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Cervical Spine Clearance in Obtunded Patients After Blunt Traumatic Injury: A Systematic ReviewCervical Spine Clearance in Obtunded Patients

Jetan H. Badhiwala, MD; Chung K. Lai, BHSc; Waleed Alhazzani, MD; Forough Farrokhyar, PhD; Farshad Nassiri, MD; Maureen Meade, MD; Alireza Mansouri, MD; Niv Sne, MD; Mohammed Aref, MD; Naresh Murty, MD; Christopher Witiw, MD; Sheila Singh, MD, PhD; Blake Yarascavitch, MD; Kesava Reddy, MD; and Saleh A. Almenawer, MD
[+] Article, Author, and Disclosure Information

From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2351.

Requests for Single Reprints: Saleh A. Almenawer, MD, Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8, Canada; e-mail, Dr_menawer@hotmail.com.

Current Author Addresses: Drs. Badhiwala, Nassiri, Mansouri, and Witiw: Division of Neurosurgery, University of Toronto, 563 Spadina Crescent, Toronto, Ontario M5S 2J7, Canada.

Drs. Lai, Aref, Murty, Singh, Reddy, and Almenawer: Division of Neurosurgery, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8, Canada.

Drs. Alhazzani and Meade: Division of Critical Care, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8, Canada.

Dr. Farrokhyar: Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8, Canada.

Dr. Sne: Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8, Canada.

Dr. Yarascavitch: Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390.

Author Contributions: Conception and design: J.H. Badhiwala, C.K. Lai, W. Alhazzani, F. Farrokhyar, S.A. Almenawer.

Analysis and interpretation of the data: J.H. Badhiwala, C.K. Lai, F. Farrokhyar, F. Nassiri, M. Meade, C. Witiw, S. Singh, S.A. Almenawer.

Drafting of the article: J.H. Badhiwala, C.K. Lai, B. Yarascavitch, S.A. Almenawer.

Critical revision of the article for important intellectual content: J.H. Badhiwala, W. Alhazzani, F. Farrokhyar, F. Nassiri, M. Meade, A. Mansouri, N. Sne, M. Aref, N. Murty, C. Witiw, S. Singh, B. Yarascavitch, K. Reddy, S.A. Almenawer.

Final approval of the article: J.H. Badhiwala, W. Alhazzani, F. Farrokhyar, F. Nassiri, M. Meade, A. Mansouri, N. Sne, M. Aref, N. Murty, C. Witiw, S. Singh, B. Yarascavitch, K. Reddy, S.A. Almenawer.

Provision of study materials or patients: S.A. Almenawer.

Statistical expertise: F. Farrokhyar, F. Nassiri, S.A. Almenawer.

Administrative, technical, or logistic support: B. Yarascavitch, S.A. Almenawer.

Collection and assembly of data: J.H. Badhiwala, C.K. Lai, W. Alhazzani, A. Mansouri, S.A. Almenawer.


Ann Intern Med. 2015;162(6):429-437. doi:10.7326/M14-2351
Text Size: A A A

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.

Figures

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Appendix Figure.

Summary of evidence search and selection.

CT = computed tomography.

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Figure 1.

Forest plots of effect sizes for missed cervical spine injury (top), surgical intervention (middle), and collar use (bottom) after negative computed tomography results and additional findings on magnetic resonance imaging.

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Figure 2.

Forest plots of effect sizes for missed cervical spine injury (top), surgical intervention (middle), and collar use (bottom) after negative computed tomography results and additional findings on clinical examination follow-up.

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Figure 3.

Forest plots of effect sizes for missed cervical spine injury (top), surgical intervention (middle), and collar use (bottom) after negative computed tomography results and additional findings on dynamic imaging.

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Figure 4.

Forest plots of effect sizes for missed cervical spine injury (top), surgical intervention (middle), and collar use (bottom) after a well-interpreted, high-quality computed tomography scan and additional findings on confirmatory testing.

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Comments

Submit a Comment/Letter
Trauma guidelines for the Internist?
Posted on March 22, 2015
Joseph Shiber, MD, FACP, FCCM
Dept. of Surgical Critical Care; UF College of Medicine - Jacksonville
Conflict of Interest: None Declared
Dear Ann Intern Med Editor,
I am probably one of only a few readers who can say that I read the article by Badhiwala and colleagues with great interest, since I don't think many Internists practice in a Surgical/Trauma ICU. The review was comprehensive and done well. It has quite similar conclusions as the Eastern Association for the Surgery of Trauma (EAST) updated guidelines (J Trauma. 78(2):430-441, February 2015). I am surprised though that Ann Intern Med published this article since the topic is not within the scope of practice for the majority of Internists, and it may have been better received in a Surgical or Trauma journal.
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