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National Clinical Guideline Centre (UK). Spinal Injury: Assessment and Initial Management. London: National Institute for Health and Care Excellence (UK); 2016 Feb. (NICE Guideline, No. 41.)

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Spinal Injury: Assessment and Initial Management.

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7Spinal injury assessment risk tools

7.1. Introduction

If a person has the potential for a spinal injury their spine should be routinely protected during the assessment for life threatening injuries. This does not mean, however, that routine immobilisation should be continued after the point at which a risk tool can be applied. This has an impact on ambulance service and emergency department’s (EDs) resources. It has also been suggested that unnecessary spinal immobilisation may lead to some adverse effects, such as discomfort or skin breakdown. It is important for healthcare practitioners assessing people for spinal injuries to have access to a risk tool that can accurately predict those patients who 1) have an injury and therefore require immobilisation and imaging and 2) do not have an injury and therefore do not need further immobilisation or imaging of the spine. The previous chapter showed that although some tools lead to missed injuries, some appear to be safe, and are thus useful in reducing the side effects, and costs, of unnecessary immobilisation. This chapter explores further which tools are accurate in predicting spinal injury and the need for immobilisation and imaging.

7.2. Review question: What tools are most predictive of spinal injury in people with suspected traumatic spinal injury when trying to exclude spinal cord injury (with or without spinal column injury) or isolated spinal column injury?

For full details see review protocol in Appendix C.

Table 11PICO Characteristics of review question

PopulationChildren, young people and adults with suspected traumatic spinal injury
Clinical assessment tool
  • Canadian C-Spine Rules (CCR)
  • National Emergency X-Radiography Utilization Study (NEXUS)
  • Australian SPINEX card
  • American Spinal Injury Association [ASIA]
  • REMSSAP
  • Any tools relevant to the thoracic or lumbosacral spine.
Reference standard
  • Later imaging findings
  • Later surgical findings
  • Later clinical findings
  • Autopsy
OutcomesDiagnostic accuracy (sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios)
Study designCohort studies

7.3. Clinical evidence

This review was initially framed by area of the spine (cervical or thoracic and lumbosacral spine) and then type of spinal injury: 1) clinical decision tools for ruling out spinal cord injury (SCI) (with or without spinal column injury), and 2) clinical decision tools for ruling out isolated spinal column injury (with no associated cord injury). Only 2 clinical decision tools were identified with diagnostic evidence; these were the CCR derived by Stiell et al., 2001105 and the NEXUS low-risk criteria derived by Hoffman et al., 1992.63 Both of these clinical decision tools focus specifically on suspected injuries of the cervical spine. The NEXUS and CCR do not distinguish between type of suspected spinal injury (cord or column), therefore, information provided in the identified papers does not allow us to analyse the diagnostic accuracy of these tools to rule out specifically cord or specifically column injuries. Instead, we can only provide the diagnostic accuracy of CCR and NEXUS for excluding injury (cord or column) of the cervical spine. No tools which focus on suspected injury of the thoracic and/or lumbar spine were identified.

Details of the included rules are in Table 12. Evidence from these included studies are summarised in the clinical evidence profile in Table 14.

Table 12. Summary of clinical decision rules identified: imaging for suspected cervical spine injury.

Table 12

Summary of clinical decision rules identified: imaging for suspected cervical spine injury.

Table 13. Summary of studies included in the review.

Table 13

Summary of studies included in the review.

Table 14. Clinical evidence profile: diagnostic accuracy for decision rules for people with a suspected traumatic cervical spine injury.

Table 14

Clinical evidence profile: diagnostic accuracy for decision rules for people with a suspected traumatic cervical spine injury.

Where appropriate, diagnostic meta-analysis was conducted (that is, when 5 or more studies were available per threshold). Test accuracy for the studies was pooled using the bivariate method modelled in Winbugs®.74 The bivariate method uses logistic regression on the true positives, true negatives, false positives and false negatives reported in the studies. sROC curves were constructed and confidence regions plotted. See also the study selection flow chart in Appendix D, study evidence tables in Appendix G, paired sensitivity/specificity plots and diagnostic meta-analysis plot in Appendix I and exclusion list in Appendix J.

