Northwell Health Interdisciplinary Spine Center Journal Club 2-26-18

Department of Orthopaedics

Interdisciplinary Spine Center Eastern Region Journal Club Library A
301 East Main Street
Southside Hospital Southside Hospital
Regularly Scheduled Series Bay Shore, NY 11706

Topic: Clearing the Cervical Spine in the Blunt Trauma Patient February 26, 2018
5:30pm-6:30 pm
Speakers: Daniel Brandenstein, DO

Learning Objectives:
Upon completion of this session, participants should be able to:

1. Integrate best practices into patient care ensuring that care is reliable and appropriate.
2. Employ evidence based practice integrating research with clinical experience to provide optimum care.
3. Analyze and compare new technology against current standards of care.
4. Examine trends that may either positively or negatively impact on the standard of care.
5. Review medical and non-spinal presentations that may coexist or mimic primary spinal pathology.

Target Audience: Physicians (MD/DO), Residents, Nurses, Physical Therapists and Allied Health Professionals affiliated with
Physical Medicine & Rehabilitation, Orthopaedic Surgery, Non-Operative Orthopaedics, Neurosurgery, Neurology,
Radiology/Imaging, Rheumatology.

CME Accreditation:
Northwell Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical
education for physicians.

Credit Designation:
Northwell Health designates this live activity for a maximum of 1 AMA PRA Category 1 credit ™. Physicians should only claim
credit commensurate with the extent of their participation in the activity.

Disclosure Policy:
Northwell Health adheres to the ACCME’s Standards for Commercial Support. Any individuals in a position to control the
content of a CME activity, including faculty, planners, reviewers or others are required to disclose all relevant financial
relationships with commercial interests. All relevant conflicts of interest will be resolved prior to the commencement of the
activity.

Planner and Speaker’s Disclosures:
Daniel Brandenstein has no relevant financial relationships to disclose.

Recognition of Program Support:
An announcement of program support will be made to all attendees at the beginning of each Regularly Scheduled Session.

Review Article

Clearing the Cervical Spine in the
Blunt Trauma Patient

Paul A. Anderson, MD Abstract
Zbigniew Gugala, MD, PhD
Ronald W. Lindsey, MD The goal of cervical spine clearance is to establish that injuries are
Andrew J. Schoenfeld, MD not present. Patients are classified into four groups: asymptomatic,
Mitchel B. Harris, MD, FACS temporarily nonassessable secondary to distracting injuries or
intoxication, symptomatic, and obtunded. Level I evidence supports
that the asymptomatic patient can be cleared on clinical grounds
and does not require imaging. The temporarily nonassessable
patient may have short-term mental status changes (eg,
intoxication, painful distracting injuries) and can be evaluated by
two methods. When there is urgency, the evaluation is similar to
that for the obtunded patient. Alternatively, the patient can be
reevaluated within 24 to 48 hours, after return of mentation or
following treatment of painful injuries. The patient then can be
assessed as the asymptomatic patient is. The symptomatic patient
requires advanced imaging. The obtunded patient should undergo,
at minimum, a multidetector CT scan. Two methods are advocated.
One uses only multidetector CT; a normal result is sufficient to
clear the obtunded patient. The alternative method is obtaining a
magnetic resonance image subsequent to a negative multidetector
CT scan. Because at present information is insufficient to
determine whether MRI is indicated, this is an area of controversy.

From the Department of Orthopedics The assessment of the cervical challenging. The emergency setting
and Rehabilitation, University of spine is a priority in the treat- presents a host of confounding and
Wisconsin, Madison, WI ment of the more than 10 million pa- distracting impediments to the clear-
(Dr. Anderson), the Department of tients who annually present for emer- ance process. These obstacles not-
Orthopaedic Surgery and gency center evaluation.1 Cervical withstanding, the timely clearance of
Rehabilitation, University of Texas spine injury occurs in only 1% to these patients is essential. Protracted
Medical Branch, Galveston, TX 3% of these patients but is a major cervical spine evaluation may pro-
(Dr. Gugala and Dr. Lindsey), and cause of long-term disability.2,3 His- long bed rest immobilization, inhibit
Brigham and Women’s Hospital, torically, nearly one third of cervical or restrict the thorough assessment
Department of Orthopedic Surgery, spine–injured patients, if inappropri- of other organ systems, and compli-
Harvard Medical School, Boston, ately assessed, are at risk of delay in cate or delay general patient recov-
MA (Dr. Schoenfeld and Dr. Harris). diagnosis or treatment.4 Early recog- ery. A haphazard approach to cervi-
nition of these injuries may prevent cal spine clearance can generate
J Am Acad Orthop Surg 2010;18: or limit neurologic compromise and needless costs and inefficiently use
149-159 optimize eventual functional restora- medical resources.
tion.5
Copyright 2010 by the American The Advanced Trauma Life Sup-
Academy of Orthopaedic Surgeons. Although most blunt trauma pa- port (ATLS) protocol for the initial
tients do not have a cervical spine in- management of the trauma patient
March 2010, Vol 18, No 3 jury, a reliable method to clear the can be used in the process of cervical
cervical spine of these persons is spine clearance in four recognized

