Comparison of CT and MRI findings for cervical spine clearance in obtunded patients without high impact trauma

Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis

BACKGROUND

Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma.

METHODS

A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology.

RESULTS

744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity.

CONCLUSIONS

Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma.

IMPLICATIONS OF KEY FINDINGS

Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.

Cervical Collar Clearance in Obtunded Children Presenting Without a Known Traumatic Mechanism: Is Imaging Necessary?

BACKGROUND

Obtunded pediatric patients are often placed in cervical collars (c-collars) to protect their cervical spine (c-spine) while injury is being ruled out, even without a known traumatic injury. The goal of this study was to determine the necessity of c-collars in this population by determining the rate of c-spine injury among patients with suspected non-traumatic mechanisms of loss of consciousness.

METHODS

A single institution, ten-year retrospective chart review was conducted including all obtunded patients admitted to the Pediatric Intensive Care Unit without a known traumatic event. Patients were categorized into five groups based on etiology of obtundation: respiratory, cardiac, medical/metabolic, neurologic, and other. Comparisons were made between those placed in a c-collar and a control group who were not, using Wilcoxon rank sum test for continuous measures, and Chi-square or Fisher's exact test for categorical measures.

RESULTS

464 patients were included, of which 39 (8.41%) were placed in a c-collar. There was a significant difference in whether a patient was placed in a c-collar based on diagnosis category (p < 0.001). Those placed in a-c-collar were more likely to undergo imaging studies than the control group (p < 0.001). The overall incidence of c-spine injury in this patient population in our study was zero.

CONCLUSION

Cervical collar placement and radiographic evaluation is not necessary in obtunded pediatric patients who present without a known traumatic mechanism as the overall risk of injury is low. Consideration for collar placement should be given in cases when trauma cannot be definitively ruled out at initial evaluation.

LEVELS OF EVIDENCE

III.

Clinical significance of "positive" cervical spine MRI findings following a negative CT

PURPOSE

To review and analyze the clinical significance of positive acute traumatic findings seen on MRI of the cervical spine (MRCS) following a negative CT of the cervical spine (CTCS) for trauma.

METHODS

We performed a sub-cohort analysis of 54 patients with negative CTCS and a positive MRCS after spine trauma from the previous multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Both CTCS and MRCS were independently reviewed by two emergency radiologists and two spine surgeons. The surgeons also commented on the clinical significance of the traumatic findings seen on MRCS and grouped them into unstable, potentially unstable, and stable injuries.

RESULTS

Among 35 unevaluable patients, MRCS showed one unstable (hyperextension) and two potentially unstable (hyperflexion) injuries. Subtle findings were seen on CTCS in 2 of 3 patients upon careful retrospective review that would have suggested these injuries. Of 19 patients presenting with cervicalgia, 2/5 (40%) patients with neurological deficit demonstrated clinically significant findings on MRCS with predisposing factors seen on CT. None of the 14 patients with isolated cervicalgia and no neurological deficit had clinically significant findings on their MRCS.

CONCLUSION

While CTCS is adequate for clearing the cervical spine in patients with isolated cervicalgia, MRCS can play a critical role in patients with neurological deficits and normal CTCS. Clinically significant traumatic findings were seen in 8.5% of unevaluable patients on MRCS, though these injuries in fact could be identified on the CT in 2 of 3 patients upon careful retrospective review.

Cervical Spine Injuries in Older Patients with Falls Found on Magnetic Resonance Imaging After Computed Tomography

INTRODUCTION

In this study we aimed to determine the rate of traumatic abnormalities on cervical spine magnetic resonance imaging (MRI) after a normal cervical spine computed tomography (CT) in older patients with ground-level falls. We hypothesized that MRI is low yield following a normal physical examination and normal CT after a ground-level fall.