Adults

Eleven studies Duane 201344, Duane 201143, Griffith 201352, STIELL 2001105, STIELL 2003104, COFFEY 201132, DICKINSON 200438, HOFFMAN 200062, TOUGER 2002, 110} were identified in adults investigating the diagnostic accuracy of cervical spine injury (CSI) clinical decision rules. Two of these studies included patients of all ages. Hoffman 1992 was the NEXUS derivation study and Hoffman 2000 was NEXUS validation. Viccellio 2001 was a sub-study of children (under 18 years) from the Hoffman 2000 NEXUS validation study, therefore, it was possible to separate the information for adults (18 years and over) from Hoffman 2000 for analysis separately. Touger 2002 was another sub-study of Hoffman 2000, looking at the diagnostic accuracy of NEXUS in the older adult population (over 65 years). The other eight studies included cover adults either 16 years and over or 18 years and over.

Both the CCR and NEXUS criteria derivation studies assessed the decision rules against a reference standard of plain X-rays (with some additional CT or MRI scanning requested at the discretion of the treating physician and telephone follow-up for those who did not undergo imaging). It is noted that Duane et al., 2011 and 2013, and Griffith et al., 2011 and 2013 tested the NEXUS low-risk criteria and CCR (and modifications of the CCR) using a reference standard of patients having a cervical spine CT.

Children and infants

Two studies EHRLICH 200945, VICCELLIO 2001113 were identified in children investigating the diagnostic accuracy of CSI clinical decision rules.

Ehrlich et al., 2009 is a retrospective case-matched study applying CCR and NEXUS criteria to the medical records of patients 10 years and under in two cohorts, those who underwent C-spine imaging as part of their initial ED work-up and those who did not. Only data from the imaged children cohort is presented in this review. Viccellio et al., 2001 is a subgroup of patients younger than 18 years from the NEXUS validation study.

Quality of evidence

Risk of bias for each outcome was determined by the QUADAS-2 criteria (see chapter 4). This informed the risk of bias rating given on the GRADE table in Appendix I. The QUADAS-2 covers four domains: patient selection, the index test, the reference standard and flow and timing. Each domain is assessed for risk of bias, and the first 3 are also assessed for applicability (in reference to the review protocol). If there were 2 or more major limitations according to the QUADAS criteria, a rating of very serious limitations was given. If there was a single major limitation a rating of serious limitations was given.

7.4. Economic evidence

Published literature

No relevant economic evaluations comparing the CCR and the NEXUS clinical decision rules for selecting patients with head injury and suspected CSI for initial imaging with an X-ray or CT scan were identified. There were no excluded studies.

New cost-effectiveness analysis

This area was prioritised for new cost-effectiveness analysis. A summary of the analysis can be seen in Table 15. The GDG identified non-imaging assessment and acute stage imaging for spinal injury as key areas which would benefit from de novo modelling. These questions were looked at in combination to inform components of an overall strategy to clear the spine.

Table 15. Economic evidence profile: Diagnosis of traumatic spinal injury (NCGC model).

Table 15

Economic evidence profile: Diagnosis of traumatic spinal injury (NCGC model).

This area has been identified as a high economic priority due to the high economic costs and harms associated with variation in practice around imaging and unnecessary imaging.

However, the clinical reviews of these relevant areas revealed a major paucity of data. Treatment pathways were also constructed with assistance of clinical experts, it was clear that many tenuous assumptions would have to be made. For these reasons in depth formal economic modelling was considered to be not useful in decision making.

Instead of a formal economic model, a simple model was constructed which assisted the GDG to understand the economic implications and trade-offs given different assumptions regarding the accuracy of a diagnostic modality. This model needed to be simple given that downstream treatments were varied and outside the scope of the guideline.

The GDG were able to enter a given prevalence of spinal injury within the trauma population (adult patients that arrive at A&E with suspected spinal column injury) as well as an assumed accuracy for an imaging modality. Accuracy estimates were selected from the clinical evidence review. With costs of different imaging modalities provided, the tool is able to estimate the cost of a particular diagnostic outcome (such as for missed injury), QALY gain per patient and number of missed injuries in a particular strategy to name a few.

This model addresses diagnostic accuracy of decision rules and imaging modalities in patients with column injury ONLY – it however, does take into account patients who convert to a cord injury as a result of their column injury. Isolated SCI was not addressed in this model due to the lack of data. The clinical review did not find accuracy data for X-ray or CT scan for cord injuries. Only MRI accuracy data for cord injuries was identified. Expert opinion supports that if a trauma patient arrives in A&E with neurological signs and symptoms associated with a cord injury an MRI will always be required. The clinical review also highlighted MRI as the Gold standard diagnostic investigation for suspected cord injuries.

