Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial

Pediatric C-spine Clearance by CT: A Retrospective Cohort Study

BACKGROUND

Pediatric cervical spinal injury (CSI) remains a significant concern following blunt trauma, with mortality rates as high as 48%. Current protocols involve cervical immobilization and clearance through multidetector computed tomography (MDCT) scans, followed by magnetic resonance imaging (MRI) or clinical examination. However, prolonged collar use poses risks, necessitating timely clearance. This study assessed the efficacy of MDCT in pediatric CSI clearance.

METHODS

A retrospective cohort study, spanning January 2019 to January 2023, included pediatric patients under 18 undergoing cervical CT scans.

RESULTS

MDCT sensitivity was evaluated, with 13.8% positive scans, detecting clinically significant injuries. MRI identified no additional injuries, affirming MDCT reliability. The average clearance time was 24.9 hours, impacting hospitalization durations. Mortality unrelated to CSI was excluded.

CONCLUSION

These results align with recent studies advocating cervical collar removal based on negative MDCT, emphasizing its potential to decrease the time that patients remain in C-collars and expedite hospital courses, including therapy and discharge. The study encourages consideration of MDCT-based protocols for timely pediatric CSI clearance, promoting patient care efficiency and informed medical decision-making.

Traumatic Brain Injury and Traumatic Spinal Cord Injury

OBJECTIVE

This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury.

LATEST DEVELOPMENTS

Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated.

ESSENTIAL POINTS

Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Utility of Magnetic Resonance Imaging for Ligamentous Injury in Cervical Spine Trauma: A 2-Year Consecutive Case Cohort

BACKGROUND

Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma.

METHODS

We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings.

RESULTS

Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n = 13) and falls (n = 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature.

CONCLUSIONS

MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

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.

Pediatric cervical spine clearance: A 10-year evaluation of multidetector computed tomography at a level 1 pediatric trauma center

INTRODUCTION

Efficient and accurate evaluation of the pediatric cervical spine (c-spine) for both injury identification and posttraumatic clearance remains a challenge. We aimed to determine the sensitivity of multidetector computed tomography (MDCT) for identification of cervical spine injuries (CSIs) in pediatric blunt trauma patients.

METHODS

A retrospective cohort study was conducted at a level 1 pediatric trauma center from 2012 to 2021. All pediatric trauma patients age younger than 18 years who underwent c-spine imaging (plain radiograph, MDCT, and/or magnetic resonance imaging [MRI]) were included. All patients with abnormal MRIs but normal MDCTs were reviewed by a pediatric spine surgeon to assess specific injury characteristics.

RESULTS

A total of 4,477 patients underwent c-spine imaging, and 60 (1.3%) were diagnosed with a clinically significant CSI that required surgery or a halo. These patients were older, more likely to be intubated, have a Glasgow Coma Scale score of <14, and more likely to be transferred in from a referring hospital. One patient with a fracture on radiography and neurologic symptoms got an MRI and no MDCT before operative repair. All other patients who underwent surgery including halo placement for a clinically significant CSI had their injury diagnosed by MDCT, representing a sensitivity of 100%. There were 17 patients with abnormal MRIs and normal MDCTs; none underwent surgery or halo placement. Imaging from these patients was reviewed by a pediatric spine surgeon, and no unstable injuries were identified.

CONCLUSION

Multidetector computed tomography appears to have 100% sensitivity for detecting clinically significant CSIs in pediatric trauma patients, regardless of age or mental status. Forthcoming prospective data will be useful to confirm these results and inform recommendations for whether pediatric c-spine clearance can be safely performed based on the results of a normal MDCT alone.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Factors Associated with Overutilization of Computed Tomography of the Cervical Spine

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model. Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule. Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture. Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.

Canal narrowing in adult patients with cervical spinal cord injury without computed tomography evidence of trauma

PURPOSE

Cervical spinal cord injury can be a particularly devastating sequela of trauma. The purpose of this study was to describe the imaging findings of adult patients with cervical spinal cord injury without computed tomography evidence of trauma (SCIWOCTET).

