Abstract
Background
The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear.
Methods
All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (<24 h) repeat physical examination, MRI, and/or flexion–extension films.
Results
Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30–53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion–extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging.
Conclusion
C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.
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References
McCaig LF, Ly N (2002) National Hospital Ambulatory Medical Care Survey: 2000 emergency department summary. Advance data from vital and health statistics. National Center for Health Statistics, Hyattsville [DHHS publication no. (PHS) 2002-1250 02-0259]
Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB (2010) Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma 68(1):109–113
Menaker J, Philp A, Boswell S, Scalea TM (2008) Computed tomography alone for cervical spine clearance in the unreliable patient—are we there yet? J Trauma 64(4):898–903
Como JJ, Thompson MA, Anderson JS, Shah RR, Claridge JA, Yowler CJ, Malangoni MA (2007) Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma? J Trauma 63(3):544–549
Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, Holevar MR, Khwaja KA, Mayglothling JA, Shapiro MB, Winston ES (2009) 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. J Trauma 67(3):651–659
American College of Surgeons Committee on Trauma (2012) Spine and spinal cord trauma. Advanced trauma life support (ATLS) student course manual, 9th edn. American College of Surgeons, Chicago, pp 174–205
American College of Radiology (2015) ACR appropriateness criteria on suspected spine trauma. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedSpineTrauma.pdf. Accessed 5 April 2015
Hoffman JR, Wolfson AB, Todd K, Mower WR (1998) Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 32(4):461–469
Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M (1992) Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 21(12):1454–1460
Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J (2001) The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 286(15):1841–1848
Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA (2003) The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 349(26):2510–2518
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI (2000) Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 343(2):94–99
Schuster R, Waxman K, Sanchez B, Becerra S, Chung R, Conner S, Jones T (2005) Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg 140(8):762–766
Ackland HM, Cameron PA, Varma DK, Fitt GJ, Cooper DJ, Wolfe R, Malham GM, Rosenfeld JV, Williamson OD, Liew SM (2011) Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med 58(6):521–530
Ackland HM, Cameron PA, Wolfe R, Malham GM, Varma DK, Fitt GJ, Cooper DJ, Rosenfeld JV, Liew SM (2013) Outcomes at 12 months after early magnetic resonance imaging in acute trauma patients with persistent midline cervical tenderness and negative computed tomography. Spine 38(13):1068–1081 (Phila Pa 1976)
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Mavros, M.N., Kaafarani, H.M.A., Mejaddam, A.Y. et al. Additional Imaging in Alert Trauma Patients with Cervical Spine Tenderness and a Negative Computed Tomographic Scan: Is it Needed?. World J Surg 39, 2685–2690 (2015). https://doi.org/10.1007/s00268-015-3182-6
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DOI: https://doi.org/10.1007/s00268-015-3182-6