The perspective adopted was that of the NHS. The time horizon of the model included the 4 hours in A&E and any extra time to realise the short term outcomes. To calculate QALYs a lifetime horizon was used. A total of 18 strategies were compared, blanket strategies that involved imaging all patients suspected of a spinal injury with either X-ray, CT scan or MRI, combinations of these were also included, such as X-ray plus CT and CT plus MRI, and selective strategies in which a decision rule is applied to determine if a patient should be imaged by one or a combination of these modalities. The prevalence of spinal column injury combined with the performance of prediction rules and the performance of diagnostic imaging techniques determined the number of patients correctly provided treatment (TP), incorrectly provided treatment (FP), correctly left untreated (TN) and incorrectly left untreated (FN). With costs of different imaging modalities provided, the tool is able to estimate the cost of a particular diagnostic outcome (that is, for missed injury), QALY gain per patient and number of missed injuries in a particular strategy. Litigation costs associated with a missed injury, both column and column injuries that convert to a cord, were included in the base-case analysis.

Base-case probabilistic analysis identified that CCR + CT scan dominated all other strategies and was therefore optimal in a population of suspected column injury. This strategy remained optimal in sensitivity analyses; such as certain variations in the accuracy estimates, when litigation costs were included, when the QALY loss associated with false negatives was increased, when the time horizon was extended, when the risk and consequences of radiation exposure were included and discounting applied. At the assumed prevalence rates and accuracy data, CT scans in combination with a decision rule are most likely to be cost effective. CT scanning only those with a positive X-ray at the assumed prevalence and accuracy rates results in many missed injuries.

The results of the base-case and sensitivity analysis clearly point out that decision rules are important tools in clearing spinal injuries. It highlights the importance of clinical expertise and the role of the medical professional in deciding on imaging a patient with suspected spinal injury.

Although CCR featured among the top ranked strategies in the base case and the HI model, the sensitivity and specificity of the decision rules made an impact on the results. In varying the accuracy estimates of the decision rules a strategy with a decision rule still featured in terms of most cost effective strategy compared to all other strategies. It can be concluded that although results support the use of the CCR, in general the use of a decision rule is recommended.

The economic analysis conducted in the Head Injury guideline concluded that for patients with head injury and suspected cervical spinal injury, the CCR for CT scan was cost effective for selecting patients for diagnostic imaging83. This supports the results presented in this analysis.

It has to be acknowledged that the analysis undertaken in this guideline does not fully account or quantify all of the trade-offs involved in the diagnostic decision on which this analysis is based. No weighting or penalty was given to outcomes such as false positive (although the cost of observation and treatment is taken into account), there are no indeterminate images, patients are cleared or found to have an injury, only spinal column injured patients who are missed (FN) can convert to a cord injury. TP’s do not convert to cord injuries in the model. The same conversion rate to cord injury is applied to patients with bony column injury or ligamentous column injuries. The analysis also assumed that patients would remain well and experience no deterioration after treatment or no treatment.

The time horizon adopted in this analysis focused on relatively short-term outcomes. QALYs were estimated using utilities from proxy conditions and long-term spinal cord injured patients. The adverse events associated with spinal clearance strategies and the decision to remove spinal protective measures was not fully explored in this analysis. The adverse events associated with spinal protection methods, such as pressure sores, raised intracranial pressure and pneumonia, were not included. Radiation risk associated with imaging modalities is also an important long-term consideration not included; however, this was included in a sensitivity analysis.

It is, therefore, necessary to interpret this analysis to have potentially serious limitations. However, the GDG felt that despite the limitations, the analysis is sufficient for purposes of decision making as it explicitly shows and attempts to quantify the parameters, assumptions and structure underpinning the clinical decision.

See also Appendix L for full write up.

7.5. Evidence statements

Adults

NEXUS low-risk criteria

A meta-analysis of 5 diagnostic cohorts in 45,720 adults showed that the NEXUS low-risk criteria had pooled high sensitivity (95% CI) of 0.94 (0.78 to 0.98) and a very poor specificity (SD) of 0.25 (0.12 to 0.46) relative to plain film radiography and/or CT at picking up a CSI in adults, however, there was high variability in these results (Very low quality evidence).

