Q: Following a neck injury, How does the physician decide if Xrays are necessary.
A: This is a question which is commenly asked. The answer is not simple. In general anyone with obvious neck injury, spinal cord injury, or severe pain will need Xrays. Beyond that, it may be difficult to decide if Xray is necessary. There have been several sets of rules which have been devised to help the physician decide:
The Nexs rules state that no Xray is necessary if....
There is no Midline Cervical Spinal Tenderness
The patient has a normal level of altertness
There is no evidence of intoxication due to alcohol or drugs
The neurological exam is normal
There are no painful distractin injuries.
In a study of 34000 patients, the NEXS investigators claim to have missed no injuries and tho have a 12% specificity.57
Somewhat more complicated to understand than the NEXUS rules, the Canadian Cspine rules are though to be more complete. They involve A three step decision Tree...58
For patients who are alert (GCS=15/15) and stable where Cspine injury is a concern
Is there any High risk feature that Mandates Radiography ? ( if so pt must have radiographs)
Age Over 65 years
Dangerous mechanism such as...
Fall from greater than 1m or 5 stairs
Axial load to head such as diving
MVC with high speed, rollover, or ejection.
Motorized Recreational Vehicles
Bicycle Collision
Paresthesia in Extremities
Is there any low risk features which allow safe range of motion? If so, proceed to step 3, if not, do NOT proceed to step 3 but DO obtain radiographs.
Simple Rearend MVC (does not include pushed into oncoming traffic, hit by bus or large truck, Rollover, or Hit by High Speed Vehicle)
Sitting position in ED
Ambulatory at ANY time
Delayed onset of neck pain (not immediate onset)
absence of midline Cspine Tenderness
Is the patient able to actively rotate neck 45degrees to left and right regardless of pain ? If so, the patient does NOT need radiography.
The authors claim a sensitivity rate of 100% and a 42.5% specificity for detection of clinically important Cspine injury.
Q: Which Cspine injuries are NOT clinically important ?
A: Cspine injuries which are not clinically important, are those that do not usually require any specific treatment.
The patient MUST be neurologically intact. Generally one of the following four injuries are present.59
Isolated avulsion fracture of an osteophyte
Isolated fracture of a transverse process not involving a facet joint
Isolated fracture of a spinous process not involving the lamina
Simple compression fracture involving less than 25% height loss.
Q: When Xrays are taken to rule-out cervical spine fractures, should the helmet be removed or left on?
A: It may be difficult to remove helmets and protective padding. If this is done, it should be done VERY carefully and requires 3 skilled health-care providers to perform the task.
Usually Xrays will be adequate for athletes wearing hockey helmets and shoulder pads, although it may be difficult to visualize the cervico-thoracic junction.
Conversely, football padding and helmets are much more likely to lead to inadequate films.