The daunting task of “clearing” the cervical spine

Grunau, Brian; Dibski, Daniel; Hall, Jeremy

doi:10.2310/8000.2011.110397

Cited by 3 publications

(6 citation statements)

References 32 publications

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“…51,52 As outlined in our PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] 53 diagram (Fig. 2), 12 studies were included in the qualitative synthesis and data extraction.…”

Section: Resultsmentioning

confidence: 99%

“…The quality of the evidence was further reduced because of indirectness of evidence relative to our wide definition of obtunded (population), noncomparable institutional imaging protocols (intervention and comparator), and inconsistently reported and often unavailable outcomes. Publication bias was present, as there is at least one case report 51 noting neurologic change after collar clearance with a negative C-spine CT result. Moreover, across multiple institutions, we have encountered at least one case of neurologic change.…”

Section: Resultsmentioning

confidence: 99%

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Cervical spine collar clearance in the obtunded adult blunt trauma patient

Patel

Humble

Cullinane³

et al. 2015

Journal of Trauma and Acute Care Surgery

116

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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.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Cervical spine collar clearance in the obtunded adult blunt trauma patient

Patel

Humble

Cullinane³

et al. 2015

Journal of Trauma and Acute Care Surgery

116

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“…McCracken et al noted that the radiologist only reported 23% of FE to be inadequate compared with 80% found by the authors . The limitation of FE in the acute setting where muscle spasm‐limited range of motion is common has been highlighted by several case series/reports . These authors recommend FE be delayed for several days until muscle spasm has subsided, with immobilisation in the interim.…”

Section: Resultsmentioning

confidence: 99%

“…10 The limitation of FE in the acute setting where muscle spasmlimited range of motion is common has been highlighted by several case series/reports. [35][36][37] These authors recommend FE be delayed for several days until muscle spasm has subsided, with immobilisation in the interim.…”

Section: Active Flexion-extensionmentioning

confidence: 99%

Utility of flexion–extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine

Asha

2015

Emerg Medicine Australasia

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Detecting the presence of injuries to the cervical spine is an important component of the initial assessment of patients sustaining blunt trauma. A small proportion of cervical spine injuries consists of ligamentous disruption. Accurate detection of ligamentous injury is essential as it may result in sequelae including radiculopathy, quadriplegia and death. Flexion-extension (FE) radiography has traditionally been utilised for the detection of ligamentous injury in patients who have been cleared of bony injury. There are controversies surrounding the use of FE for alert patients with neck pain. There are studies that call into question the diagnostic accuracy of FE, the high proportion of inadequate FE images due to muscle spasm and the adverse effects of prolonged cervical collar immobilisation while awaiting FE. Other literature indicates that FE provides no additional diagnostic information following a multi-detector helical computed tomography. This review evaluates the literature on the utility of FE for the detection of ligamentous injury and explores alternate strategies for clearing the cervical spine of ligamentous injury.

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“…7 The EAST guidelines emphasized difficulty in reaching a conclusion due to heterogeneity of the population and small sample sizes in the studies they reviewed and possible publication bias, with several case reports describing unstable injuries missed using CT alone. [8][9][10] This study sought to determine if a negative 64-slice CT scan alone is sufficient to clear clinically significant CS injury in high-risk obtunded (GCS < 14) blunt trauma patients admitted to the intensive care unit (ICU). If a negative 64-slice CT scan is insufficient, we sought to determine whether a negative CT combined with gross movement Â 4 would be sufficient.…”

Section: Introductionmentioning

confidence: 99%

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

McCallum

McLaughlin

Hameed

et al. 2017

Trauma

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Objective: Clearance of cervical spine injury including ligamentous injury is of paramount importance as results of missed injury may have serious consequences. In obtunded patients, cervical spine clearance is challenging. This study sought to determine whether a negative 64-slice CT scan alone is sufficient to clear cervical spine injury. Patients and methods: All consecutive blunt trauma patients admitted to a regional (level 1) trauma center from 1 April 2008 to 31 March 2012 were screened for inclusion in this study. High-risk, GCS < 14, blunt trauma patients were included if they were admitted to the intensive care unit, had a negative 64-slice CT, and MRI of diagnostic quality. GCS was measured at the time of CT scan. Patients with a positive finding on CT scan were excluded. All images were reinterpreted by a trauma radiologist blinded to clinical outcome. Details of missed injuries and clinical impact were reported. The primary outcome was missed clinically significant injury, defined as any injury requiring an additional intervention including continued immobilization or surgery. Results: There were 5891 blunt trauma patients admitted to the ICU, 44 of whom met inclusion criteria. Patients had a median injury severity score of 35 and MRI three (2-9) days after CT. Eight of 44 (18%) patients had a positive finding on MRI and five of the findings were clinically insignificant. Three patients (7%) with focal neurologic findings on clinical exam had missed injuries requiring immobilization with a collar. Two of these patients had spine disease, which may have increased their injury risk. Conclusions: In high-risk obtunded blunt trauma patients admitted to the ICU, a negative 64-slice CT scan alone is insufficient to clear clinically significant cervical spine injury, with a missed clinically significant injury rate of 7%. When considered with symmetric motor function, a negative 64-slice CT scan may be sufficient. A prospective study is required to confirm these findings.

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The daunting task of “clearing” the cervical spine

Cited by 3 publications

References 32 publications

Cervical spine collar clearance in the obtunded adult blunt trauma patient

Cervical spine collar clearance in the obtunded adult blunt trauma patient

Utility of flexion–extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine

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

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