METHODS

This was a retrospective cohort study of patients 65 years and older evaluated with a cervical spine MRI following a ground-level fall. Inclusion criteria included age 65 years and older, ground-level fall, normal cervical spine CT followed by a cervical spine MRI. We abstracted data following accepted methodologic guidelines. Patients with any focal neurological finding were considered to have an abnormal neurological examination. Imaging studies were considered to be abnormal if there was a report of an acute traumatic injury. The primary outcome was a traumatic abnormality identified on MRI. We described data with simple descriptive statistics.

RESULTS

Eighty-seven patients with a median age of 74 (interquartile range [IQR] 69, 83]) years had an MRI following a normal cervical spine CT. Median emergency department length of stay was 8.2 hours (IQR 5.3, 13.5). Sixty-four (73.6%) patients had a normal neurological examination on arrival; eight of these patients (12.5% (95% confidence interval [CI], 5.6-23.2%) had an abnormal cervical spine MRI. Twenty-three patients (26.4%) had an abnormal neurological examination on arrival; two of these patients (8.7%, 95% CI, 1.1-28%) had an abnormal cervical spine MRI. Overall, 10 patients (11.5%) had an abnormal cervical spine MRI. One patient underwent operative intervention due to an unstable injury. Of the remaining nine patients with acute findings on cervical spine MRI, there were no other unstable injuries; two patients were managed with cervical orthosis, and seven patients had no additional management.

CONCLUSION

In this study of older patients with ground-level falls and normal, atraumatic, cervical spine CT, a small portion had traumatic abnormalities on MRI, with few requiring further intervention. Further study is required to identify criteria to determine when MRI should be performed in older patients after a ground-level fall.

Achieving Value in Spine Surgery: 10 Major Cost Contributors

STUDY DESIGN

Narrative Review.

OBJECTIVES

The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.

METHODS

We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.

RESULTS

We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.

CONCLUSIONS

In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

Application of intraoperative electrophysiological monitoring in vertebral canal decompression surgery for acute spinal cord injury

OBJECTIVE

This study aimed to evaluate the joint monitoring of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) in vertebral canal decompression surgery for acute spinal cord injury.

METHODS

Twenty-four patients, who were admitted to the hospital for the surgical treatment of spinal cord injury with SEP and MEP monitoring, were assigned to the intraoperative monitoring group (group I). In addition, 24 patients who were admitted to the hospital for the surgical treatment of spinal cord injury without SEP or MEP monitoring were assigned to the control group (group C).

RESULTS

In group I, there were significant changes before and after decompression surgery in the P40 latency and amplitude, and in the latency of MEP in the abductor hallucis brevis (AHB), in patients with improved spinal nerve function following surgery. In contrast, there were no significant differences in the P40 latency or amplitude, or the latency of MEP in the AHB, in patients who showed no improvement after surgery.

CONCLUSION

In vertebral canal decompression surgery for acute spinal cord injury, the application of joint MEP and SEP monitoring can timely reflect changes in spinal cord function.

Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis

OBJECTIVE

The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury.

METHODS

We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year.

RESULTS

The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%.

CONCLUSION

A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.

Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review

BACKGROUND

A missed cervical spinal injury could have devastating consequences. Patients with a suspected cervical spinal injury are kept in rigid collars for cervical immobilisation. Prolonged collar use has important clinical implications. A well-defined guideline related to the removal of cervical collars from adult obtunded blunt trauma patients has not been developed.

AIM

We sought to determine if Magnetic Resonance Imaging offered a definitive benefit over Computer Tomography with respect to patient management.

METHOD

We searched Ovid Online, EBSCO, NICE Evidence Journals, Medline, PubMED, BNI, CINAHL and Google Scholar as well as the grey literature. Data extraction and synthesis were performed on studies that compared the radiologic findings and clinical outcomes of Computer Tomography scan and Magnetic Resonance Imaging in this patient group.

