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LONG TERM OUTCOME IN CERVICAL SPONDYLOTIC MYELOPATHY

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LONG TERM OUTCOME IN CERVICAL SPONDYLOTIC MYELOPATHY Powered By Docstoc
					Spine clearance in intubated patients



            No consensus
The National Hospital for Neurology and
             Neurosurgery
          Queen Square, London




  A.Singh, S. Fairley, S.Wilson, T. Yousry
        A.Crockard and ATH Casey
             Uncleared Spine

 HI and polytrauma patients
 Immobilisation is standard practice
 Detrimental to nursing care
 Lack of assessment criteria
(Morris et al 2004, Holly et al 2002 and Harris
  et al 2000)
               Risks

•   Head injury
•   Facial injuries
•   RTA aetiology
•   <GCS
•   Supraclavicular injury
•   Polytrauma
                Incidences
Cervical Spine Injury
  Head          5%
  Face          4%
  Clavicle      7%
  GCS>14        4%
  GCS<14        7%
  GCS 3         12%
  Fatal HI      16%

       Bell -N Carolina Tr Register/ Drainer
       2003
                  Assessment


A,B,C,D,E

Other injuries

C-Spine control
                      Collars
Pressure sores

I.C.P. effects

Ventilation morbidity –
pneumonia

Nursing and Physiotherapy
Access

Oral hygiene/sepsis
1.     Complex Multidisciplinary Process


     Trauma team
     Intensivists
     Neuro/Spinal surgeons
     Radiologists
     Nurses
     2.   Inadequate Lateral Films

Single lateral
   Misses 65% fractures
   Misses 45% subluxations

       Woodring 1993


       META-ANALYSIS
73-90% FRACTURES IDENTIFIED
        10-20% MISSED
         UK SURVEY -ITU

48% HAPPY WITH SINGLE
FILM LATERAL


Sensitivity of 85%
>10% prevalence of Cx Spine
Injury …
                   UNACCEPTABLE
Miss 1.5%....
                    Imaging
3 view CSX            3 view Cx Sp Xray missed
   Lateral               90/172 CxSI
   AP                    14/15 occipital
   Open mouth peg        17/36 C1-3
   <1% missed            59/121 C4-T1
   unstable              5/29    unstable CSI
                         2/2     SCIWORA
                         Overall sensitivity 44%

    McDonald 1990             Diaz 2003
                Imaging

5 view CSX

  3 views plus supine obliques

  No clinically relevant improvement

  Cost implications

       Turetsky 1993/ Daffner 1992
                       CT Scan
Directed CT
Non-Directed CT


Non-directed entire cervical spine CT may detect
injuries in a further 8-14% of patients.
 “Computerised tomography scanning does not add
excessive time to trauma evaluations and is time-effective
and cost-effective.”
                    Imaging
CTdiagnosed
 721/740 #s
 76/85 subluxations
 34/35 locked facets
 29 #s in normal x-rays (4%)
 Sensitivity 97.4%
      Holmes 2002
                 META-ANALYSIS
                92-100% SENSITIVE
1/3RD CCJ Injuries detected by CT but missed by X-ray
       ½ Cx Thoracic Junction missed by X-ray
                       Imaging

MRI diagnosed
 69/69 SCI
 37/43 subluxations
 38/38 ligamentous injuries
 14/18 locked facets

        Holmes 2002

Insult to HI patient + cost/resources?
Brooks RA - Evaluation of the Oxford
protocol for total spine clearance in the
unconscious trauma patient. J Trauma
      Brooks RA. J Trauma 2001; 50:862-7

             2001; 50:862-7
210 pts - 73pts dynamic fluoroscopy

5 cervical fractures or instability

1 ligamentous instability

Significantly reduced time of wearing of collar
                  Best Summary
Dynamic Flouroscopy requires further evaluation and
lacks sufficient evidence of sensitivity/specificity/
safety to recommend its routine use

No formal prospective comparison with high
resolution CT or MRI

High NNT (295–500) to detect significant injuries
makes the yield of questionable clinical significance

Its use - best assessed in prospective clinical trials.