149

Clearing the Cervical Spine in the Blunt Trauma Patient

groups of adult blunt trauma pa- secondary evaluation.7 The ATLS radiograph is warranted to provide
tients who require cervical spine protocol mandates that all patients initial information on the status of
clearance. Here, we discuss the pro- be presumed to have a cervical spine the cervical spine. In the event of sig-
cess applying to the adult trauma pa- injury until proved otherwise. There- nificant malalignment, cranial tongs
tient; pediatric evaluation has been fore, all trauma patients are initially may be placed and traction applied
recently reviewed.6 immobilized with a cervical collar, during the resuscitation period. Fur-
sandbags, and/or a backboard as if ther definitive radiographs can be
Clearance: Definition and they have an unstable injury to the obtained once the patient is stabi-
Rationale cervical spine. The ATLS system is lized.
not intended to diagnose all cervical
Cervical spine clearance after blunt spine injuries but rather to establish When the cervical spine cannot be
trauma is defined as accurately con- a high level of suspicion for cervical cleared clinically, the patient’s status
firming the absence of a cervical spine injury, avoid missed injuries, reverts to the ATLS category of “sus-
spine injury. Contrary to a common and prevent neurologic deterioration pected unstable cervical injury,” and
perception, cervical spine clearance in the patient with a potentially un- the collar is left in place. The Ameri-
does not entail injury detection or stable cervical spine. All blunt can College of Surgeons recommends
classification or the determination of trauma patients must undergo a that, in most instances, “doctors
optimal treatment. The objective of standardized cervical clearing pro- who are skilled in the evaluation and
cervical spine clearance is to estab- cess. management of the spine-injured pa-
lish that an injury does not exist. tient should be consulted ... where a
Current ATLS recommendations spine injury is detected or suspect-
ATLS Protocol advocate immediate collar removal ed.”7 The criteria that the consultant
in the awake, alert, sober, and neuro- should use are not specified.
The ATLS protocol was developed logically normal patient who has no
by the American College of Surgeons tenderness to palpation in the cervi- Clinical Assessment
with the intent of creating a repro- cal spine and who exhibits full, pain-
ducible approach to rapidly identify free range of motion (ROM). These The clinical examination is an essen-
injuries and initiate intervention for guidelines were based on well- tial component of the clearance pro-
limb- and life-threatening injuries.7 designed prospective level I studies cess. This assessment includes a
In addition, ATLS guidelines seek to and consensus among experts. How- review of the history of trauma,
reduce the incidence of missed inju- ever, when a patient exhibits midline identification of pain or tenderness
ries and delayed diagnosis. The pro- cervical tenderness with palpation or in the head, neck, or thoracolumbar
tocol should be applied to any pa- neck pain with active ROM, a spine, and any neurologic changes of
tient in any trauma situation. The screening cervical spine CT scan per- sensation or muscle strength in the
initial vital steps in the ATLS evalua- formed with a multidetector CT trunk and extremities. Any patient
tion include assessment of the air- (MDCT) scanner is indicated.8 A history of transient motor or sensory
way, breathing, and circulation while similar protocol is initiated in the pa- changes, such as parasthesias or pa-
maintaining strict vigilance of spinal tient who exhibits altered levels of ralysis, may indicate significant spi-
precautions. consciousness or who has distracting nal pathology, and, when noted,
injuries. requires radiographic assessment.
Immobilization in a cervical collar Physical examination includes palpa-
should be initiated at the scene of in- The major exception to this more tion from the occiput to the sacrum
jury and maintained until a directed contemporary algorithm is the pa- and identification of areas of tender-
examination is performed during the tient who is in extremis and there- ness, crepitus, or other abnormality,
fore unable to undergo a CT scan. In
this situation, a lateral cervical plain