METHODS

All adult patients (≥18 years) treated for acute cervical SCIWOCTET at a single Level I adult trauma center over an eight-year period were retrospectively identified. CT imaging was evaluated for degenerative changes narrowing the midsagittal canal diameter (SCD) of the cervical spine and relative congenital cervical stenosis (CCS; congenital narrowing of the SCD <13 mm). Magnetic resonance imaging (MRI) scans were evaluated for signal intensity change (SIC) suspicious for cord edema/contusion as well as ligamentous injury, hemorrhage, and epidural hematoma.

RESULTS

Ninety-six patients with cervical SCIWOCTET met inclusion criteria. The most common mechanism of injury was fall from standing (47.9%). On CT, 86 patients (89.6%) had CCS. Degenerative changes were present in 95 patients (99.0%). In 98/99 patients (99.0%), the point of narrowest cervical SCD was ≤8 mm. On MRI, 79 patients (82.3%) demonstrated signal intensity change (SIC) indicative of cord edema/contusion, while 16 (16.7%) had ligamentous injury. Intramedullary cord hemorrhage was seen in two patients (2.1%) and epidural hematoma in three (3.1%).

CONCLUSION

Degenerative changes or CCS may narrow the minimum cervical SCD beyond the threshold at which low-energy trauma results in C-SCI. Adult patients with cervical spinal stenosis, whether congenital and/or degenerative, and neurologic findings referable to the cervical spine should be assessed for C-SCI.

Geriatric Odontoid Fractures: Treatment Algorithms of the German Society for Orthopaedics and Trauma Based on Expert Consensus and a Systematic Review

STUDY DESIGN

Systematic review/expert consensus.

OBJECTIVES

Fractures of the axis represent the most frequent injury of the spine in elderly patients. Both, operative and non-operative treatment are associated with a high rate of complications and mortality. The aim of this article was to summarize the current literature on the management of odontoid fractures in geriatric patients and to weigh it based on an expert consensus process.

METHODS

In a joint consensus process, members of the Spine Section of the German Orthopaedic and Trauma Society (DGOU) aimed to formulate recommendations for the diagnostic workup and treatment of odontoid fractures in geriatric patients. Based on the previously published recommendations, this article is an updated version with incorporating a systematic review of the recent literature.

RESULTS

Based on the new data available, the recommendations established in the initial consensus process were adapted.

CONCLUSIONS

Computed tomography represents the diagnostic standard for patients with suspected injuries of the upper cervical spine. Anderson/D'Alonzo odontoid fractures type 1, non-displaced type 2, and type 3 can be treated conservatively. Even non-unions do not necessarily result in poor clinical outcome. In Anderson/D'Alonzo type 2 fractures, surgical therapy offers the advantage of relatively safe osseous healing with no increased complication rate even in elderly patients and can thus be recommended. In very high aged patients, however, a case-by-case decision should be made. When surgical stabilization of osteoporotic odontoid fractures is indicated, posterior techniques are biomechanically advantageous and can be considered the standard.

Feasibility analysis of high pitch cervical spine CT in uncooperative patients with acute cervical spine trauma: An initial experience

Cervical computed tomography (CT) often suffers from examination failure in uncooperative patients with acute cervical spinal trauma. Therefore, this study aimed to evaluate the feasibility of using high-pitch cervical CT (HP-CT) in such populations. A total of 95 patients with acute neck/head-neck trauma who underwent HP-CT (n = 29) or standard cervical CT (SD-CT, n = 66) from October 2020 to June 2021 were included in this study. Differences in patient characteristics between the HP-CT group and the SD-CT group were firstly compared. Then, the objective image quality based on the mean score of the signal-to-noise ratio (SNR)/contrast noise ratio (CNR) was evaluated, while double-blind five-point scoring was adopted for the subjective evaluation. Finally, radiation doses in HP-CT and SD-CT were compared. Furthermore, the Student t test and/or Mann-Whitney U test were performed to analyze differences in patient characteristics, image quality, and radiation dose between the two regimes. A total of 17 cases of cervical spine fractures were found in 95 patients, including 6 cases in the HP-CT group and 11 cases in the SD-CT group. The average age of patients who received HP-CT was higher than that of those who received SD-CT, and the scan time using HP-CT was shorter than that SD-CT. The differences were statistically significant (both, P < .05). In addition, there was no significant difference between HP-CT and SD-CT in terms of sex, body mass index, field of view (FOV), and scan length (all P > .05). The SNR/CNR at the middle and upper neck was not significantly different between HP-CT and SD-CT (all P > .05). However, the SNR/CNR at the lower neck in HP-CT was lower than that in SD-CT (all P < .05). There was no significant difference in the subjective scores between HP-CT and SD-CT images in both the soft tissue and bone window (P = .129 and 0.649, respectively). The radiation dose in HP-CT was lower than that in SD-CT (all P < .05). With a scan time reduction of 73%, radiation dose reduction of 10%, and similar image quality, high-pitch cervical CT was of feasibility to evaluate cervical spine injury in uncooperative patients with acute cervical spine trauma.

