Defining the cervical spine clearance algorithm: A single-institution prospective study of more than 9,000 patients.

BACKGROUND: Variability exists in the approach to cervical spine (c-spine) clearance after significant trauma. Using concurrently gathered data on more than 9,000 such patients, the current study develops an evidence-based and readily adoptable algorithm for c-spine clearance aimed at timely removal of collar, optimal use of imaging, and appropriate spine consultations. METHODS: Prospective study of adult blunt trauma team alert (TTA) patients presenting at a Level I trauma center who underwent screening computed tomography (CT) to diagnose/rule out c-spine injury (January 2008 to May 2014). Regression analysis comparing patients with and without c-spine injury-fracture and/or ligament-was used to identify significant predictors of injury. The predictors with the highest odds ratio were used to develop the algorithm. RESULTS: Among 9,227 patients meeting inclusion criteria, c-spine injury was identified in 553 patients (5.99%). All 553 patients had a c-spine fracture, and of these, 57 patients (0.6% of entire population and 10.31% of patients with injury) also had a ligamentous injury. No patient with a normal CT result was found to have an injury. The five greatest predictors of ligament injury that follow were used to develop the algorithm: (1) CT evidence of ligament injury; (2) fracture pattern "not" isolated transverse/spinous process; (3) neurologic symptoms; (4) midline tenderness; and (5) Glasgow Coma Scale score <15. CONCLUSION: TTA patients should undergo screening c-spine CT to rule out injury. Most patients will have a negative CT and can have their collars removed. A select group of patients will require collars and spine consultation and a smaller subset of magnetic resonance imaging to rule out ligament injury. LEVEL OF EVEDINCE: Therapeutic study, level III.

Computed tomographic scan: it's not just about the fracture.

BACKGROUND: Computed tomography (CT) scan is the criterion standard to rule out cervical spine (c-spine) injury after blunt trauma. Many algorithms still include other tools to exclude ligamentous injuries that often lead to unnecessary prolonged collar use. The purpose of this study was to determine the accuracy of CT to rule out any clinically significant c-spine injury that would require intervention. METHODS: We performed a retrospective review of a prospective study of blunt trauma patients between January 2008 and December 2012 at a Level 1 trauma center. For those patients identified with ligamentous injury, further chart review was performed to determine how it was diagnosed and treated. RESULTS: A total of 5,676 patients were identified. The median age was 39.0 years (18-103 years), median Glasgow Coma Scale (GCS) score was 15 (3-15), median Injury Severity Score (ISS) was 5 (1-75), median length of stay was 2 days (1-175 days), and mortality was 2.6%. The incidence of any injury to the c-spine was 7.4% (420 of 5,676). The incidence of fracture was 7.2% (409 of 5,676), while that of ligamentous injury was 0.92% (52 of 5,676). Of the 52 patients with ligamentous injury, 20 (38.4%) were suspected by CT. However, for those that were not suspected, all had associated fractures identified by CT, requiring further interventions. Hence, CT had a 100% sensitivity and specificity in ruling out c-spine injuries. CONCLUSION: CT scan of the c-spine is an excellent tool to rule out c-spine injury. For patients with a normal CT finding of the c-spine, no further imaging is necessary, and collars should be cleared as soon as possible. LEVEL OF EVIDENCE: Prognostic study, level II; diagnostic study, level II.