Dr. Anderson or an immediate family member has received royalties from Pioneer Surgical and Stryker; serves as a paid consultant
to or is an employee of Medtronic Sofamor Danek, Pioneer Surgical, and Expanding Orthopedics; has received research or
institutional support from Medtronic Sofamor Danek and Titan; and has stock or stock options held in Titan Surgical, Pioneer Surgical,
Expanding Orthopedics, Crosstrees, and Titan. Dr. Schoenfeld or an immediate family member has received research or institutional
support from DePuy, Stryker, and Synthes. Dr. Harris or an immediate family member has received research or institutional support
from Synthes. Neither of the following authors nor any immediate family member has received anything of value from or owns stock
in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Gugala and Dr. Lindsey.

150 Journal of the American Academy of Orthopaedic Surgeons

Paul A. Anderson, MD, et al

such as a hematoma, step-off, or gap Table 1
between the spinous processes.
ROM can be tested only in the Classification and Characteristics of Blunt Trauma Patients Requiring
asymptomatic patient, as described Clearance
below. This is performed first by ask-
ing the patient to turn her or his Group Classification Important
head 45° to each side. If no symp- Characteristics
toms are elicited by head rotation,
the patient is then asked to actively 1 Asymptomatic Awake, alert
flex and extend the head. A detailed No neck pain/tenderness
neurologic examination according to Normal neurologic function
American Spinal Injury Association No intoxication
protocol should be performed.9 No distracting injuries

The clinical examination has been 2 Temporarily nonassessable Asymptomatic
shown to have low sensitivity, rang- Intoxicated or has distracting injuries
ing from 79% to 93%, even in the Expect resolution in 24-48 h
awake, alert patient.2,10,11 However,
in the studies cited, most injuries not 3 Symptomatic Cervical pain or tenderness
identified by clinical examination Neurologic deficits
were minor, with none requiring sur-
gery or resulting in neurologic defi- 4 Obtunded Abnormal cognitive function that interferes
cits. Thus, although the clinical as- with clinical examination
sessment may miss minor injuries to
the cervical spine, the clinical exami- Figure 1
nation appears to identify significant
unstable injuries in the awake, alert,
cooperative patient.

Classification

Several basic principles are applied Algorithm for the evaluation of the asymptomatic blunt trauma patient.
to all blunt trauma patients undergo-
ing the cervical spine clearance pro- trauma patients can be acutely cate- tients (Figures 1-4).
cess. First, a meaningful clinical ex- gorized into four fundamental pa- The asymptomatic patient (group
amination of the cervical spine is an tient groups (Table 1): asymptomatic
essential component of the process. (group 1), temporarily nonassessable 1) can be reliably cleared by clinical
The principal requirement is a lucid (group 2), symptomatic (group 3), or examination alone without imaging
patient. Therefore, the initial step is obtunded (group 4). A treatment al- (ie, no plain radiography, CT, MRI,
to determine the patient’s level of gorithm for each group may be used other modality). The patient must
alertness. Although all patients to guide the treatment of these pa- exhibit no evidence of intoxication
should be thoroughly evaluated, only or distracting injury, which may in-
patients with an unimpaired level of
consciousness can be conclusively
cleared. Secondarily, the alert, ori-
ented patient should be assessed for
the presence or absence of signs and
symptoms that can either be attrib-
uted to or possibly mask cervical
spine injury. These include intoxica-
tion and distracting injuries.