Accuracy of ct evaluation for cervical spine clearance in the ground level fall population - a retrospective cohort study

Background

Clinically occult cervical spine (CS) injuries are well described in blunt trauma, however delay in identifying these injuries and clearing the CS can result in morbidity. Our study examines the ground level fall (GLF) population to analyze whether computed tomography (CT) alone can rule out unstable injury in this group with lower force mechanism.

Methods

This is a single center, retrospective cohort study. All GLF patients in the institutional trauma registry between 6/1/2012 through 12/31/2019 were included. These comprise all trauma patients evaluated in the emergency department with Injury Severity Score (ISS) > 0, including both activations and consults with both clinical and radiological spine evaluation. Patients who could not be cleared by National Emergency X-ray Utilization Study (NEXUS) criteria underwent CT. Patients with CT or clinical suspicion of cord or ligamentous injury underwent MRI. CT occult injuries were identified by MRI and clinical exam, with MRI identifying all unstable injuries.

Results

Sixty-nine (2.0%) of patients had CS injury without acute CT abnormality. Of these, 11 (0.3%) required surgery and were considered unstable. All patients who required surgery had a neurologic deficit. Negative predictive value (NPV) of CT for unstable CS injury was 99.7%. The combination of acute CT findings and neurologic deficit ruled out unstable CS injury with 100% NPV.

Conclusion

In the GLF population, CT alone rules out unstable CS injury with high, but not perfect NPV. The combination of absence of acute CT findings and acute neurologic deficits rules out unstable CS injury with 100% NPV.

Supplementary information

The online version contains supplementary material available at 10.1186/s12873-022-00657-x.

Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes

OBJECTIVE

Magnetic resonance imaging (MRI) is often used in practice to investigate for cord or discoligamentous injury following blunt trauma and a normal computed tomography (CT). This study investigates the MRI findings and surgical outcomes of patients in this cohort.

METHODS

Retrospective analysis of patients following trauma with suspected cervical spine injury from 2016 to 2019. Inclusion criteria included patients receiving a normal CT of the cervical spine and subsequent MRI due to cervical spine injury symptomatology (persistent tenderness and/or neurology). Inclusion criteria included: age ≥16 years, alert and <72 h from CT to MRI. Mann-Whitney and χ2 statistical analysis techniques were employed.

RESULTS

Two hundred and twenty-eight patients with persistent midline tenderness and/or persistent neurology following blunt trauma and negative CT report were included. One hundred and eighty-one patients received an MRI for persistent tenderness of which 35 revealed abnormal MRI findings. Twenty-one cases required no treatment, 14 cases were treated with a rigid collar with no patients requiring operative management. Forty-seven patients received an MRI for neurological symptoms following blunt trauma and negative CT, with 11 abnormal MRI findings. Management included no treatment (three cases), application of rigid collar (six cases) and operative management (two cases).

CONCLUSION

No alert neurologically intact patient with 'persistent tenderness only' received operative management following a normal CT examination. While MRI is sensitive for detecting soft tissue injuries, the prevalence for detecting clinically significant cervical spine injury in blunt trauma patients in the absence of neurology is low. The utility of MRI in this cohort is questionable considering prolonged spinal immobilisation is not without harm.

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.

