Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan—A meta-analysis and cohort study

Clinical Uncertainty at the Intersection of Advancing Technology, Evidence-Based Medicine, and Health Care Policy

“…3,4 There is published evidence available to support both contentions, although the level of quality in peer-reviewed studies is less than adequate. [1][2][3][4] While acknowledging that MRI can identify injuries missed by MDCT, many physicians argue that such findings are often clinically insignificant and unlikely to alter treatment plans. [1][2][3] In their view, the use of MRI needlessly increases health care costs ($1000-$4000 per noncontrast MRI) and places patients at risk of unnecessary interventions, whether surgical or nonoperative.…”

“…[1][2][3][4] While acknowledging that MRI can identify injuries missed by MDCT, many physicians argue that such findings are often clinically insignificant and unlikely to alter treatment plans. [1][2][3] In their view, the use of MRI needlessly increases health care costs ($1000-$4000 per noncontrast MRI) and places patients at risk of unnecessary interventions, whether surgical or nonoperative. Those who support the use of adjunct MRI counter that neither the status of the spinal cord nor the integrity of the spinal ligamentous structures can be comprehensively assessed without the use of magnetic resonance technology.…”

“…3,4 Owing to the quality of the present literature, the actual false-normal rate of computed tomography imaging, particularly with respect to clinically significant occult injuries, remains unknown. [1][2][3][4] At the dimly lit crossroads of advancing medical technology, evidence-based medicine, and health care policy, the medical community would benefit patients and support physicians by adopting a research agenda that can realistically provide highquality evidence to inform policy choices. A multicenter, prospective investigation designed to accurately assess the specificity and negative predictive value of MDCT would undoubtedly assist in resolving this controversy; yet, to our knowledge, no such study is under way.…”

Utility of flexion–extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine

“…There have been three meta‐analyses looking at CT as the sole modality to rule out ligamentous injury. Raza et al reviewed 10 studies of 1850 obtunded blunt trauma patients, four of which were prospective . CT was compared against MRI or clinical follow up as a gold standard and found that CT had NPV and PPV of 99.7% and 93.7%, respectively.…”

“…Raza et al reviewed 10 studies of 1850 obtunded blunt trauma patients, four of which were prospective. 54 CT was compared against MRI or clinical follow up as a gold standard and found that CT had NPV and PPV of 99.7% and 93.7%, respectively. Badhiwala et al systematically reviewed seven prospective studies with 1686 obtunded blunt trauma patients who underwent MRI following negative CT. 55 There were no missed ligamentous injuries.…”