One diagnostic sub-study in 2963 adults aged 65 years and over showed that the NEXUS low-risk criteria had a sensitivity of 1.00 (95% CI, 0.63 to 1.00) and specificity of 0.14 (95% CI, 0.13 to 0.15) relative to plain film radiography, CT and/or MRI at picking up a CSI in older adults (Very low quality evidence).

CCR

Four diagnostic cohorts in 22,964 adults showed that the CCR had a median sensitivity of 1.00 (95% CI, 0.63 to 1.00) and a median specificity of 0.33 (95% CI, 0.31 to 0.36) relative to plain film radiography and/or CT at picking up a CSI in adults (Very low quality evidence).

Modified NEXUS or CCR

One diagnostic cohort in 8924 adults aged 16 years and over showed that reinterpreting CCR criteria within the NEXUS framework had a sensitivity of 0.93 (95% CI, 0.87 to 0.96) and a specificity of 0.38 (95% CI, 0.37 to 0.39) relative to radiography at picking up a CSI in adults (Very low quality evidence).

One diagnostic cohort in 2606 adults aged 16 years and over showed that a modified CCR excluding the neck rotation criterion had a sensitivity of 0.83 (95% CI, 0.76 to 0.88) and a specificity of 0.46 (95% CI, 0.44 to 0.48) relative to complete cervical-spine CT at picking up a CSI in adults (Very low quality evidence).

One diagnostic cohort in 507 adults showed that a modified CCR excluding the low-risk factors criteria had a sensitivity of 1.00 (95% CI, 0.40 to 1.00) and a specificity of 0.29 (95% CI, 0.25 to 0.34) relative to CT at picking up a CSI in adults (Very low quality evidence).

NEXUS – all patients

The NEXUS derivation and validation studies included both children and adults. The derivation study of 974 children and adults found that when the NEXUS criteria included midline neck tenderness, altered level of alertness or intoxication and excluded whiplash mechanism it had a sensitivity of 1.00 (95% CI, 0.87 to 1.00) and a specificity of 0.52 (0.49 to 0.55) (Low quality evidence). The much larger validation study of 34,069 children and adults showed that the NEXUS had a sensitivity of 1.00 (95% CI, 0.99 to 1.00) and a specificity of 0.13 (0.13 to 0.13) relative to radiography, and possibly CT and/or MRI at picking up a CSI in children and adults (Low quality evidence).

Children and infants

NEXUS low-risk criteria

Two diagnostic cohorts with 3173 children showed that the NEXUS low-risk criteria has a median sensitivity of 0.57 (95% CI, 0.18 to 0.90) and median specificity of 0.20 (95% CI, 0.18 to 0.21) relative to plain film radiography and/or CT at picking up a CSI in children (Very low quality evidence).

CCR

One diagnostic cohort of 109 children showed that the CCR has a sensitivity of 0.86 (95% CI, 0.42 to 1.00) and minimal specificity of 0.15 (95% CI, 0.08 to 0.23) relative to plain film radiography and/or CT at picking up a CSI in children (Very low quality evidence).

Economic

No relevant economic evaluations were identified.

An original health economic model found that, for patients with suspected spinal column injury, the CCR (followed by a CT scan) was part of the most cost-effective diagnostic pathway to clear the spine. This analysis is directly applicable with potentially serious limitations.

7.6. Recommendations and link to evidence

RecommendationsPre-hospital assessment and management
9.

Assess whether the person is at high, low or no risk for cervical spine injury using the Canadian C-spine rule as follows:

  • the person is at high risk if they have at least one of the following high-risk factors:

    age 65 years or older

    dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)

    paraesthesia in the upper or lower limbs

  • the person is at low risk if they have at least one of the following low-risk factors:

    involved in a minor rear-end motor vehicle collision

    comfortable in a sitting position

    ambulatory at any time since the injury

    no midline cervical spine tenderness

    delayed onset of neck pain

  • the person remains at low risk if they are:

    unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high-risk factors)

  • the person has no risk if they:

    have one of the above low-risk factors and

    are able to actively rotate their neck 45 degrees to the left and right

10.

Be aware that applying the Canadian C-spine rule to children is difficult and the child’s developmental stage should be taken into account.

