C-spine Clearance in The Obtunded Trauma Patient

This one offered by our excellent chief resident, trauma extraordinaire, and world liberator, Dave Callaway.

************************

CT Based Protocols for C Spine Clearance in the Obtunded Blunt Trauma Patient

1. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal? Radiology. 2005 Oct;237(1):106-13.

a. 1400 trauma patients received helical CT (HCT) with 4-16 slice scanner AND MRI
b. 366 obtunded blunt trauma patients with negative HCT got MRI
c. MRI stats
i. Negative 354/366
ii. Positive 12/366
1. Cord contusion 7/12 (no intervention)
2. Ligamentous injury 4/12 (single column, no interv)
3. Interveterbral disk edema 3/12 (no intervent)
4. Combination 1/12 (no intervention)
d. Conclusions:
i. CT Sensitivity for ligamentous injury 98.9%
ii. CT Sensitivity for unstable cervical injury 100%
iii. MRI very sensitive for injuries, however helical CT reliable excludes clinically significant injury

2. Brohi K, Healy M, Fotheringham T, Chan O, Aylwin C, Whitley S, Walsh M. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005 May;58(5):897-901.

a. Four hundred thirty-seven unconscious, intubated, blunt trauma patients underwent CT scanning of the cervical spine.
b. 61 pt w/ cervical spine injury- 31 (7.0%) were unstable.
c. CT scanning had a sensitivity of 98.1%, a specificity of 98.8%, and a negative predictive value of 99.7%.
d. Conclusion: Significant ligamentous injury results in malalignment or malrotation detectable by HCT. Therefore, Helical CT is sensitive enough to clear cervical spine in obtunded blunt trauma patient.

3. Schuster R, Waxman K, Sanchez B, Becerra S, Chung R, Conner S, Jones T. 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. 2005 Aug;140(8):762-6.

a. 2603 blunt trauma patients, 100 c- spine or SC injuries
b. HCT detected 85/100
c. All 15 missed had neurologic deficits on exam
d. Withdrawal/localization adeqaute in assessing motor fx in comatose patient
e. 12 comatose patients, moving all 4 extrem on arrival w/ nml CT of cervical spine were examined with MRI. All MRI results were negative for injury. No patients experienced neurologic deterioration. No patient required operative management of spinal injury.
f. MRI added no clinical information
g. Conclusion: Obtunded blunt trauma patients w/ normal motor examination results and normal CT results of the c- spine do not require further radiologic examination before clearing the cervical spine.