MSK week 1 module 1 module 2 Flashcards
Traumatic cervical spine injury is one of the most importtant and challenging issues in the management of patients in emergency departments [1]. These patients comprise a signifcant portion of long lasting injuries and severe disabilities [2]. Most physicians prefer to conduct various imaging evaluation to rule out cervical spine fracture-dislocations or vertebral instability [3].
However, clinically important
cervical injuries are found in less than 3% of patients and the imaging evaluations performed for 97% of these subjects are unnecessary [4]. Moreover, exposure to radiation is another issue. Accordingly, identifying patients with higher risk of cervical spine injuries seems to be very important in the management of trauma patients.
In the past decade, two criteria for ruling out clinically important cervical spine injuries were designed. These
two models, presented nearly at the same time, include the Canadian C-spine rule [11] and the National Emergency X-Radiography Utilization Study (NEXUS) criteria [12]. They were designed to decrease the rate of unnecessary imaging in
low risk patients for blunt cervical spine injuries.
The C-spine scoring criterion is used to identify high-risk patients for traumatic cervical injury.
The Canadian C-spin rule is used for alert, and stable condition patients and it is a decision rule to perform radiography based on patient’s clinical signs and symptoms.
The NEXUS criteria for C-Spine imaging were introduced by Hofman etal. in 2000. The guidelines recommend
that if NEXUS criteria for a patient was negative, imaging
is
not necessary
What was the purpose of the article on Value ofCanadian C‑spine rule versustheNEXUS criteria inruling
outclinically important cervical spine injuries: derivation ofmodifed Canadian C‑spine rule?
Although, NEXUS and Canadian C-spine decision rules have been validated using large prospective studies, no consensus exist as to which rule should be endorsed. Therefore, the present study aimed to compare the accuracy of the Canadian C-spine and NEXUS criteria in ruling out clinically important cervical spine injuries in trauma patients. Finally, we introduced the modifed Canadian C-spine rule.
the results of Value ofCanadian C‑spine rule versustheNEXUS criteria inruling
outclinically important cervical spine injuries: derivation ofmodifed Canadian C‑spine rule?
The results of this study showed that both the Canadian C-spine and modifed Canadian C-spine are able to rule out all clinically important cervical spine injuries, while the NEXUS criteria missed four of these injuries (4 false negative).
modified canadian c spine rule in rule out of imaging in cervical trauma patients
age 65 with paresthesias in extremities
if yes than radiography
if no
sitting position in ED or ambulatory at any time or delayed onset of neck pain or absense of midline c-spine tenderness
if no than radiography
if yes
able to actively rotate neck 45 degrees L and R
if unable radiography
if able
no radiography
another conclusion of Value ofCanadian C‑spine rule versustheNEXUS criteria inruling
outclinically important cervical spine injuries: derivation ofmodifed
Canadian C‑spine rule
In conclusion, we found that the Canadian C-spine and
the modifed Canadian C-spine are preferable to the NEXUS
criteria for ruling out clinically important cervical spinal
injuries.
What is clinical reasoning?
- Involves synthesis of information and collaboration between all
parties - Requires integration of information from:
- Intake paperwork
- The patient
- The objective exam
- Best available evidence
- The outcome: clinical decision-making
What influences clinical decision-making?
- Problem-solving strategies
- Knowledge and experience
- Interpersonal skills
- Patient factors
Problem Solving: What can guide clinical-
decision making?
Step 1: Hypothesis-Oriented Algorithm
* Determine hypotheses at the end of the
subjective exam/eval
* Goal is 2-3, based on all components of
LOCIDA and SINSS
* Test out the hypotheses during the
objective exam/eval
* Goal is to rule-in a top hypothesis by the end
of the objective evaluation
Step 1: Hypothesis-Oriented Algorithm
* Determine hypotheses at the end of the
subjective exam/eval
* Goal is 2-3, based on all components of
LOCIDA and SINSS
* Test out the hypotheses during the
objective exam/eval
* Goal is to rule-in a top hypothesis by the end
of the objective evaluation
“Filter and Funnel”
to achieve the
overall goal:
diagnosis
Priorities of the Subjective Exam/Eval: Diagnosis
- Primary care: medical history,
determining presence of red flags,
determining best course of action - Is the patient appropriate for physical
therapy? - Orthopedic diagnosis
- Did you obtain enough information to
answer the following:
Also locida
also sinss - Test out hypotheses
- Rule in a top hypothesis
- Identify movement impairments
- Activity and Participation Restrictions
- Identify impairments in body structures
& function via tests and measures - Will assist with ruling in- or out- a diagnosis
Problem Solving: What can guide clinical-
decision making?
* Step 2: Evidence-Based Practice
(EBP)
- Use EBP to guide the subjective and
objective examination - 3 Pillars
- Best available evidence
- Experience
- Patient values
- Clinical Practice Guidelines
- Tests and Measures: Diagnostic Accuracy
- Clinical Prediction Rules
- Clinical Practice Guidelines
- Diagnosis-specific
- A reference point for all components of the plan of care
- See supplemental lecture
- Minimum Detectable Change (MDC): minimum amount of
measured change needed before measurement error can be ruled
out - When this is exceeded, we can be confident that a true change in status
has occurred - Doesn’t take into account impact on the patient
- Minimally Clinically Important Difference (MCID): minimum
amount of measured change that signifies an important difference
in the patient’s condition
Minimum Detectable Change (MDC):
minimum amount of measured change needed before measurement error can be ruled out
* When this is exceeded, we can be confident that a true change in status has occurred
* Doesn’t take into account impact on the patient
Minimally Clinically Important Difference (MCID):
minimum amount of measured change that signifies an important difference in the patient’s condition
Sensitivity (SN)
the probability of a positive test result in someone with the pathology
* SNout
* Tests with a high SN are valued as screening tests to rule out a pathology when negative
Specificity (SP)
The probability of a negative test result in someone without the pathology
* SPin
* Tests with a high SP are utilized to rule in a pathology when positive
* Want the value to be as close to 1.0 as possible (>0.90 generally results in fewer “false” results)
SpPin - with high specificity, a positive test rules ___ diagnosis
in
SnNout - with high sensitivity, a negative test rules ____ diagnosis
out
Positive likelihood ratio (LR+):
indicates how much a positive test result increases the probability of a pathology being present
* Used when interpreting a positive test result
- Negative likelihood ratio (LR-):
indicates how much a negative test result decreases the probability of a pathology being present
* Used when interpreting a negative test result
Clinical Prediction Rules
- Combines diagnostic accuracy of a variety of variables for a condition or intervention into overall diagnostic accuracy values
- i.e. clusters of findings
Problem Solving: What can guide clinical-
decision making?
* Step 3: Apply the ICF Model
- Use the subjective and objective examination to fill out all components of the ICF model
- Allows you to evaluate and analyze (assess) your findings