11.

Assess the person with suspected thoracic or lumbosacral spine injury using these factors:

  • age 65 years or older and reported pain in the thoracic or lumbosacral spine
  • dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
  • pre-existing spinal pathology, or known or at risk of osteoporosis – for example steroid use
  • suspected spinal fracture in another region of the spine
  • abnormal neurological symptoms (paraesthesia or weakness or numbness)
  • on examination:

    abnormal neurological signs (motor or sensory deficit)

    new deformity or bony midline tenderness (on palpation)

    bony midline tenderness (on percussion)

    midline or spinal pain (on coughing)

  • on mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).
12.

Be aware that assessing children with suspected thoracic or lumbosacral spine injury is difficult and the child’s developmental stage should be taken into account.

13.

Carry out or maintain full in-line spinal immobilisation if:

  • a high-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule
  • a low-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule and the person is unable to actively rotate their neck 45 degrees left and right
  • indicated by one or more of the factors listed in recommendation 11.
14.

Do not carry out or maintain full in-line spinal immobilisation in people if:

  • they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C-spine rule, are pain free and are able to actively rotate their neck 45 degrees left and right
  • they do not have any of the factors listed in recommendation 11.
Hospital assessment and management
15.

Assess the person with suspected cervical spine injury using the Canadian C-spine rule (see recommendations 9 and 10).

16.

Assess the person with suspected thoracic or lumbosacral spine injury using the factors listed in recommendation 11 and 12.

17.

Carry out or maintain full in-line spinal immobilisation and request imaging if:

  • a high-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule or
  • a low-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule and the person is unable to actively rotate their neck 45 degrees left and right or
  • indicated by one or more of the factors listed in recommendation 11.
18.

Do not carry out or maintain full in-line spinal immobilisation or request imaging for people if:

  • they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C-spine rule, are pain free and are able to actively rotate their neck 45 degrees left and right
  • they do not have any of the factors listed in recommendation 11.
Relative values of different outcomesAlthough the objective of this review focuses on excluding those without spinal cord and/or column injury from unnecessary immobilisation and imaging the primary outcome for this evidence review was sensitivity (an indication of the false negative rate). False negatives (a negative test result when there is a spinal injury) may cause considerable clinical and health economic harms. For example, failure to pick up an unstable cervical column injury could lead to conversion to a SCI.
The GDG also considered specificity, as false positive results present harm to the patient both in exposure to imaging-related radiation and in terms of the adverse effects of spinal protection. This is of particular importance in children who have a lower rate of spinal injury and where unnecessary immobilisation may lead to imaging.
Although the harms resulting from suboptimal specificity were considered serious, they were not regarded as important as the harms resulting from suboptimal sensitivity, so sensitivity was the more important outcome.
Trade-off between clinical benefits and harmsCervical spine
The GDG discussed the sensitivity of the two identified decision tools. It was agreed that greater clinical benefit would be gained by prioritising sensitivity in order to minimise false negatives (missing a cervical spine cord or column injury) than concentrating on specificity (minimising radiation risk of unnecessary imaging for those without injury).
While unable to compare a meta-analysis of the diagnostic accuracy of CCR with NEXUS, the CCR studies are generally more precise with consistently higher sensitivity ratings compared with the NEXUS studies. No harms were noted for CCR or Nexus.
Thoracic and lumbosacral spine
No evidence concerning the diagnostic accuracy of decision tools designed for the thoracic and lumbosacral spine was found. The benefits of having a set of criteria to identify a thoracic and lumbosacral spinal injury and to avoid missed injuries and unnecessary imaging is clear. A consensus assessment criteria was developed by the GDG as a basis for the recommendation.
Children
Most of the evidence was in adults, but limited evidence suggested such tools have lower sensitivity in children, with a high variability between studies. The difficulties of applying the risk tools to children are well known and the CCR is not validated for use in children under eight years. The benefits of using a risk tool, particularly in avoiding unnecessary imaging, in children outweigh the risks of not using a tool.
Economic considerationsThe original economic analysis conducted for this guideline based on accuracy evidence for decision rules from the clinical review identified the CCR and CT scan strategy to be optimal. It was found to dominate all other strategies in the model. This result was robust to various assumptions if mean accuracy data retrieved from the systematic review is felt credible. Throughout all sensitivity analyses, use of some form of decision rule was better than moving directly to imaging to clear the spine.
At the assumed prevalence rates and accuracy data, CT scans in combination with a decision rule are most likely to be cost effective. The results of the base-case and sensitivity analysis clearly point out that decision rules are important tools in clearing spinal injuries. It highlights the importance of clinical expertise and the role of the medical professional in deciding on imaging a patient with suspected spinal injury.
Although CCR featured among the top ranked strategies in the base case, the sensitivity and specificity of the decision rules made an impact on the results. In varying the accuracy estimates of the decision rules, a strategy with a decision rule (either CCR or NEXUS) still featured in terms of the most cost effective strategy. It can be concluded that although the base-case results support the use of the CCR, in general, the use of a decision rule is recommended.
The economic analysis conducted in the Head Injury guideline concluded that for patients with head injury and suspected cervical spinal injury, the CCR for CT scan was cost effective for selecting patients for diagnostic imaging. This reassuringly supports the results presented here. For further discussion on the findings of the model please refer to Appendix L.
The model was in the adult population and the GDG felt the results could not be extrapolated to children which are likely to differ in terms of epidemiology of the injury. However a sensitivity analysis was undertaken in the model whereby; the proportion of ligamentous injuries was varied, and also radiation risk was incorporated which is more of a concern in children. The result showed that again a decision rule was included in the most optimal clearance strategy (CCR), with the optimal imaging modality following this depending on the proportion of ligamentous injuries (if this is more than around 27%, MRI is cost effective).
Quality of evidenceThe observational nature of the studies available and variation in sensitivity and specificity found across studies (inconsistency) led to the evidence being rated as Very low for both the CCR and NEXUS.
The GDG recognised that evidence for currently available clinical decision tools focussed specifically on suspected injuries of the cervical spine.
No tools which focus on suspected injury of the thoracic and/or lumbar spine were identified.
Other considerationsThe GDG noted that the CCR is a tool designed for decision to image. The GDG considered that it is also a proxy for the identification of a potential column (or cord) injury and can be used for assessment as well as imaging. People that need imaging will need to be immobilised.
Once someone is trained to use the CCR it is easy and quick to apply and the GDG considered that it could also be applied in the pre-hospital setting to assess spinal injury and not only in the ED. The GDG recognised that training in the use of the CCR was of utmost importance if it is to be applied properly.
Thoracic and lumbosacral spine
Despite the absence of evidence, the GDG agreed there was an urgent need for assessment criteria to support healthcare professionals in identifying thoracic or lumbosacral spinal injury. Through consensus, the GDG agreed on a set of criteria that could be used as a guide to assessment rather than a definitive predictor. The GDG were keen to emphasise that the criteria had not been validated for use as a risk tool.
The criteria for identifying thoracic or lumbosacral spinal injury was extrapolated from the CCR and adjusted to suit the region of the spine. The CCR indicates a fall from 1 metre and the thoracic or lumbosacral spinal criteria 3 metres, more energy is needed to disrupt the thoracic or lumbosacral spine than the cervical spine.
The thoracic or lumbosacral spinal criteria suggest a high-risk factor is both being over 65 years and reported pain, and not just over 65 years as in the CCR, in this age group the risks of precautionary immobilisation outweigh the benefits of routine immobilisation. In the case of the cervical spine, the risks of missed injury are greater.
In addition, specific criteria for the thoracic or lumbosacral spinal region on examination have been added. This outlines the need for concern in those people with focal signs as well as exacerbation of pain on movement.
Children and young people
There are no validated risk tools for children and young people and the GDG agreed that the CCR could be extrapolated to and used in this population. The GDG were keen to make a recommendation highlighting the need for caution when using the rule. Some of the assessments (such as pain assessment or controlled exploratory movements) cannot be carried out in very young children. The GDG make it clear that the child’s developmental age should be taken in to account when assessing for spinal injury.
The GDG noted that the assessment in the ED was the same as in the pre-hospital and cross referred to the pre-hospital recommendations in the ED setting.
The recommendations to carry out immobilisation based on the assessment also state the need to image in the ED as this is the only way to confirm or exclude a spinal injury. However this is not relevant to the pre-hospital setting.
Copyright © National Clinical Guideline Centre, 2016.
Bookshelf ID: NBK367841

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