Based on these principles, all blunt

March 2010, Vol 18, No 3 151

Clearing the Cervical Spine in the Blunt Trauma Patient

Figure 2 tients.1 The NEXUS method uses
specific criteria to identify the low-
Algorithm for the evaluation of the temporarily nonassessable blunt trauma risk patient who can be cleared clini-
patient. cally without imaging. All of the fol-
lowing criteria must be met for a
terfere with the patient’s ability both a neurologic deficit. Patients in group patient to be considered low-risk: an
to feel pain associated with cervical 4 are obtunded, intubated, and/or phar- awake, alert patient; no history,
spine injury and to cooperate with macologically compromised such that signs, or laboratory evidence of in-
the examination, as well as impair they cannot submit to a meaningful toxication or distracting injury (ie,
communication.1,12 clinical examination. major injury above the shoulder, pel-
vic fracture, long bone or periarticu-
Patients in group 2, or those who are Group 1: Asymptomatic lar fracture, thoracolumbar spine in-
temporarily nonassessable, are asymp- jury, severe soft-tissue injury, major
tomatic but have evidence of intoxica- Large clinical studies, systematic re- visceral cavity injury); no cervical
tion or distracting injuries that invali- views, meta-analyses, and expert pan- spine pain or midline tenderness; and
date their examination. The expectation els have concluded that asymptomatic no neurologic signs or symptoms.
that these temporary conditions will re- patients can receive cervical spine clear-
solve in 24 to 48 hours makes this ance based on clinical examination Twenty-one centers prospectively
group unique. Symptomatic patients without imaging studies.1,13-16 The screened 34,069 patients using the
(group 3) require diagnostic imaging in National Emergency X-Radiography NEXUS criteria.1 Two weeks later,
addition to a clinical examination to be Utilization Study (NEXUS) validated patients were reassessed by nurses to
reliably cleared. These patients are fully a clinical protocol that cleared the confirm the presence or absence of
alert and have neck pain, tenderness, or cervical spine in asymptomatic pa- cervical spine injury. Overall, 2.8%
of patients had cervical injuries. The
overall sensitivity of the screening
method was excellent—99.0% for
patients with all cervical injuries and
99.6% for those with significant cer-
vical injuries. Eight cases of cervical
spine fractures had false-negative
screening tests. Six were deemed not
significant (minor process fractures).
Two significant injuries occurred
without neurologic sequelae. The
negative predictive value was excel-
lent at 99.8%, indicating that a pa-
tient who does not meet criteria for
radiographs is extremely unlikely to
have a significant cervical injury.
However, because of very low speci-
ficity (12.9%), many potentially un-
necessary radiographs were taken
when the NEXUS criteria were used.

The NEXUS criteria have also been
validated in geriatric populations.
Touger et al17 reported that the inci-
dence of injury was twofold greater
in the geriatric population and that
odontoid fractures occurred in 20%
of cases. The NEXUS criteria had
equally high sensitivity and negative
predictive value, with only 2 of
2,943 patients having cervical spine

152 Journal of the American Academy of Orthopaedic Surgeons

Paul A. Anderson, MD, et al

injuries despite negative screenings. Figure 3
Both injuries were insignificant frac-
tures and did not result in neurologic Algorithm for the evaluation of the symptomatic blunt trauma patient.
deterioration. MDCT = multidetector CT, STIR = short tau inversion recovery

An alternative to the NEXUS pro- would have required radiographs. Rule, and nine institutional protocols.
tocol is the Canadian C-Spine Rule.13 Hadley16 reported a systematic review The overall sensitivity based on a ran-
This rule applies to awake, nonin- dom effects model was 98.1%, and
toxicated patients with a Glasgow of the evaluation of the cervical spine specificity was 35.0%. Of 28 missed in-
Coma Scale (GCS) score of 15 and in asymptomatic patients. Based on nine juries, only 2 were deemed significant;
identifies those who require radio- studies, many of which used NEXUS none was associated with neurologic
graphs by answering three questions. criteria or the Canadian C-Spine Rule, deterioration.
First, is the patient high-risk enough this study concluded that there was level
that radiographs are required? These I evidence that asymptomatic patients Recommendation
risk factors include age >65 years, re- do not require radiographic evaluation. Based on level I evidence, our recom-
ports of paresthesia, and a dangerous Tontz et al14 performed a meta-analysis mendation is that asymptomatic
mechanism of injury (ie, fall from a totaling >63,000 patients, including patients be clinically evaluated by
height >1 m or five stairs, axial load three NEXUS, two Canadian C-Spine
to the head, high-speed [>100 km/h]
automobile, motorcycle, recreational
vehicle, or bicycle accident). Second,
is there a low risk factor that would
allow safe assessment of ROM? Ex-
amples of such a factor are a simple
rear-end motor vehicle crash, a pa-
tient who has already sat upright in
the emergency department or was
ambulatory at any time, a delay of
onset of pain, and absence of tender-
ness. Third, can the patient actively
rotate the head 45° to the right and
left without pain? A patient who is
not at high risk and can safely per-
form the rotation test can be cleared
clinically without radiographs.

