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.

Intensive Care Physician-Led Clearance of the Cervical Spine: A Retrospective Review of the Utility of a Normal Cervical CT Scan for Safe Removal of Hard Collars by Critical Care Physicians

Background: Cervical spine clearance in intubated patients due to blunt trauma remains contentious. Accumulating evidence suggests that a normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department. However, whether this strategy can safely be employed by critical care physicians with intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, has not been definitively studied. Methods: A retrospective review of 730 intubated victims of trauma who presented to the Level 1 Trauma center of a tertiary hospital was conducted. The rates of missed cervical injuries in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine, were reviewed. Secondary outcomes included rates of collar-related complications. Results: Three hundred and fifty patients had their cervical collars removed by Trauma ICU doctors based on a high-quality, radiologist-interpreted normal CT cervical spine. Seventy percent of patients were sedated and/or comatose at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%. Conclusion: Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be associated with increased complications. An algorithm is suggested to assist critical care decision-making in this patient cohort.

Emergency MRI in Spine Trauma of Children and Adolescents-A Pictorial Review

Severe spinal trauma is uncommon in the pediatric population, but due to the potentially devastating consequences of missed injury, it poses a diagnostic challenge in emergency departments. Diagnostic imaging is often needed to exclude or confirm the injury and to assess its extent. Magnetic resonance imaging (MRI) offers an excellent view of both bony and soft tissue structures and their traumatic findings without exposing children to ionizing radiation. Our pictorial review aims to demonstrate the typical traumatic findings, physiological phenomena, and potential pitfalls of emergency MRI in the trauma of the growing spine.

Diagnostic Benefit of MRI for Exclusion of Ligamentous Injury in Patients with Lateral Atlantodental Interval Asymmetry at Initial Trauma CT

Background Cervical spine CT is regularly performed to exclude cervical spine injury during the initial evaluation of trauma patients. Patients with asymmetry of the lateral atlantodental interval (LADI) often undergo subsequent MRI to rule out ligamentous injuries. The clinical relevance of an asymmetric LADI and the benefit of additional MRI remain unclear. Purpose To evaluate the diagnostic benefit of additional MRI in patients with blunt trauma who have asymmetry of the LADI and no other cervical injuries. Materials and Methods Patients who underwent cervical spine CT during initial trauma evaluation between March 2017 and August 2019 were retrospectively evaluated. Those who underwent subsequent MRI because of LADI asymmetry of 1 mm or greater with no other signs of cervical injury were identified and reevaluated by two readers blinded to clinical data and initial study reports regarding possible ligamentous injuries. Results Among 1553 patients, 146 (9%) had LADI asymmetry of 1 mm or greater. Of these, 46 patients (mean age ± standard deviation, 39 years ± 22; 28 men; median LADI asymmetry, 2.4 mm [interquartile range, 1.8-3.1 mm]) underwent supplementary MRI with no other signs of cervical injury at initial CT. Ten of the 46 patients (22%) showed cervical tenderness at clinical examination, and 36 patients (78%) were asymptomatic. In two of the 46 patients (4%), MRI revealed alar ligament injury; both of these patients showed LADI asymmetry greater than 3 mm, along with cervical tenderness at clinical examination, and underwent treatment for ligamentous injury. In 13 of the 46 patients (28%), signal intensity alterations of alar ligaments without signs of rupture were observed. Four of these 13 patients (31%) were subsequently treated for ligamentous injury despite being asymptomatic. Conclusion Subsequent MRI following CT of the cervical spine in trauma patients with lateral atlantodental interval asymmetry may have diagnostic benefit only in symptomatic patients. In asymptomatic patients without proven cervical injuries, subsequent MRI showed no diagnostic benefit and may even lead to overtreatment. © RSNA, 2021 Online supplemental material is available for this article.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Functional Outcomes of Subaxial Spine Injuries Managed With 2-Level Anterior Cervical Corpectomy and Fusion: A Prospective Study

Objective

To evaluate the results of operative management of subaxial spine injuries managed with 2-level anterior cervical corpectomy and fusion with a cervical locking plate and autologous bone–filled titanium mesh cage.

Methods

This study included 23 patients with a subaxial spine injury who matched the inclusion criteria, underwent 2-level anterior cervical corpectomy and fusion at our institution between 2013 and 2016, and were followed up for neurological recovery, axial pain, fusion, pseudarthrosis, and implant failure.

Results

According to Allen and Ferguson classification, there were 9 cases of distractive extension; 4 of compressive extension; 3 each of compressive flexion, vertical compression, and distractive flexion; and 1 of lateral flexion. Sixteen patients had a score of 6 on the Subaxial Injury Classification system, and the rest had a score of more than 6. The mean follow-up period was 19 months (range, 12–48 months). Neurological recovery was observed in most of the patients (78.21%). All patients experienced relief of axial pain. None of the patients received a blood transfusion. Twenty-one patients (91.3%) showed solid fusion and 2 (8.69%) showed possible pseudarthrosis, with no complications related to the cage or plate.

