Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma

Bush, Lisa D.; Brookshire, Robert G.; Roche, Breanna; Johnson, Amelia G.; Cole, Frederic J.; Karmy‐Jones, Riyad; Long, William B.; Martin, Matthew J.

doi:10.1001/jamasurg.2016.1248

Cited by 30 publications

(19 citation statements)

References 34 publications

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“…Other studies have investigated the utility of CT scan to allow clearance of the C-spine in obtunded non-intubated patients presenting to the Emergency Department (14,15). To the best of our knowledge this is the rst study in the literature to focus on the feasibility of CT scan-based cervical spine clearance in intubated trauma victims admitted to a Trauma Intensive Care Unit.…”

Section: Discussionmentioning

confidence: 99%

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Cervical Spine Clearance on Trauma Intensive Care: Can We Trust a Negative CT Scan?

Hasandarras

Strandvik

Faramawy

et al. 2021

Preprint

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Background: Cervical spine clearance in intubated victims of blunt trauma remains contentious; accumulating high level evidence suggests that a normal CT cervical spine can be used to clear the c-spine and remove the collar in obtunded emergency department patients to prevent collar-related complications. However, it is unclear whether this holds true for intubated patients in the trauma intensive care unit (TICU).Methods: We performed a retrospective review of 730 intubated trauma patients who presented to the Level 1 Trauma center of a tertiary hospital. We reviewed the rate of missed cervical injuries in patients who had their cervical collars removed based on a normal computed tomography (CT) scan of the cervical spine, as well as rates of collar-related complications.Results: Three hundred and fifty patients had their cervical collars removed in the TICU based on the findings of a high-quality, well-interpreted normal CT cervical spine. Seventy percent of patients were intubated and sedated at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%.Conclusion: Based on our findings, it is safe to remove the cervical collar for patients in the TICU following normal CT cervical spine, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be related to increased complications. We provide an algorithm to assist critical-care clinicians in decision-making in this patient cohort

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Section: Discussionmentioning

confidence: 99%

“…Two seminal articles published in 2016 and 2017 strongly supported the use of CT scan alone to exclude signi cant cervical spine injury in emergency department (ED) patients who failed NEXUS criteria; a prospective group of over 1600 alcohol-intoxicated patients, and a retrospective study of over 10 000 patients (14,15).…”

Section: Introductionmentioning

confidence: 99%

Cervical Spine Clearance on Trauma Intensive Care: Can We Trust a Negative CT Scan?

Hasandarras

Strandvik

Faramawy

et al. 2021

Preprint

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“…Using a single institution's data, this study showed that a normal CT finding alone could predict the absence of significant spinal injuries in more than 99% of cases. 3 The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed. However, caution must be taken in making conclusions based on these data.…”

mentioning

confidence: 86%

“…With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars. Bush et al 3 showed that the average cervical spine clearance times were 6 to 12 hours longer among intoxicated patients compared with sober patients, presumably equivalent to the time required to become sober. The increased risk of pressure ulcers, which is the most commonly reported adverse effect associated with prolonged collar use, has been demonstrated only in patients who remain in cervical collars for more than 24 hours.…”

mentioning

confidence: 99%

“…2 However, among the relatively small proportion of patients who may have missed injuries based on CT alone, the potential spinal cord injuries associated with premature cervical spine clearance could lead to long-term disability and even death. 4 With our knowledge that intoxicated patients form up to half of the population of trauma patients, 3 is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times? Without doubt, this study echoes the conclusions of previous studies regarding the low utility of subsequent magnetic resonance imaging following normal CT results.…”

mentioning

confidence: 99%

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Does the Computed Tomographic Scan Tell the Whole Story for Cervical Spine Clearance?

Olufajo

Salim

2016

JAMA Surg

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Stabilization of the spine with rigid collars has been well established as a useful early intervention for preventing spinal cord injuries among trauma patients.1 Clinical examination and, in some cases, radiographic evidence showing the absence of clinically significant injuries are routinely required prior to making decisions regarding the removal of these collars, a process known as cervical spine clearance.2 Because thorough clinical examinations require intact sensorium and sobriety, there have been debates on the safety of cervical spine clearance among intoxicated patients. 2 The study by Bush et al 3 in this issue of JAMA Surgery is an impressive effort to prospectively evaluate the accuracy of using only computed tomographic (CT) scans as the basis for excluding potential spinal cord injuries among intoxicated trauma patients. Using a single institution's data, this study showed that a normal CT finding alone could predict the absence of significant spinal injuries in more than 99% of cases. 3 The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed. However, caution must be taken in making conclusions based on these data. Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread. With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars. Bush et al 3 showed that the average cervical spine clearance times were 6 to 12 hours longer among intoxicated patients compared with sober patients, presumably equivalent to the time required to become sober. The increased risk of pressure ulcers, which is the most commonly reported adverse effect associated with prolonged collar use, has been demonstrated only in patients who remain in cervical collars for more than 24 hours. 2 However, among the relatively small proportion of patients who may have missed injuries based on CT alone, the potential spinal cord injuries associated with premature cervical spine clearance could lead to long-term disability and even death. 4 With our knowledge that intoxicated patients form up to half of the population of trauma patients, 3is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times? Without doubt, this study echoes the conclusions of previous studies regarding the low utility of subsequent magnetic resonance imaging following normal CT results. 5,6 In this era of cost containment, this provides additional evidence for the avoidance of unnecessary diagnostic tests. Whether these results preclude the need for a thorough clinical examination in an intoxicated trauma patient remains a question that may be too soon to answer.

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The Devil Is in the Details When Removing Cervical Collars After Blunt Trauma

2018

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Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma

Cited by 30 publications

References 34 publications

Cervical Spine Clearance on Trauma Intensive Care: Can We Trust a Negative CT Scan?

Cervical Spine Clearance on Trauma Intensive Care: Can We Trust a Negative CT Scan?

Does the Computed Tomographic Scan Tell the Whole Story for Cervical Spine Clearance?

The Devil Is in the Details When Removing Cervical Collars After Blunt Trauma

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