Stiell et al13 reported the sensitivity
and specificity of the Canadian
C-Spine Rule after enrolling 8,924
patients from eight centers. The sen-
sitivity of this protocol was 100%
and specificity was 42.5%, which
were a significant improvement over
the NEXUS protocol measures. By
use of these results, a 25% to 50%
reduction in radiographs can be
achieved. In a separate study, Stiell
et al18 found that, compared with the
NEXUS Low-Risk Criteria, the Ca-
nadian C-Spine Rule had signifi-
cantly higher sensitivity and greater
specificity. In applying the Canadian
C-Spine Rule compared with the
NEXUS criteria, 10% fewer cases

March 2010, Vol 18, No 3 153

Clearing the Cervical Spine in the Blunt Trauma Patient

Figure 4 be cleared on clinical grounds with-
out radiographs. Alternatively, or if
urgency is required for treatment of
other injuries, the patient is evalu-
ated as if she or he were obtunded.

Group 3: Symptomatic

A patient who has neck pain, tender-
ness, or neurologic symptoms re-
quires radiographic imaging as an
adjunct to physical examination to
evaluate the cervical spine. Imaging
options include plain radiography,
flexion-extension radiography, CT,
and MRI.

Algorithm for the evaluation of the obtunded blunt trauma patient. Plain Radiography
MDCT = multidetector CT, STIR = short tau inversion recovery
In the acute setting, plain radiography
NEXUS or Canadian C-Spine Rule ably participate in the clinical exami- is often the first screening modality em-
criteria. If negative, their cervical nation.8,19 This group has not been ployed. It is readily available, inexpen-
spines may be cleared without radio- adequately defined, nor has the reli- sive, quick, and specific for cervical
graphs. ability of clearance methods been de- spine injury; however, there are cur-
termined in the literature. The rec- rently no validated guidelines for its use
Group 2: Temporarily ommendations below are opinions of in blunt trauma patients. Sensitivity of
Nonassessable the authors. plain radiography is low, ranging from
52% to 85%, although many missed
Temporarily nonassessable patients Recommendation injuries have little significance.20,21
have short-term cognitive dysfunc- Collar immobilization should be The major limitation is inability to
tion, usually from intoxication, or maintained and the clinical examina- delineate injuries at the occipitocer-
have distracting injuries that pre- tion repeated 24 to 48 hours after vical and cervicothoracic junctions in
clude a valid clinical examination. initial presentation, following man- many patients.
Group 2 patients are expected to agement of distracting injuries and
have resolution of pain from dis- after the return of normal cognitive The standard set of cervical radio-
tracting injuries and recovery of cog- function. At that time, if the patient graphs usually consists of lateral,
nitive dysfunction within 24 to 48 is “asymptomatic,” she or he should odontoid, and AP views. The inclu-
hours, at which time they can reli- sion of oblique and swimmer’s views
only slightly improves the sensitivity
and, therefore, has been deemed
cost-inefficient.22-24 If further imaging
is required, CT is recommended.

The efficacy of cervical radio-
graphs is dependent on the quality of
the views obtained. Davis et al25
demonstrated that 94% of the errors
leading to missed or delayed diagno-
sis of cervical spine injuries resulted
from the inability to obtain adequate
radiographs. This problem has been
addressed by the widespread use of
CT and MRI, which display areas of-
ten inadequately revealed by plain
radiography.