Conclusion

Two-level anterior cervical corpectomy and fusion, along with stabilization with a cervical locking plate and autologous bone graft-filled titanium mesh cage, can be considered a feasible and safe method for treating specific subaxial spine injuries, with the benefits of high primary stability, anatomical reduction, and direct decompression of the spinal cord.

Management of irreducible unilateral facet joint dislocations in subaxial cervical spine: two case reports and a review of the literature

Background

Skeletal and soft tissue damage are often associated with unilateral facet dislocations, which undoubtedly lead to instability of the spine and further increase difficulties in cervical reduction. This type of irreducible facet dislocation is usually accompanied with potential catastrophic consequences including neurological deficit and severe disability. Therefore, a consistent and evidence-based treatment plan is imperative.

Case presentation

The literature regarding the management of traumatic unilateral locked cervical facet dislocations was reviewed. Two patient cases (a 30-year-old Asian man and a 25-year-old Asian woman) who suffered irreducible cervical facet dislocations were presented. These two patients received surgical treatments including posterior reduction by poking facet joints, adjacent spinous process fixation by wire rope banding, anterior plate fixation, and intervertebral fusion after the failure of skull traction and closed reduction. At the postoperative 24-month follow-up, intervertebral fusion was achieved and our patients’ neurological status improved based on the American Spinal Injury Association scale, compared with their preoperative status.

Conclusions

Unilateral facet joint dislocations of subaxial cervical spine are difficult to reduce when complicated with posterior facet fractures or ligamentous injury. Magnetic resonance imaging can be beneficial for identifying ventral and dorsal compressive lesions, as well as ligamentous or capsule rupture. The combination of posterior reduction and anterior fixation with fusion has advantages in terms of clinical safety, ease of operation, and less iatrogenic damage.

Utility of Adding Magnetic Resonance Imaging to Computed Tomography Alone in the Evaluation of Cervical Spine Injury: A Propensity-Matched Analysis

STUDY DESIGN

Adult patients who received computed tomography (CT) alone or CT-magnetic resonance imaging (MRI) for the evaluation of cervical spine injury.

OBJECTIVE

To evaluate the utility of CT-MRI in the diagnosis of cervical spine injury using propensity-matched techniques.

SUMMARY OF BACKGROUND DATA

The optimal evaluation (CT alone vs. CT and MRI) for patients with suspected cervical spine injury in the setting of blunt trauma remains controversial.

METHODS

The primary outcome was the identification of a cervical spine injury, with decision for surgery and change in management considered secondarily. A propensity score was developed based on the likelihood of receiving evaluation with CT-MRI, and this score was used to balance the cohorts and develop two groups of patients around whom there was a degree of clinical equipoise in terms of the imaging protocol. Logistic regression was used to evaluate for significant differences in injury detection in patients evaluated with CT alone as compared to those receiving CT-MRI.

RESULTS

Between 2007 and 2014, 8060 patients were evaluated using CT and 693 with CT-MRI. Following propensity-score matching, each cohort contained 668 patients. There were no significant differences between the two groups in baseline characteristics. The odds of identifying a cervical spine injury were significantly higher in the CT-MRI group, even after adjusting for prior injury recognition on CT (odds ratios 2.6; 95% confidence interval 1.7-4.0; P < 0.001). However, only 53/668 patients (8%) in the CT-MRI group had injuries identified on MRI not previously recognized by CT. Only a minority of these patients (n = 5/668, 1%) necessitated surgical intervention.

CONCLUSION

In this propensity-matched cohort, the addition of MRI to CT alone identified missed injuries at a rate of 8%. Only a minority of these were serious enough to warrant surgery. This speaks against the standard addition of MRI to CT-alone protocols in cervical spine evaluation after trauma.

LEVEL OF EVIDENCE

3.

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.

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

BACKGROUND

For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury.

METHODS

This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings.

RESULTS

Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease.

CONCLUSIONS

For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.

LEVEL OF EVIDENCE

Diagnostic tests, level II.

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.

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.

Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm

BACKGROUND

Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient.

METHODS

The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies.

RESULTS

Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting.

CONCLUSION

Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial.

Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care

Spinal cord injury is uncommon in the pediatric population with a lifelong impact for the patient and family. Knowledge of spine embryology, mechanisms of injury that lead to specific injuries, appropriate utilization of radiographic imaging based on suspected injury, prehospital and hospital management of various spinal cord injuries is essential for providers attending to traumatically injured patients. In addition to patients who present with soft tissue and bony injuries diagnosed with clinical examination and confirmed with computed tomography or magnetic resonance imaging, it is important to note that the pediatric population is at a higher risk for spinal cord injury without radiographic abnormality than the adult population. Patients who survive the acute phase of injury face long-term rehabilitation and have an increased risk of depression and mortality. Understanding the long-term sequelae of spinal cord injuries is also an essential management component of traumatically injured children. A program that provides long-term rehabilitation, psychosocial and spiritual support, and adaptive environmental supports gives patients and their families the best opportunity for long-term recovery. A review of the current literature on the diagnosis, management, and follow-up of pediatric spinal cord injury is presented.