Computed tomography-occult discoligamentous instability following blunt cervical spine trauma

Plain CT is routinely ordered following blunt trauma of the cervical spine, and performs well in the exclusion of significant bony injuries. MRI is reserved for cases of suspected neural or posterior ligamentous compromise, and when other imaging modalities are contraindicated. There are patients however, with unremarkable radiology, and without suggestive clinical features, who are later found to have significant discoligamentous instability. In this report, we present two such cases. In both instances, worsening neurological symptoms prompted follow-up imaging, that demonstrated interval development of sub-axial cervical spondylolisthesis, requiring surgery and instrumentation. We identify and discuss radiological features that may be associated with occult discoligamentous injury, and highlight them as avenues for future research. These may prove useful in stratifying at-risk patients for further imaging in the acute setting.

Emergency management of older people with cervical spine injuries: an expert practice review

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.

Utilization of computerized tomography and magnetic resonance imaging for diagnosis of traumatic C-Spine injuries at a level 1 trauma center: A retrospective Cohort analysis

Background

Computerized tomography (CT) is a common imaging modality for trauma patients, but there is debate regarding the role of magnetic resonance imaging (MRI) in cervical (C)-spine clearance. We aim to investigate the utilization of CT and MRI imaging in traumatic C-spine clearance and associated outcomes on patients who undergo both imaging modalities.

Methods

A 4-year retrospective review was performed to evaluate the trauma patient imaging algorithm at our institution. The algorithm required CT as a screening examination for traumatic injury patients who are unexaminable because of distracting injury, altered mental status, an abnormal neurological examination, and/or central neck pain. MRI was performed after CT in patients with C-spine injuries identified on CT, those who remained unexaminable, had an abnormal neurological examination, or experienced persistent central neck tenderness. Univariate analyses and adjusted multivariate logistic regression were performed with significance defined as p < 0.05.

Results

805 patients were analyzed. Compared to MRI, CT had a sensitivity of 50.2%, specificity of 76.6%, positive predictive value of 69.7%, and negative predictive value of 59.0% in detecting C-spine injuries. CT and MRI differed significantly in their ability to detect C-spine soft tissue injuries and C1 vertebral fractures (p < 0.05).

Conclusions

MRI is more capable of detecting soft tissue injuries whereas CT is superior in detecting vertebral fractures. Our findings support the need to utilize CT and MRI in conjunction to detect both bony and soft tissue C-spine injuries in traumatically injured patients, who are either unexaminable, have an abnormal neurologic examination, or ongoing central neck tenderness.

Geriatric clinical screening tool for cervical spine injury after ground-level falls

BACKGROUND

A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI.

METHODS

The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set.

RESULTS

Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%).

CONCLUSION

Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.

CT Cervical Spine Fracture Detection Using a Convolutional Neural Network

BACKGROUND AND PURPOSE

Multidetector CT has emerged as the standard of care imaging technique to evaluate cervical spine trauma. Our aim was to evaluate the performance of a convolutional neural network in the detection of cervical spine fractures on CT.

MATERIALS AND METHODS

We evaluated C-spine, an FDA-approved convolutional neural network developed by Aidoc to detect cervical spine fractures on CT. A total of 665 examinations were included in our analysis. Ground truth was established by retrospective visualization of a fracture on CT by using all available CT, MR imaging, and convolutional neural network output information. The ĸ coefficients, sensitivity, specificity, and positive and negative predictive values were calculated with 95% CIs comparing diagnostic accuracy and agreement of the convolutional neural network and radiologist ratings, respectively, compared with ground truth.

RESULTS

Convolutional neural network accuracy in cervical spine fracture detection was 92% (95% CI, 90%-94%), with 76% (95% CI, 68%-83%) sensitivity and 97% (95% CI, 95%-98%) specificity. The radiologist accuracy was 95% (95% CI, 94%-97%), with 93% (95% CI, 88%-97%) sensitivity and 96% (95% CI, 94%-98%) specificity. Fractures missed by the convolutional neural network and by radiologists were similar by level and location and included fractured anterior osteophytes, transverse processes, and spinous processes, as well as lower cervical spine fractures that are often obscured by CT beam attenuation.