154 Journal of the American Academy of Orthopaedic Surgeons

Paul A. Anderson, MD, et al

Flexion-extension Radiography increased radiation exposure, and sensitive to fluid and hemorrhage,
Cervical spine radiographs may fail to limited availability (compared with whereas T1-weighted sagittal images
detect an unstable cervical spine injury plain radiography).34 can depict the anterior and posterior
in 15% of cases.26 To identify these in- longitudinal as well as the supra-
juries, lateral flexion-extension radio- Magnetic Resonance Imaging spinous ligaments. A disruption of
graphs have been recommended. These MRI is an effective noninvasive im- the black stripe on T1-weighted im-
would be appropriate only for the alert aging tool for the detection of neu- ages and increased signal that ex-
patient with negative cervical radio- ral, ligamentous, or disk injury. MRI tends through normal ligamentous
graphs and persistent symptoms who is primarily indicated for the patient structures on fat-suppressed images
can voluntarily undergo the study and who presents with neurologic deficit. can be indicative of ligamentous in-
whose entire cervical spine can be vi- In this setting, MRI is an effective jury. Delays that allow resolution of
sualized on the standard views. The ef- and safe method for evaluating the edema and hemorrhage can decrease
ficacy of lateral flexion-extension views spinal cord because it can depict epi- MRI sensitivity in cervical spine
in the acute setting is controversial.27 dural hematoma, spinal cord edema, clearance. Although 48 to 72 hours
The NEXUS study reported that and spinal cord compression. Addi- has been suggested as an optimal
flexion-extension radiographs obtained tional MRI is indicated when liga- time interval, no data exist to sub-
acutely added little to the screening pro- mentous injury is suspected. This in- stantiate this notion.36
cess considering the risk involved.28,29 cludes when focal tenderness or gaps
Furthermore, flexion-extension radio- are present between spinous pro- Recommendation
graphs for acute cervical spine clearance cesses on examination or when ky-
are not cost-effective and are reserved phosis or interspinous widening is Symptomatic patients require imag-
for the subacute setting.15,30 seen on CT or plain radiographs. ing of the cervical spine. Current
practice and evidence support two
Computed Tomography MRI is not indicated for the pri- options: three-view plain radiogra-
CT with reformations has gradually mary cervical spine clearance imag- phy with adjunctive CT if needed for
replaced plain radiography for cervi- ing procedures. MRI requires exten- inadequate radiographs, or MDCT.
cal spine clearance. Helical MDCT sive time to perform, interferes with In the symptomatic patient undergo-
offers volume imaging, providing the patient’s monitoring equipment, ing CT scanning of other locations,
quick and efficient imaging in all and is expensive. MRI is most useful the addition of cervical MDCT is
planes, and is becoming the primary in the patient for whom other imag- recommended. Flexion-extension ra-
method for the detection of spinal in- ing modalities are not consistent diography for cervical clearance is
jury in many trauma centers. MDCT with the neurologic presentation. In not recommended but is appropriate
has equal sensitivity in all planes, so one study, 25% of patients with cer- in the subacute setting (ie, 2 weeks)
there is less risk of missing nondis- vicothoracic injuries and a neuro- if symptoms persist.15 MRI is not in-
placed transverse fractures such as a logic deficit on presentation had dicated for screening; however, it
type II dens fracture. CT alone iden- their preliminary treatment plan al- may be warranted for evaluation of
tifies 99.3% of all cervical spine tered after MRI, whereas imaging the patient with spinal cord injury,
fractures; in one study, the missed had no effect on neurologically intact suspected ligamentous injury, or neu-
fractures required minimal or no patients.35 Although MRI can have rologic deterioration.
treatment.31 Recent studies have rec- negative predictive value approach-
ognized the cost-effectiveness of heli- ing 100%, its positive predictive Group 4: Obtunded
cal CT to complement its superior value has been less impressive.36
sensitivity.32 The cost-effectiveness of Clearance of the cervical spine in the pa-
cervical spine CT is even greater Unlike flexion-extension radiogra- tient with cognitive dysfunction is con-
when applied as an extension of a phy, MRI provides valuable informa- troversial and unresolved. The decision
primary CT of other organs (eg, tion regarding cervical ligaments, to discontinue the cervical collar for
head, thorax, abdomen). Some au- disks, and joint capsules without such a patient is not synonymous with
thors advocate CT as the preferred placing the spinal cord or neural ele- determining that the cervical spine has
initial imaging modality for patients ments at risk. However, no consen- been cleared, as in groups 1 and 3. In
with moderate to high risk for cervi- sus exists on the imaging criteria for a group 4 patient, the risks of an occult
cal spine injury.33 The disadvantages establishing a significant ligamentous cervical spine injury must be weighed
of CT include its greater expense, injury. Fat suppression sequences, in- against the potential morbidities of con-
cluding T2-weighted and short tau tinued cervical immobilization. The
inversion recovery MRI, are most