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.

A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT

Clearance of cervical spine injury (CSI) in the obtunded or comatose blunt trauma patient remains controversial. In patients with unreliable physical examination and no evidence of CSI on computed tomography (CT), magnetic resonance imaging of the cervical spine (CS-MRI) is the typical follow-up study. There is a growing body of evidence suggesting that CS-MRI is unnecessary with negative findings on a multi-detector CT (MDCT) scan. This review article systematically analyzes current literature to address the controversies surrounding clearance of CSI in obtunded blunt trauma patients. A literature search through MEDLINE database was conducted using all databases on the National Center for Biotechnology Information (NCBI) website (www.ncbi.nlm.nih.gov) for keywords: "cervical spine injury," "obtunded," and "MRI." The search was limited to studies published within the last 10 years and with populations of patients older than 18 years old. Eleven studies were included in the analysis yielding data on 1535 patients. CS-MRI detected abnormalities in 256 patients (16.6%). The abnormalities reported on CS-MRI resulted in prolonged rigid c-collar immobilization in 74 patients (4.9%). Eleven patients (0.7%) had unstable injury detected on CS-MRI alone that required surgical intervention. In the obtunded blunt trauma patient with unreliable clinical examination and a normal CT scan, there is still a role for CS-MRI in detecting clinically significant injuries when MRI resources are available. However, when a reliable clinical exam reveals intact gross motor function, CS-MRI may be unnecessary.

Subaxial cervical spine trauma: evaluation and surgical decision-making

Study Design Literature review. Objective To discuss the evaluation and management of subaxial cervical spine trauma (C3-7). Methods A literature review of the main imaging modalities, classification systems, and nonsurgical and surgical treatment performed. Results Computed tomography and reconstructions allow for accurate radiologic identification of subaxial cervical spine trauma in most cases. Magnetic resonance imaging can be utilized to evaluate the stabilizing discoligamentous complex, the nerves, and the spinal cord. The Subaxial Injury Classification (SLIC) is a new system that aids in injury classification and helps guide the decision-making process of conservative versus surgical treatment. Though promising, the SLIC system requires further validation. When the decision for surgical treatment is made, early decompression (less than 24 hours) has been associated with better neurologic recovery. Surgical treatment should be individualized based on the injury characteristics and surgeon's preferences. Conclusions The current state of subaxial cervical spine trauma is one of great progress. However, many questions remain unanswered. We need to continue to account for the individual patient, surgeon, and hospital circumstances that effect decision making and care.

Sixty-four-slice computed tomographic scanner to clear traumatic cervical spine injury: systematic review of the literature

PURPOSE

Cervical spine (CS) injury in blunt trauma is a prevalent and devastating complication. Clearing CS injuries in obtunded patients is fraught with challenges, and no single imaging modality or algorithm is both safe and effective. Increased time in c-spine precautions is associated with greater patient morbidity including increased ventilator associated pneumonia, delirium and ulceration. We systemically reviewed the literature to assess the effectiveness of 64-slice computed tomographic (CT) scanners in clearing traumatic CS injuries.

MATERIALS AND METHODS

Studies were identified using MEDLINE and Embase, the references of identified studies, international experts on CS clearance and authors of primary studies. Three reviewers independently selected and extracted data from studies that reported on both CT and MRI in traumatic CS injury.

RESULTS

We included five studies involving a total of 3443 patients; however, heterogeneity and lack of sample size precluded quantitative summation of the results. Qualitative assessment showed that 64-Slice CT scan, when applied within a set protocol, performed favourably in clearing injury.

CONCLUSIONS

Data suggests that using 64-slice CT scans on obtunded trauma patients with grossly intact motor function, in the context of a defined clearance protocol with interpretation by an experienced radiologist, may be sufficient to safely clear significant CS injury. A prospective study comparing MRI and 64-slice CT scan clearance in this population is necessary to corroborate these conclusions.

Cervical spine injury

Once a child is determined to be at risk of having a cervical spine injury, clinicians must take appropriate precautions to avoid potential worsening of neurologic deficits. Occasionally these decisions are made in the absence of adequate cervical spine imaging when dealing with a child's unstable airway or other life-threatening injuries. Furthermore, clinicians have to make decisions regarding appropriate diagnostic testing to evaluate for potential injury. Decisions regarding testing should take into consideration the clinical presentation of the patient, aiming to order appropriate testing for those at risk and avoid unnecessary testing for those without signs of cervical spine injury.