a soft collar, it's of no clinical use. Miami-J is a different story.

Yeah. I always love the looks I get when I tell the nurses "get them out of the insurance collar and into a real cervical collar".

 

[GeneralVeers]

Yeah. I always love the looks I get when I tell the nurses "get them out of the insurance collar and into a real cervical collar".

C-collar, discharge with strict instructions to follow up with neurosurgeon in 48 hours if pain is not improving, or to return immediately to ER for worsening pain or paresthesias.

 

[Rendar5]

Soft collar or Miami-J? If it's a soft collar, it's of no clinical use. Miami-J is a different story.

I think it was Philadelphia collar, but forget. Are those different from soft collars? It was definitely not a Miami-J collar. We did it at his request for his comfort, not for stabilization prior to outpt w/u

 

[Arcan57]

I'll buck the trend here. Unless I'm very suspicious for a ligamentous injury, then if the CT is negative I dc the collar. It's obviously riskier than keeping them in a collar, but the rate of unstable ligamentous injury with normal CT c-spine is ridiculously low. Someone has to be impressive to warrant the Miami-J and follow-up. Of note, I don't have anywhere near that level of confidence in plain films.

 

[GeneralVeers]

A couple of questions I've never heard an answer to:

1. What percentage of minor MVAs lead to clinically significant ligamentous injury? (signicant meaning surgical intervention or prolonged immobilization)

2. What percentage of ligamentous injury leads to neuroligic problems?

In short, I hate working up semi-traumatic neck pain.

 

[deleted109597]

I think it was Philadelphia collar, but forget. Are those different from soft collars? It was definitely not a Miami-J collar. We did it at his request for his comfort, not for stabilization prior to outpt w/u

Lots of people have neck pain after MVCs. I have had it after skiing. A soft collar can actually lead to worsening as it makes the muscles weak. Early mobilization (unless they actually have a ligamentous injury, and most don't).

 

[Hawkeye Kid]

A couple of questions I've never heard an answer to:

1. What percentage of minor MVAs lead to clinically significant ligamentous injury? (signicant meaning surgical intervention or prolonged immobilization)

2. What percentage of ligamentous injury leads to neuroligic problems?

In short, I hate working up semi-traumatic neck pain.

Along this line, what do you guys do with midline neck pain/tenderness after minor trauma (fall from standing, low speed MVC, etc) in patients who are low-risk (ie. not old, osteopenic, etc)?

Do you not work them up at all? Plain films only? Plain film followed by CT if still having pain? I recently saw a 40ish yo lady with midline pain/tenderness that started an hour after low-speed MVC (basically bumped from behind at a stop light, minimal damage to car). The resident ordered plain films and then wanted to d/c without additional w/u. I think we'd all agree that her risk for significant injury approaches zero, but like GV, I've never seen/read/heard about any evidence for this.

Is there an SDN community standard for this type of thing?

 

[Arcan57]

Links to the American College of Radiology guidelines for imaging C-spine following trauma.

"The role of CT is currently debated. A recent study of 366 patients who were assessed with MDCT and MRI for instability found that CT produced negative predictive values of 99% for ligamentous injury and 100% for unstable cervical spine injury, respectively. "

The chance of low-speed MVC with minimal midline TTP and a negative CT having a unstable cervical spine injury is neglible. I group those patients in with heterotopic pregnancies as things I know exist but do not merit further work-up.

 

[Jeff698]

I'll buck the trend here. Unless I'm very suspicious for a ligamentous injury, then if the CT is negative I dc the collar.

I'm with you.

"Hi, my name is Dr. 698. I D/C collars in awake patients after negative CT".

I feel like we could start a club or something.

BTW, even with minimal trauma, midline TTP fails the NEXUS criteria and buys some imaging.

If it's low risk and my gestalt of the probability of adequate plain films is high, I go with those. If I'm trying to clear Jabba, he gets lubed up and squeezed into the scanner.

Take care,
Jeff

 

[Seaglass]

Regarding midline pain - try the Canadian rule. You don't have to image midline pain in that rule, it is as sensitive as the NEXUS criteria. I use them both.

 

[GeneralVeers]

I'm with you.

"Hi, my name is Dr. 698. I D/C collars in awake patients after negative CT".

I feel like we could start a club or something.

BTW, even with minimal trauma, midline TTP fails the NEXUS criteria and buys some imaging.

If it's low risk and my gestalt of the probability of adequate plain films is high, I go with those. If I'm trying to clear Jabba, he gets lubed up and squeezed into the scanner.

Take care,
Jeff

Can I join your club? Also, can we avoid rectal exams in abdominal pain? What about no CT scan for kidney stone pain?

We'll definitely need our own insurance plan...