CONCLUSIONS

The convolutional neural network holds promise at both worklist prioritization and assisting radiologists in cervical spine fracture detection on CT. Understanding the strengths and weaknesses of the convolutional neural network is essential before its successful incorporation into clinical practice. Further refinements in sensitivity will improve convolutional neural network diagnostic utility.

Impact of MRI to clear the cervical spine after a negative CT for suspected spine trauma

PURPOSE

To describe the clinical presentation of trauma patients receiving a negative cervical spine MRI (CSMRI) after cervical spine CT (CSCT) without acute findings and calculate the associated costs.

METHODS

Our cohort consisted of 55 retrospectively reviewed consecutive trauma patients with CSMRI performed between October 2016 and March 2020, who had negative CSCT within 7 days of CSMRI and no other clinically significant injuries. Our outcome was the cost related to CSMRI, estimated by CSMRI charges and the charges related to additional hours of prolonged hospital stay from CT until MRI.

RESULTS

The most common presenting mechanisms of injury were fall from standing (20/55, 36%), followed by motor vehicle accident (18, 33%). Indications for CSMRI included persistent neck pain (32/55, 58%), followed by recommendation from the radiologist (12, 22%), and neurological symptoms concerning for spine injury (9, 16%). An average of 11.2 h (median: 8.5, range: 0.2-25.4 h) passed from CSCT to CSMRI. Fifty-four (98%) of the CSMRI exams were completed within 24 h of the CSCT. The Medicare reimbursement for non-contrast CSMRI is $309 with the average cost for waiting in ED observation of $907. The total cost of CSMRI and associated wait time ranged from $325 to $2366 with an average of $1216 per patient.

CONCLUSIONS

The cost of negative CSMRI following a negative CSCT for cervical spine clearance in trauma patients without other significant injury is substantial. The length of time that trauma patients remain in observation in the cervical collar prior to the finalized MRI exam is not only distressing to the patient but also adds costs to health care systems in both time and resources.

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

BACKGROUND

Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI.

METHODS

We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement.

RESULTS

Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10).

CONCLUSION

Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI.

LEVEL OF EVIDENCE

Diagnostic, level II.

Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination

BACKGROUND

The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination.

METHODS

We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS.

RESULTS

A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47 years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18 min, p < 0.0001) and time to collar removal (median: 1042 vs. 49 min, p < 0.0001) were significantly greater at the US trauma center.

CONCLUSIONS

Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.

Traumatic Injuries to the Spinal Cord and Peripheral Nervous System

Both blunt and penetrating trauma can cause injuries to the peripheral and central nervous systems. Emergency providers must maintain a high index of suspicion, especially in the setting of polytrauma. There are 2 major classifications of peripheral nerve injuries (PNIs). Some PNIs are classically associated with certain traumatic mechanisms. Most closed PNIs are managed conservatively, whereas sharp nerve transections require specialist consultation for urgent repair. Spinal cord injuries almost universally require computed tomography imaging; some require emergent magnetic resonance imaging. Providers should work to minimize secondary injury. Surgical specialists are needed for closed reduction, surgical decompression, or stabilization.

Is magnetic resonance imaging becoming the new computed tomography for cervical spine clearance? Trends in magnetic resonance imaging utilization at a Level I trauma center

BACKGROUND

Increasing evidence supports the limited use of magnetic resonance imaging (MRI) for cervical spine (C-spine) clearance following blunt trauma. We sought to characterize the utilization of MRI of the C-spine at a Level I trauma center.

METHODS

All blunt trauma patients undergoing a computed tomography (CT) of the C-spine between January 2009 and December 2018 were reviewed. The CT and MRI results, demographics, clinical presentation, subspecialty consultations, and interventions were recorded. The MRI results were considered clinically significant if they resulted in cervical thoracic orthosis/halo placement or surgical intervention. Linear regression models were utilized to identify trends.