March 2010, Vol 18, No 3 155

Clearing the Cervical Spine in the Blunt Trauma Patient

concern is that cervical injuries result- the injuries identified by MRI was cervical spine ligamentous injuries.
ing from high-energy trauma might in- deemed clinically significant. This The authors found that the negative
clude soft-tissue damage that may not led the authors to conclude that the predictive value of CT for ligamen-
be readily identifiable on plain radio- use of MRI is obviated by a negative tous injury was only 78%. Based on
graphs or CT. Chiu et al37 estimated MDCT. Similar results were reported these findings, the authors concluded
a 0.6% incidence of isolated liga- by Como et al45 and Schuster et al.48 that CT is not effective in evaluating
mentous cervical spine injuries in all ligamentous injuries and recom-
blunt trauma patients. These isolated Hogan et al46 published results of mended that obtunded patients un-
soft-tissue injuries are difficult to de- 366 obtunded blunt trauma patients dergo MRI.
tect and may result in neural injury, evaluated with both MDCT and
ranging from minor sensory deficits MRI. These authors found that Recently, Muchow et al36 published
to complete tetraplegia.5,38-40 Neuro- MDCT had a 98.9% negative pre- a meta-analysis involving five level I
logic sequelae associated with a spi- dictive value for ligament injury and studies, representing 464 trauma pa-
nal injury are 10 times more likely to a 100% negative predictive value for tients evaluated using MRI and plain
occur in the event of a missed inju- cervical instability. In this investiga- radiographs or CT. Comparable to
ry.41 tion, 4 of the 366 patients with nega- other published reports, these au-
tive MDCT results had isolated liga- thors found a 20.9% incidence of
There is consensus that the patient mentous injuries on MRI, none of abnormalities on MRI that were not
who has altered mentation requires which was felt to be unstable. Stelfox detected by plain radiographs or CT.
imaging of the cervical spine.7,15,42-44 et al47 compared the results of a clini- They found that MRI demonstrated
A variety of methods has been rec- cal examination with helical CT re- a sensitivity of 97.2%, a specificity
ommended, but no definitive stan- construction with those of MRI. CT of 98.5%, and a negative predictive
dard currently exists. Numerous al- alone had sensitivity equal to that of value of 100%. Based on these find-
gorithms have been advocated and MRI but was faster and resulted in ings, Muchow et al36 concluded that
incorporate clinical examination (of- 67% fewer adverse events, such as a negative MRI study is the definitive
ten unreliable), plain radiographs, decubiti, delirium, and hospital- standard for cervical spine clearance
dynamic fluoroscopy, CT, and MRI. acquired pneumonia while awaiting in the obtunded patient. However,
In the past decade, CT and MRI imaging. the high rate of false negatives makes
have largely replaced these other im- the usefulness of MRI as a screening
aging modalities; the current debate Magnetic Resonance Imaging tool questionable.
revolves around the extent to which
MDCT can direct clearance of the Although CT is sensitive in the identi- Stassen et al39 advocated an algo-
cervical spine. fication of osseous abnormalities, it rithm in which the obtunded trauma
has not been shown to have the same patient undergoes both a helical CT
Computed Tomography level of accuracy as MRI in detecting and MRI procedure to facilitate cer-
an isolated ligamentous injury. Menaker vical spine clearance. In the authors’
Several recent investigations have ad- et al50 analyzed 203 obtunded trau- investigation, 30% of the patients
vocated CT as a single modality ca- ma patients who had normal CT re- with normal CT findings demon-
pable of detecting all clinically signif- sults and found an 8.9% incidence of strated abnormal findings on MRI (P
icant cervical spine injuries.42,44-49 abnormality identified by MRI. In < 0.01). Furthermore, MRI identified
Harris et al42 analyzed 367 obtunded this study, 2 patients found to have a all abnormalities that were indicated
trauma patients using CT and re- normal cervical spine by CT inter- by CT. These authors suggested that
ported that all clinically significant pretation required surgical interven- both helical CT and MRI be em-
cervical spine injuries were identi- tion for ligamentous injury, and 14 ployed in the evaluation of the cervi-
fied. Furthermore, CT failed to de- others required immobilization in an cal spine in obtunded trauma pa-
tect minor injury in only one patient. orthosis. These researchers con- tients.
Tomycz et al49 analyzed 180 ob- cluded that CT cannot reliably detect
tunded blunt trauma patients with all clinically significant cervical inju- Such a recommendation is in ac-
no neurologic deficits and Glasgow ries and that MRI remains a neces- cord with the American College of
Coma Scale scores ≤13 by CT, and sary adjunct in the evaluation of the Radiology (ACR) Appropriateness
then, if the result was normal, by obtunded patient with suspected cer- Criteria on suspected spine trauma.15
MRI. MRI identified acute abnor- vical trauma. The ACR has stated that CT and
malities in 21% of patients with a MRI are the most appropriate mo-
negative CT result; however, none of Similarly, Diaz et al41 reported a dalities for cervical spine evaluation
32% sensitivity for helical CT for in the obtunded trauma patient.