RESULTS

There is evidence that supports the safe discontinuation of cervical collar use after a negative multidetector Computer Tomography scan result alone. Magnetic Resonance Imaging may detect a significant number of ligamentous injuries, but such injuries are rarely of clinical significance because they rarely alter clinical management. Its use should be limited to specific circumstances.

CONCLUSION

It is important for institutions to re-examine the latest evidence regarding cervical spinal clearance in order to update their guidelines.

Safe management of acute cervical spine injuries

Cervical spine injuries are frequent and often caused by a blunt trauma mechanism. They can have severe consequences, with a high mortality rate and a high rate of neurological lesions.Diagnosis is a three-step process: 1) risk assessment according to the history and clinical features, guided by a clinical decision rule such as the Canadian C-Spine rule; 2) imaging if needed; 3) classification of the injury according to different classification systems in the different regions of the cervical spine.The urgency of treatment is dependent on the presence of a neurological lesion and/or instability. The treatment strategy depends on the morphological criteria as defined by the classification. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170076.

64-Slice CT compared to MRI to clear cervical spine injury in high-risk GCS < 14 blunt trauma patients admitted to the ICU

Objective

Clearance of cervical spine injury including ligamentous injury is of paramount importance as results of missed injury may have serious consequences. In obtunded patients, cervical spine clearance is challenging. This study sought to determine whether a negative 64-slice CT scan alone is sufficient to clear cervical spine injury.

Patients and methods

All consecutive blunt trauma patients admitted to a regional (level 1) trauma center from 1 April 2008 to 31 March 2012 were screened for inclusion in this study. High-risk, GCS < 14, blunt trauma patients were included if they were admitted to the intensive care unit, had a negative 64-slice CT, and MRI of diagnostic quality. GCS was measured at the time of CT scan. Patients with a positive finding on CT scan were excluded. All images were re-interpreted by a trauma radiologist blinded to clinical outcome. Details of missed injuries and clinical impact were reported. The primary outcome was missed clinically significant injury, defined as any injury requiring an additional intervention including continued immobilization or surgery.

Results

There were 5891 blunt trauma patients admitted to the ICU, 44 of whom met inclusion criteria. Patients had a median injury severity score of 35 and MRI three (2–9) days after CT. Eight of 44 (18%) patients had a positive finding on MRI and five of the findings were clinically insignificant. Three patients (7%) with focal neurologic findings on clinical exam had missed injuries requiring immobilization with a collar. Two of these patients had spine disease, which may have increased their injury risk.

Conclusions

In high-risk obtunded blunt trauma patients admitted to the ICU, a negative 64-slice CT scan alone is insufficient to clear clinically significant cervical spine injury, with a missed clinically significant injury rate of 7%. When considered with symmetric motor function, a negative 64-slice CT scan may be sufficient. A prospective study is required to confirm these findings.

Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma

PURPOSE

The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients.

METHODS

We performed a retrospective review of pediatric patients (aged below 18 years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared.

RESULTS

Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal.

CONCLUSION

In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.

Surgical Outcome and Prognostic Analysis of Transoral Atlantoaxial Reduction Plate System for Basilar Invagination: A Voxel-Based Morphometry Study

BACKGROUND

The use of a transoral atlantoaxial reduction plate (TARP) system is an effective surgical approach for the treatment of basilar invagination. With the aim of improving the therapeutic efficacy of the TARP operation, we conducted a voxel-based morphometric study to quantitatively investigate the descent of the odontoid process and craniocervical volume changes.

METHODS

We enrolled 20 patients with basilar invagination who underwent a TARP procedure. Craniocervical computed tomography (CT) scanning and a 3-dimensional (3-D) reconstruction of the craniocervical junction were performed. Craniocervical volumes and odontoid process descent distances were measured preoperatively and postoperatively. Individual neurological function was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system for cervical disorders. Pearson correlation analysis was applied for statistical testing.

