Elsevier

Injury

Volume 44, Issue 11, November 2013, Pages 1589-1595
Injury

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

https://doi.org/10.1016/j.injury.2013.06.005Get rights and content

Abstract

Background

A true gold standard to rule out a significant cervical spine injury in subset of blunt trauma patients with altered sensorium is still to be agreed upon. The objective of this study is to determine whether in obtunded adult patients with blunt trauma, a clinically significant injury to the cervical spine be ruled out on the basis of a normal multidetector cervical spine computed tomography.

Methods

Comprehensive database search was conducted to include all the prospective and retrospective studies on blunt trauma patients with altered sensorium undergoing cervical spine multidetector CT scan as core imaging modality to “clear” the cervical spine. The studies used two main gold standards, magnetic resonance imaging of the cervical spine and/or prolonged clinical follow-up. The data was extracted to report true positive, true negatives, false positives and false negatives. Meta-analysis of sensitivity, specificity, negative and positive predictive values was performed using Meta Analyst Beta 3.13 software.

We also performed a retrospective investigation comparing a robust clinical follow-up and/or cervical spine MR findings in 53 obtunded blunt trauma patients, who previously had undergone a normal multidetector CT scan of the cervical spine reported by a radiologist.

Results

A total of 10 studies involving 1850 obtunded blunt trauma patients with initial cervical spine CT scan reported as normal were included in the final meta-analysis. The cumulative negative predictive value and specificity of cervical spine CT of the ten studies was 99.7% (99.4–99.9%, 95% confidence interval). The positive predictive value and sensitivity was 93.7% (84.0–97.7%, 95% confidence interval).

In the retrospective review of our obtunded blunt trauma patients, none was later diagnosed to have significant cervical spine injury that required a change in clinical management.

Conclusion

In a blunt trauma patient with altered sensorium, a normal cervical spine CT scan is conclusive to safely rule out a clinically significant cervical spine injury. The results of this meta-analysis strongly support the removal of cervical precautions in obtunded blunt trauma patient after normal cervical spine computed tomography. Any further imaging like magnetic resonance imaging of the cervical spine should be performed on case-to-case basis.

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

  • 1.

    Adult blunt trauma patients with altered sensorium/obtunded

  • 2.

    Multidetector CT of the cervical spine as the core imaging modality

Exclusion criteria

  • Studies done using single-slice CT scanners (axial/helical with single -row of detectors)

  • 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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    Place where the study was conducted St George's Hospital, London, UK.

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