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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/46\\\/20\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/46\\\/20\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/46\\\/20\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/46\\\/20\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ETrauma patients must be evaluated for spinal injuries in an efficient manner. However, cervical spine (C-spine) imaging can be time-consuming, costly, and painful, and exposes the patient to radiation. This article reviewS current strategies to optimize decision making when evaluating patients with possible C-spine injuries.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ETrauma\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESpine Conditions\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETrauma Radiography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMagnetic Resonance Imaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETomography\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ETrauma\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESpine Conditions\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEmergency Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERadiography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMagnetic Resonance Imaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETomography\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ETrauma patients must be evaluated for spinal injuries in an efficient manner. However, cervical spine (C-spine) imaging can be time-consuming, costly, and painful, and exposes the patient to radiation. Swaminatha Mahadevan, MD, Stanford University, Stanford, California, USA, reviewed current strategies to optimize decision making when evaluating patients with possible C-spine injuries.\u003C\/p\u003E\u003Cp\u003EDr Mahadevan first discussed the National Emergency X-Radiography Utilization Study (NEXUS) algorithm and the Canadian C-spine Rule (CCR), both evidence-based algorithms used to determine whether C-spine imaging is necessary. The NEXUS algorithm has 5 clinical criteria:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-4\u0022\u003ENormal neurologic examination\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003ENo midline C-spine tenderness\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003EPatient alert and oriented\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003ENo evidence of intoxication\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003ENo distracting painful injury\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n      \u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe NEXUS algorithm was tested in a prospective observational study at 21 medical centers in the United States. A total of 34 069 blunt trauma patients who had radiographs of the C-spine were studied. Of 818 C-spine injuries in this population, the NEXUS criteria identified all but 8 cases [Hoffman JR et al. \u003Cem\u003ENew Eng J Med.\u003C\/em\u003E 2000]. Two cases were considered clinically significant, and only one of the injuries required surgery. The NEXUS criteria were calculated to have 99.0% sensitivity (95% CI, 98.0% to 99.6%) with a 99.8% negative predictive value (95% CI, 99.6% to 100%). The specificity of this instrument was 12.9% with a positive predictive value of 2.7%.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThe CCR is based on a study of 8924 stable and alert adult patients with blunt trauma presenting to 10 Canadian emergency departments (EDs) [Stiell IG et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2001]. A total of 151 patients (1.7%) had an important C-spine injury. The CCR was found to have 100% sensitivity (95% CI, 98% to 100%) with a specificity of 42.5% (95% CI, 40% to 44%).\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe CCR consists of 3 steps. The first is to determine the absence of a high-risk factor that necessitates radiography. High-risk factors include age \u0026gt; 65 years, paresthesias in the extremities, and dangerous mechanism (fall from \u0026gt; 3 feet, axial load to head, high-speed motor vehicle accident, rollover, ejection, motorized recreational vehicles, and bicycle collision). The second step is to determine the presence of 1 or more low-risk factors that allow for a safe evaluation of range of motion. Low-risk factors include sitting position in the ED, ambulation at any time, delayed onset of neck pain, an absence of midline C-spine tenderness, and simple rear-end motor vehicle collision (MVC). The final step is to determine if the patient can actively rotate their neck 45\u00b0 to the left and right.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThe NEXUS algorithm and the CCR are both sensitive and validated instruments. Dr Mahadevan summarized that all blunt trauma victims (especially low-risk patients) do not require C-spine radiography and encouraged physicians to use the clinical decision rule that they are most comfortable with. Two examples are presented in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15532\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15532\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15532\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EExamples of Potential C-Spine Injuries\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-15\u0022\u003EIf radiography is warranted, one must determine whether to proceed with plain radiographs or computed tomography (CT). Plain radiographs are more readily available and less expensive, entail less radiation, but have relatively poor sensitivity (53%) for identifying C-spine fractures. CT, in contrast, is more sensitive, but entails more radiation exposure and higher cost. CT is felt to be particularly useful in moderate- to high-risk patients (ie, likelihood of injury \u0026gt; 5% to 10%) [Grogan EL et al. \u003Cem\u003EJ Am Coll Surg\u003C\/em\u003E. 2005], such as patients injured via a high-energy mechanism (MVC \u0026gt; 30 miles per hour or auto vs pedestrian), patients aged \u0026gt; 50 years with a moderate-energy mechanism (eg, a motorcycle or bicycle accident), patients with focal neurological deficits, or patients presenting with a severe head injury (eg, skull fracture, intracerebral hemorrhage, or altered level of consciousness) [Blackmore CC et al. \u003Cem\u003ERadiology\u003C\/em\u003E. 1999].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EIn general, patients aged \u0026gt; 65 years have a higher risk of C-spine injury (RR, 2.09; 95% CI, 1.77 to 2.59) [Lowery DW et al\u003Cem\u003E. Ann Emerg Med.\u003C\/em\u003E 2001]. The elderly are more likely to be osteopenic and at the same time may feel less pain. An epidemiologic study of 149 consecutive patients aged \u0026gt; 65 years indicated that patients aged \u0026gt; 75 years who fell from standing height were significantly more likely to sustain C-spine injuries (\u003Cem\u003EP\u003C\/em\u003E = .026 and \u003Cem\u003EP\u003C\/em\u003E = .006, respectively) [Lomoschitz FM. \u003Cem\u003EAJR Am J Roentgenol\u003C\/em\u003E. 2002]. For these reasons, Dr Mahadevan recommends that patients aged \u0026gt; 65 years be evaluated by a CT scan.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EPatients may have unstable ligamentous injuries without evidence of bony abnormality on CT scan or plain radiographs. The true incidence of unstable ligamentous injuries is not known because no diagnostic gold standard exists; however, the reported incidence ranges from 0.04% to 0.2% [Davis JW et al. \u003Cem\u003EJ Trauma\u003C\/em\u003E. 2001]. Physicians have several options in patients with persistent neck pain but a normal neurologic examination, and a negative CT: flexion-extension radiographs, magnetic resonance imaging (MRI) scan, or doing nothing.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EIn a prospective observational study [Resnick S et al. \u003Cem\u003EJAMA Surgery\u003C\/em\u003E. 2014] of 830 adults with blunt trauma, the sensitivity and specificity of CT for detecting clinically significant C-spine injury were both 100%, and MRI did not provide any additional useful information. Importantly, none of the patients in the aforementioned study had advanced cervical spondylosis, which is a reported risk factor for clinically significant injures on MRI [Ackland et al. \u003Cem\u003EAnn Emerg Med.\u003C\/em\u003E 2011]. In obtunded patients, Dr Mahadevan recommends not removing the cervical collar until a specialist can be consulted.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EDr Mahadevan concluded that low-risk patients do not require C-spine imaging and that CT is the best imaging modality for moderate- to high-risk patients.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/20\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022The editors would like to thank the many members of the American College of Emergency Physicians Scientific Assembly 2014 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-833668730\u0022 data-figure-caption=\u0022The editors would like to thank the many members of the American College of Emergency Physicians Scientific Assembly 2014 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/20\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/20\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/20\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15531\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\n            \u003Cp id=\u0022p-20\u0022 class=\u0022first-child\u0022\u003EThe editors would like to thank the many members of the American College of Emergency Physicians Scientific Assembly 2014 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/46\/20.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzohmp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzohmp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzohmp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}