RESULTS

Surgical efficacy (the JOA-score improvement rate) was significantly associated with the craniocervical volume improvement rate, the odontoid descent distance, and the absolute craniocervical volume changes (p < 0.01 for all), with correlation coefficients (r) of 0.83, 0.80, and 0.61, respectively. No significant correlation was noted between surgical efficacy and age, symptom duration, preoperative neurological function, odontoid process displacement, or change in clivus-odontoid angle (p > 0.05). The craniocervical volume improvement rate was significantly associated with the odontoid descent distance (r = 0.8; p < 0.01), but it was not associated with the odontoid displacement or the change in the clivus-odontoid angle (p > 0.05).

CONCLUSIONS

We found that the odontoid descent distance predicted the craniocervical volume improvement rate following TARP procedures in patients with basilar invagination, and we believe that both can serve as predictors of surgical efficacy. We believe that planning the odontoid descent distance preoperatively may help to improve the efficacy of TARP operations.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of MRI on changing management of the cervical spine in blunt trauma patients with a 'negative' CT scan

Background

Owing to the potential risks associated with missed injury, many blunt trauma patients with suspected cervical spine injury undergo some form of imaging technique which has progressed from primarily using plain radiography to relying on CT. Recently, studies have shown that in certain situations, adding MRI may improve the diagnostic accuracy over solely relying on CT.

Methods

Retrospective study of 3468 adult blunt trauma patients at a level I trauma center of which 94 with an initial negative CT scan underwent subsequent MRI. These 94 patients were classified as reliable or unreliable for examination; coded as either having a positive or negative MRI result; and assessed for a change in management.

Results

Of the 94 patients in the study population, 69 (73.4%) were deemed reliable and 25 (26.6%) deemed unreliable for examination. Overall, 65 (69.1%) patients had a positive MRI result—49 (71.0%) reliable and 16 (64.0%) unreliable—with some patients testing positive for more than one finding. There was no significant difference in positive MRI rates between reliable and unreliable patients. None of the 29 patients who had negative MRI had a change in management, while 31 of the 65 (47.7%) patients with positive MRI did have a change in management of either continued cervical collar immobilization or neck surgery.

Conclusions

The use of CT scans should be continued as the primary imaging technique for patients with suspected cervical spine injuries. In cases where obtundation or clinical suspicion exists for a false-negative CT scan, MRI should be considered as a supplement and should not be rejected solely based on the negative result of the CT.

Level of evidence

Level IV.

Maxillofacial trauma - Underestimation of cervical spine injury

Undiagnosed cervical spine injury can have devastating results. The aim of this study was to analyse patients with primary maxillofacial trauma and a concomitant cervical spine injury. It is hypothetised that cervical spine injury is predictable in maxillofacial surgery. A monocentric clinical study was conducted over a 10-year period to analyse patients with primary maxillofacial and associated cervical spine injuries. Demographic data, mechanism of injury, specific trauma and treatments provided were reviewed. Additionally a search of relevant international literature was conducted in PubMed by terms "maxillofacial" AND "cervical spine" AND "injury". Of 3956 patients, n = 3732 (94.3%) suffered from craniomaxillofacial injuries only, n = 174 (4.4%) from cervical spine injuries only, and n = 50 (1.3%) from both craniomaxillofacial and cervical spine injuries. In this study cohort the most prevalent craniofacial injuries were: n = 41 (44%) midfacial and n = 21 (22.6%) skull base fractures. Cervical spine injuries primarily affected the upper cervical spine column: n = 39 (58.2%) vs. n = 28 (41.8%). Only in 3 of 50 cases (6%), the cervical spine injury was diagnosed coincidentally, and the cervical spine column was under immobilised. The operative treatment rate for maxillofacial injuries was 36% (n = 18), and for cervical spine injuries 20% (n = 10). The overall mortality rate was 8% (n = 4). The literature search yielded only 12 papers (11 retrospective and monocentric cohort studies) and is discussed before our own results. In cases of apparently isolated maxillofacial trauma, maxillofacial surgeons should be aware of a low but serious risk of underestimating an unstable cervical spine injury.

Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis

OBJECTIVES

To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance.

METHODS

We undertook a systematic review of worldwide evidence across five major medical databases and performed a meta-analysis. Studies were included if they reported the number of unstable injuries or gave enough details for inference. Variables assessed included severity, CT/MRI specifications, imaging timing, and outcome/follow-up. Pooled incidences of unstable injury on follow-up weighted by inverse-of-variance among all included and obtunded or alert patients were reported.

RESULTS

Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable.

CONCLUSIONS

There is significant heterogeneity in the literature regarding the use of imaging after a negative CT. The finding rate on MRI for unstable injury is extremely low in obtunded and alert patients. Although MRI is frequently performed, its utility and cost-effectiveness needs further study.

KEY POINTS

• There were 16 unstable injuries on follow-up MRI among 5286 patients. • The positive finding rate among obtunded patients was 0.12 %. • The positive finding rate among alert, awake patients was 0.72 %. • MRI has a high false-positive rate; its utility mandates further studies. • The use and role of "confirmatory" tests shows wide variations.

Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study

OBJECTIVES

To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition.

SETTING

A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan.

PARTICIPANTS

Adult ED visits (aged ≥18 years) during 2009-2013, with or without receiving CT, were enrolled as the study participants.

MAIN OUTCOME MEASURES

For all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay.

RESULTS

In all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013).

CONCLUSIONS

ED CT utilisation rates increased significantly during 2009-2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective.

Acutely unstable cervical spine injury with normal CT scan findings: MRI detects ligamentous injury

MRI can detect ligamentous injury not detectable with CT scan. The authors present a trauma patient with normal CT imaging despite dislocation on standing radiograph. MRI detected disruption of the C5-C6 posterior ligamentous complex that requires surgery.

Best Practice in Diagnostic Imaging after Blunt Force Trauma Injury to the Cervical Spine: A Systematic Review

INTRODUCTION

The aim of this study was to investigate best practice in evidence-based clinical examinations to determine the diagnostic efficacy of plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of a cervical spine injury after blunt force trauma.

METHODS

A systematic review of recent literature was performed, with the intention of analysing only original research articles focusing on at least two imaging modalities or clinical decision guidelines in relation to blunt force trauma injuries involving the cervical spine. The search used the following databases: ProQuest Central, ScienceDirect, and Scopus. A total of 18 studies were identified as suitable for review; these were further supported by relevant secondary studies.

RESULTS

It was found that the National Emergency X-Radiology Utilization Study and the Canadian C-Spine Rule are both highly sensitive methods for screening patients after cervical spine injuries. CT was shown to have a higher validity than plain radiography and MRI for the detection of a bony cervical spine injury. MRI is recommended for obtunded or unevaluable patients with suspected neurologic deficit.

CONCLUSIONS

Overall, the literature appears to suggest that individuals with a suspected high risk of injury after examination using clinical decision rules should undergo a cervical CT examination. For patients who are found to have a low risk of injury after clinical decision guidelines, good-quality plain radiography is recommended as sufficient.

Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review

BACKGROUND

Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT).

PURPOSE

To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014.

STUDY SELECTION

English-language studies that examined patients with negative CT results having confirmatory routine testing with magnetic resonance imaging (MRI), dynamic radiography, or clinical examination and that reported outcome measures of missed cervical spine injury, need for operative stabilization, or prolonged use of cervical collars.

DATA EXTRACTION

Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol.

DATA SYNTHESIS

Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients).

LIMITATIONS

Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly.

CONCLUSION

Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice.

PRIMARY FUNDING SOURCE

None.

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance?

METHODS

Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data.

RESULTS

Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT.

CONCLUSION

In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone.

LEVEL OF EVIDENCE

Systematic review, level III.