Cervical spine collar clearance in the obtunded adult blunt trauma patient

Abstract

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.

Physicians’ perception of alternative displays of clinical research evidence for clinical decision support – A study with case vignettes

“…(17, 18) Since then, it has been widely adopted for evidence-based inquiry, especially in the development of systematic reviews and clinical practice guidelines. (19–24) Clinicians have also been recommended to structure their patient-specific clinical questions according to PICO. (18, 25–29) Finally, information retrieval tools that structure queries according to the PICO format have shown promising results.…”

Cervical spinal clearance

“…With a retrospective study design, accurate capture of the presenting clinical examination in particular remains a challenge. In 2015 the Eastern Association for the Surgery of Trauma confronted this issue by performing a systematic review of the existing literature(23). They targeted a specific population, those who could not be cleared by the NEXUS low risk criteria due to being obtunded.…”

“…The contemporary evidence base is weak because of the small patient numbers and primarily retrospective design of many of the studies that are currently being used to drive practice(6-14). In 2015, the Eastern Association for the Surgery of Trauma published a comprehensive systematic review(7, 11, 12, 14-22) and practice management guidelines specifically for the obtunded adult blunt trauma patient(23). In summarizing five studies with a total of 1,017 patients meeting their entry criteria, the summary conclusion was that they would “conditionally recommend cervical collar removal after a negative high quality C-spine CT scan result alone”.…”

Sixty-four-slice computed tomographic scan to clear cervical spine injury: Remember to examine the patient before clearing

“…Several of the same key points were highlighted in recent guidelines released by the Eastern Association for the Surgery of Trauma (EAST) [12]. The very recent EAST guidelines conditionally recommend removing the cervical collar in the obtunded blunt trauma population after a negative high-quality CT (≥3-mm axial slice) with an acceptable missed injury rate of 0.3%.…”