Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan—A meta-analysis and cohort study
Section snippets
Introduction and background
The safe management of cervical spine (CS) injury in a patient with multiple trauma is one of the major challenges faced by trauma surgeons. The incidence of cervical spine injury in the majority of blunt trauma is 2–4% [1] but rises to 34.4% in unconscious patients [2]; potentially resulting in long-term morbidity and carrying with it medico-legal repercussions.
“Clearing” the cervical spine implies declaring no significant injury and removing the spinal precautions based on clinical and/or
Objective; the clinical dilemma
In obtunded adult patients with blunt trauma, can a clinically significant injury be ruled out on the basis of a multidetector cervical spine CT scan being reported as normal?
Inclusion criteria
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Adult blunt trauma patients with altered sensorium/obtunded
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Multidetector CT of the cervical spine as the core imaging modality
Exclusion criteria
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Studies done using single-slice CT scanners (axial/helical with single -row of detectors)
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Indication for cervical spine MDCT other than altered sensorium
Literature search
The different sources searched are as follows.
- 1.
Electronic Indexed Bibliographic Databases
- 2.
Cochrane Database
- 3.
Grey literature
- 4.
Hand searches through references, relevant journals and correspondences
A search was carried out on
Results
The details of the literature search are evident from the flow chart (Fig. 1). Any study involving alert patients or where CS MDCT wasn’t core-imaging modality was excluded. A fair number of studies had to be excluded due the fact that the CT scanners were not of multidetector type. In order to have homogenous sample for the meta-analysis, few more studies involving a combination of single row and multidetector CT scanners were also excluded.
A total of 10 studies summarized in Table 1, Table 2
Methods
The medical records of 108 patients presenting to the ED of St Georges hospital in London between October 2007 and December 2008 were retrospectively reviewed. October 2007 was the date from when MDCT was considered the investigation of choice for assessing cervical spine in trauma patients. PACS (Picture Archiving and Communication System) and EPR (Electronic Patient Records) systems were reviewed for the patient records and reports of the imaging in addition to a hand search of the hospital
Discussion
Cervical spine computed tomography from the occiput to T1 with sagittal and coronal reconstructions is now advocated to be the primary screening modality in all the patients who cannot have CS clearance on clinical grounds [12]. Once the patient has a normal CT scan of the CS, clinical clearance is required in alert patients to exclude ligamentous injury. Absence of pain on full range of cervical spine movement leads to clinical clearance and CS immobilization is discontinued.
If the patient is
Conclusion
The ideal imaging modality should not only be able to detect a ligamentous CS injury but should also enable the reporting clinician to comment on the stability or not of the cervical spine as this might in turn require a significant change in patient management.
A reference standard against which CS-CT might be compared has not yet been agreed upon. This significantly limits the quality of the various studies done on this topic as a wide variety of reference standards have been used including
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Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study
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Principles of CT: Multislice CT
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Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern association for the surgery of trauma practice management guidelines committee
Journal of Trauma
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2022, World NeurosurgeryCitation Excerpt :The real question is if they underestimated clinically significant unstable spinal injuries.4,16 In comatose patients, or head-injured patients with alternated sensorium, most of the C-spine can be safely cleared with CT of the C-spine.4,17,18 For cervical ligamentous injury, MRI is the gold standard to rule out significant cervical ligamentous injury as well.19,20
The diagnostic precision of computed tomography for traumatic cervical spine injury: An in vitro biomechanical investigation
2022, Clinical BiomechanicsCitation Excerpt :There is no direct connection between these biomechanical studies and the clinical classification schemes such as the SLIC, as it is impossible for an in vitro cadaveric study to capture all the complexities of human injury. For the assessment of cervical trauma, CT is considered the best clinical tool because of its high sensitivity (reportedly over 90%) and its cost effectiveness (Raza et al., 2013; Schoenfeld et al., 2010; Woodring and Charles, 1992). However, it has limitations, some of which are clinically important.
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2019, Journal of the American College of RadiologyCitation Excerpt :MRI has been suggested for those children in whom unconsciousness is predicted to last beyond 48 hours or in whom clinical clearance within 72 hours is unlikely [72]. Meta-analyses in adults showed that it was safe to clear the adult cervical spine in unevaluable patients based on CT scans [73-75]. Interestingly, the United Kingdom’s National Institute for Health Care Excellence guidelines suggest that in children <16 years of age, cervical MRI should be the first imaging modality both for suspected spinal cord and spinal column injury [76].
Cervical spine clearance in the adult obtunded blunt trauma patient: A systematic review
2019, Intensive and Critical Care NursingCitation Excerpt :Routinely performing MRI also carries significant resource implications, requires transfer and introduces the patient to the ferromagnetic environment (Plumb and Morris, 2012), which could not be feasible in all patients (Chew et al., 2013). Although MRI offers additional information about the soft tissue that cannot be visualised with a CT scan, for it to be useful and effective it must impact treatment (Plackett et al., 2016; Raza et al., 2013). This systematics review sought to answer the following question formulated using the PICO tool: In the adult obtunded blunt trauma patient can use of the cervical collar be discontinued on the basis of a c-spine CT scan alone?
- 1
Place where the study was conducted St George's Hospital, London, UK.