RESULTS

There were 9,101 patients that underwent a CT of the C-spine, with 513 (5.6%) being positive for an acute injury. MRI was obtained for 375 (4.1%) of patients. A linear increase in the proportion of patients undergoing an MRI was noted, from 0.9% in 2009 to 5.6% in 2018 (p < 0.01). Of the 513 patients with a positive CT, 290 (56.5%) had an MRI. In 40 (13.8%) of them, the CT demonstrated a minor injury. Clinically significant MRI findings were noted only in two (5.0%) of the 40 patients, and both had a neurologic deficit on initial examination. Of the 8,588 patients with a negative CT, 85 (1.0%) underwent an MRI. Of those, 9 (10.6%) had a clinically significant MRI with all but one presenting with a neurological deficit.

CONCLUSION

MRI is increasingly utilized for C-spine clearance following blunt trauma. MRI was exceedingly unlikely to demonstrate a clinically significant finding in the absence of a neurological deficit, when the CT was negative or included minor injuries. Trauma centers are encouraged to constantly evaluate their own practices and intervene with education and collaboration to limit the excessive use of unnecessary resources.

LEVEL OF EVIDENCE

Therapeutic/Care Management Study, Level III or IV. Diagnostic test, level IV.

Cervical spine clearance after blunt trauma: current state of the art

No definite consensus exists for the clearance of the cervical spine (C-spine) after blunt trauma, despite many validated algorithms, recommendations and guidelines. We intend to answer the most relevant questions with which physicians are confronted when clearing C-spines after blunt trauma in emergency departments (EDs). To exclude significant C-spine injuries we designed an algorithm to be compatible with clinical practice, to simplify patient management and avoid unrewarding evaluation.

We conducted an exploratory PubMed search including articles published from January 2000 to October 2018. Keywords used were “cervical spine”, “injury”, “clearance”, “Canadian C-spine Rule”, “CCR” and “national emergency x-radiography utilization study”. Clinical and experimental studies were included in a detailed review.

We based our literature review on 33 articles. While answering fundamental triage questions from daily clinical practice, the current literature is discussed in detail. We designed an algorithm for the C-spine clearance suitable for any trauma centre with a high-quality multiplanar reconstruction computerized tomography (CT) scan continuously available.

The high sensitivity of the Canadian C-spine Rule (CCR) prevents missing C-spine injuries while limiting the amount of unnecessary radiologic examinations. Plain radiographs were fully abandoned for C-spine clearance. A negative CT scan is sufficient to clear the majority of C-spine injuries and allows for collar removal. In case of motor symptoms or radio-clinical discrepancy, the advice of a specialized spine surgeon must be requested. Magnetic resonance imaging must not be routinely used. Neck pain despite negative imaging is not a reason to delay removal of stiff cervical collars.

Cite this article: EFORT Open Rev 2020;5:253-259. DOI: 10.1302/2058-5241.5.190047

Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients

BACKGROUND

Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature.

METHODS

In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients.

RESULTS

For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.

Evaluating the Cervical Spine in the Blunt Trauma Patient

Following a blunt trauma, the goal of the cervical spine evaluation is to identify any injuries that might require active management: either through continued use of a collar or surgical stabilization. This is achieved through a step-wise approach that considers the nature of the patient's trauma, presenting complaints, distracting injuries and capacity to cooperate with the examination. In the last 15 to 20 years, technological advances in radiographic imaging have improved clinicians' abilities to certify the cervical spine as free of injury following blunt trauma. Within the last decade, the use of CT has supplanted plain radiograph imaging as the standard screening modality. Although MRI is more sensitive than CT in identifying occult cervical injury, particularly ligamentous or soft-tissue trauma, the standard addition of MRI to CT evaluation alone does not significantly increase the detection of clinically important cervical injuries.

Single-lateral cervical radiograph in pediatric trauma is equivalent to multiple views

BACKGROUND

Cervical spine injuries (CSI) are rare within the pediatric population. Due to the significant consequences of missed CSI, children are often imaged excessively. In an attempt to decrease imaging of the cervical spine in children, we reviewed abnormal cervical radiographs (XR) to determine if the diagnosis of CSI could be made using a single-lateral cervical radiograph (LAT). Furthermore, we reviewed cervical computed tomography (CT) and magnetic resonance imaging (MRI) to ensure there were no missed CSI.

