More than 13 million trauma patient...

More than 13 million trauma patients are brought to U and Canadian pass departments annually with injuries initially requiring cervical spine (C-spine) precautions. not many patients end up having a C-spine fracture, even now many undergo immobilization on a backboard and radiographic imaging. Stiell and others compared the accuracy of their lately validated Canadian C-Spine Rule (CCR) (see accompanying figure) with that of a 12-year elderly guideline for C-spine imaging known as the NEXUS Low-Risk Criteria (NLC)

The authors deportment ed a prospective cohort study comparing the couple C-spine decision rules at nine Canadian tertiary care hospital necessity departments. Alert and stable patients with or without neck pain, with any visible injury above the clavicles, or trauma related to a dangerous mechanism of injury were evaluated. Exclusion criteria were age younger than 16 years, pregnancy, unstable vital signs, or deduction of any points in succession the Glasgow Coma Scale.

Patients underwent plain radiography of the C-spine at the discretion of the treating physician. Any patient who was believeed not to need imaging at the time of injury was scaned by telephone 14 days later, and radiographs were obtained if any high-risk clinical findings were ready A clinically important C-spine injury was defined as any fracture, dislocation, or ligamentous instability apparent forward imaging.

Of the 12521 eligible patients, completed analysis was possible in 8283 cases. Treating physicians did not chronicle 3,603 eligible subjects (28.8 percent) and issue assessments were not available for 635 participants (51 percent) The CCR decision direction requires assessment of active neck rotation, if it were not that treating physicians declined to perform this maneuver in 845 patients (102 percent) and these bring under rules were excluded from the accuracy comparison of the brace decision rules. Clinically important C-spine injuries were identified in 169 patients overall (20 percent)

The sensitivity of the CCR authority in identifying important injuries was 994 percent and the specificity was 451 percent compared with 907 percent and 368 percent respectively, for the NLC conduct Of the patients with important injuries, the authors calculated that 16 would have been missed by way of applying the NLC rule versus single patient missed by the CCR rule

The authors gather that the CCR decision sway is more sensitive than the NLC mastership for identification of clinically important C-spine injuries and also is more specific, thereby decreasing the number of unnecessary C-spine radiographs.

REFERENCE

(1) Yealy DM Auble TE Choosing between clinical prediction sways [Editorial]. N Engl J M 2003; 349:2553-5

EDITOR'S NOTE: The be deriveds of any study where almost 30 percent of eligible patients are not listed should be viewed with any skepticism. Yealy and Auble note in an accompanying Editorial (1) that the NLC mastery was initially studied in athwart 34,000 patients, and a sensitivity of 996 percent was reported. He also notes that the CCR direction was developed at the same Canadian medical center where this application of mind was conducted. This rule may have been more familiar to the treating physicians than the U.S.-derived NLC guideline. Regardless of which empire is employed, one can diocese that with C-spine radiographs ordered in through two thirds of trauma cases and important injuries identified in simply 2 percent of them, adoption of any validated C-spine decision order would go some way toward limiting wasteful overuse of medical resources.

Stiell IG, et al. The Canadian C-Spine command versus the NEXUS low-risk criteria in patients with trauma. N Engl J M December 25 2003;349:2510-8

COPYRIGHT 2004 American Academy of Family Physicians

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