Morris & McCoy May 2004 Anaesthesia
         NHNN SITU AUDIT
85% hard collar        ‘Most cases the
8% nothing             instructions were
7% immobilised         changed on arrival at
                       NHNN’

Further investigations
15% X-ray C spine (inadequate films)
58% CT C spine & none had MRI
C spine cleared 2 - 12 days!
Others were not documented
3.   No Consensus



No gold standard?
                AIM


To explore the existing protocols
and introduce a simple and user
friendly algorithm
                           NHNN Surgical ITU Algorithm
        •Treat as unstable until formal NHNN report available
        •Change stiff collar to Miami-J-collar
        •5 person log roll as per NHNN spinal protocol
        •Consider history &clinically examine spine
        •When thoracic & lumbar injury excluded, 3 person log roll is sufficient




                                                                                                                     CT spine within 24 hrs if patient stable (this should
                                         C1-T2 imaging from referring hospital
                                                                                                                     be performed routinely when patient has next CT
                                                                                                                     head)



                                            Obtain formal report within 24hrs
                                            Neurosurgeon to review report and
                                                                                                             Unstable cervical #
                                            document in the notes
                                                                                                             •Management is dictated by precise nature of injury & its
                                                                                                             stability
                                                                                                             • Await instruction from spine team
                                                                                                             •3 person logroll as per NHNN spinal protocol
                  Is fracture or dislocation seen?


                                                           Apply Miami J Collar for ‘waking’
                                                      When awake, test neck for tenderness or     Stable cervical 
                                                      pain
                                                                                                  If patient fully sedated / paralysed, the collar can be removed to aid ICP
Miami J collar for potential ligament                                                             management when patient is supine
                                                      Dynamic flexion/extension neck x–rays
damage                                                                                            Collar applied for turning and side-lying
                                                      if patient co-operative to check for
                                                                                                  If patient only lightly sedated collar must be applied at all times
Collar only applied when turning                      instability
                                                      For unco-operative/confused patients        If thoracic / lumbar  excluded, patient can be nursed 15-30o head up
Patient can be nursed 15-30° head up                                                              3 person log roll as per NHNN Spinal Protocol
                                                      with no limb deficits remove collar and
                                                                                                  Apply Miami J Collar for ‘waking’
No need to log roll and no need for                   mobilise
                                                                                                  Obtain ongoing management plan from Neurosurgical team(consider
straight bed tilt                                     If unexplained limb deficit, MRI spine as
                                                                                                  MRI or Dynamic Flouroscopy)
                                                      soon as clinically possible
       NHNN Surgical ITU Algorithm

•Treat as unstable until formal NHNN report
available
•Change stiff collar to Miami-J-collar
•5 person log roll as per NHNN spinal protocol
•Consider history & clinically examine spine
•When thoracic & lumbar injury excluded, 3 person
log roll is sufficient
       NHNN Surgical ITU Algorithm

C1-T2 imaging from       NO   CT spine within 24
referring hospital            hrs if patient stable
                              (this should be
                              performed routinely
                              when patient has
                              next CT head)
Obtain formal report
within 24hrs
Neurosurgeon to review
report and document in
the notes
        NHNN Surgical ITU Algorithm
                    Is fracture dislocation seen?


                            NO

    ·   Apply Miami J Collar for ‘waking’
    ·   When awake, test neck for tenderness or pain
    ·   Dynamic flexion/extension neck x–rays if patient
        co-operative
·       If unexplained limb deficit, MRI spine as soon as clinically
        possible
      NHNN Surgical ITU Algorithm

                     Is fracture dislocation seen?




Unstable cervical 
·      Management is dictated by precise nature of injury and
       its stability
·      Await instructions from Spinal team
·      3 person log roll as per NHNN Spinal Protocol
       NHNN Surgical ITU Algorithm
Stable cervical 
·     If patient fully sedated / paralysed, the collar can be
      removed to aid ICP management when patient is
      supine
·     Collar applied for turning and side-lying
·     If patient only lightly sedated collar must be
      applied at all times
·     If thoracic / lumbar  excluded, patient can be
      nursed 15-30o head up
·     3 person log roll as per NHNN Spinal Protocol
·     Apply Miami J Collar for ‘waking’
·     Obtain ongoing management plan from
      Neurosurgical team (consider MRI or dynamic
      fluoroscopy)
          Recommendations


• One protocol

• Multi-centre observational
             Acknowledgements
Sandra Fairley - Clinical Nurse Specialist SITU

Dr Sally Wilson - Consultant Neuro-Anaesthetist

Professor Tariq Yousry - Consultant Radiologist

Professor Alan Crockard - Professor in Neurosurgery

Mr Adrian Casey - Consultant Neurological & Spinal
Surgeon

				
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posted:8/20/2012
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