METHODS

Electronic medical records of trauma patients treated at a Level I Pediatric Trauma Center with abnormal XR findings followed by confirmatory CT or MRI between 2012 and 2017 were reviewed. All abnormal imaging on XR was compared with the LAT. In addition, all abnormal CTs and MRIs were reviewed to ensure there were no false negative XR.

RESULTS

A total of 3,735 XR were performed with 26 abnormal interpretations. All bony CSI were visualized on LAT. Confirmatory imaging found 13 (50%) were false positive and 13 (50%) were true positive. Secondary analysis of CT identified 12 injuries with prior XR; 8 of 12 LAT identifying the injury and 4 of 12 false positive on CT. Secondary analysis of MRI identified nine injuries with prior XR; 5 of 9 LAT identifying the injury. The four false-negative reads on MRI were ligamentous injuries.

CONCLUSION

Radiographs are commonly performed when evaluating CSI. In our population, initial assessment with a single LAT was equivalent to a multiple view XR. On secondary review, the only false-negative LAT reports were due to ligamentous injuries. This data suggests limiting exposure to LAT would accomplish the goal of reducing imaging without missing bony CSI and when ligamentous injury is suspected MRI should be the confirmatory study rather than CT.

LEVEL OF EVIDENCE

Diagnostic Test, level III.

Imaging of Spine Trauma

Every year in North America, approximately 3 million patients are evaluated for spinal injury. Of blunt trauma patients presenting to the emergency department, 3% to 4% will have a cervical spine injury, and up to 18% will suffer a thoracolumbar spine injury. Failure to identify an unstable spine injury can lead to devastating outcomes.

Spectrum of diagnostic errors in cervical spine trauma imaging and their clinical significance

PURPOSE

To describe and categorize diagnostic errors in cervical spine CT (CsCT) interpretation performed for trauma and to assess their clinical significance.

METHODS

All CsCTs performed for trauma with diagnostic errors that came to our attention based on clinical or imaging follow-up or quality assurance peer review from 2004 to 2017 were included. The number of CsCTs performed at our institution during the same time interval was calculated. Errors were categorized as spinal/extraspinal, involving osseous/soft tissue structures, by anatomical site and level. Images were reviewed by a radiologist and two spine surgeons. For each error, the need for surgery, immobilization, CT angiogram of the neck, and MRI was assessed; if any of these were needed, the error was considered clinically significant.

RESULTS

Of an approximate total 59,000 CsCTs, 56 reports containing diagnostic errors were included. Twelve were extraspinal, and 44 were spinal (26 fractures, 15 intervertebral disc protrusions, two subluxations, one lytic bone lesion). The most common sites of spinal fractures were vertebral body (n = 10) and transverse process (n = 8); the most common levels were C5 (n = 8) and C7 (n = 6). All (n = 26) fractures and two atlantooccipital subluxations were considered clinically significant, including three patients who would have required urgent surgical stabilization (two subluxations and one facet fracture). Two transverse processes fractures did not alter the need for surgical intervention/surgical approach, immobilization, or MRI.

CONCLUSIONS

In our study, 66% of spinal diagnostic errors on CsCT were considered clinically significant, potentially altering clinical management. Transverse process and vertebral body fractures were commonly missed.

Current Challenges in the Use of Computed Tomography and MR Imaging in Suspected Cervical Spine Trauma

There is controversy regarding the optimal imaging strategy in adult blunt trauma patients for suspected cervical spine trauma. Some investigators recommend negative computed tomography (CT) alone to clear the cervical spine in adult blunt trauma patients, while others insist that MR imaging is necessary, especially among obtunded adult blunt trauma patients. CT is an excellent imaging modality for bony cervical spine injury; however, there is a nonzero rate of clinically significant cervical spine injuries missed on CT. MR imaging has high sensitivity for soft tissue cervical spine injuries, but low specificity for the rare isolated unstable ligamentous cervical spine injury.

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey

BACKGROUND

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.

METHODS

A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.

RESULTS

Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.

CONCLUSION

For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.

LEVEL OF EVIDENCE

Diagnostic tests or criteria, level II.

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma

STUDY OBJECTIVE

Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population.

METHODS

A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies.

RESULTS

The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed.

CONCLUSION

MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.