156 Journal of the American Academy of Orthopaedic Surgeons

Paul A. Anderson, MD, et al

Moreover, the ACR advocates that The initial screening should be optimally clear the obtunded patient
“... MRI be used to evaluate the cer- MDCT. When the CT result is nor- (group 4) does not currently exist.
vical spine in patients whose neuro- mal, two options are available to ul- The authors propose the use of
logic status cannot be fully evaluated timately clear the cervical spine. The MDCT or a combination of CT and
within 48 hours of injury, including first is to accept a negative CT scan MRI. Creation and implementation
those in whom computed tomo- as clearing the spine and to discon- of clearance protocols such as those
graphic results are normal.”15 tinue collar and restrictions. Alterna- described here, based on the best
tively, cervical MRI should be ob- available medical evidence, are rec-
Dynamic Radiography tained to ultimately clear the cervical ommended at each institution.
Dynamic radiography in the ob- spine. Both of these options are sup-
tunded patient has been obtained un- ported in the current literature and References
der physician’s supervision and with by consensus panels as discussed
the use of bedside fluoroscopy, trac- above. The authors recommend the Evidence-based Medicine: Levels of
tion, and general anesthesia.27 Stud- use of the first method: MDCT alone evidence are described in the table of
ies have shown that approximately for clearing the cervical spine in ob- contents. In this article, references 1,
1% of patients may demonstrate an tunded patients. 13, 17, 18, 29, 32, 33, 38, 42, 49, and
undiagnosed ligamentous injury and 50 are level I studies. References 23,
that most such applications are inad- Summary 24, and 47 are level II studies.
equate because they do not visualize References 2, 3, 10-12, 14, 16, 20, 28,
the cervicothoracic junction.51 Fur- Clearance of the cervical spine in the 36, 41, 45, 51, and 52 are level III
ther cases of neurologic deterioration adult trauma patient is a critical as- studies. References 4, 5, 21, 25, 30,
from flexion-extension radiographs sessment. The objective of this pro- 31, 35, 37, 39, 40, 44, 46, and 48 are
have been noted.52 We therefore do cess is to efficiently exclude the pres- level IV studies. References 6-8, 15,
not recommend their use in the ob- ence of a significant injury. This 19, 22, 27, 34, and 43 are level V
tunded patient.15,27,52 should occur in all blunt trauma pa- expert opinion.
tients in an orderly and timely man-
Upright Radiograph ner. Patients can be classified into Citation numbers printed in bold type
An alternative to dynamic radio- four groups: asymptomatic, tempo- indicate references published within
graphs is an upright lateral radio- rarily nonassessable, symptomatic, the past 5 years.
graph as a potentially functional test. and obtunded. Clearance of the
This is often used as an initial assess- asymptomatic patient (group 1) on 1. Hoffman JR, Mower WR, Wolfson AB,
ment of stability in the nonsurgical clinical assessment without radiogra- Todd KH, Zucker MI: Validity of a set of
treatment of a patient with spinal phy has been established by level I clinical criteria to rule out injury to the
fracture. Harris et al42 recently evalu- evidence. The asymptomatic but cervical spine in patients with blunt
ated the efficacy of this in evaluating temporarily nonassessable patient trauma: National Emergency
obtunded patients. They could not (group 2) has been described only re- X-Radiography Utilization Study Group.
find a single case in which the up- cently and requires further investiga- N Engl J Med 2000;343:94-99.
right radiograph identified an injury tion. The authors recommend that a
after a negative CT finding and, group 2 patient be immobilized for 2. Roberge RJ, Wears RC: Evaluation of
thus, did not believe this was an ef- 24 to 48 hours until mentation be- neck discomfort, neck tenderness, and
fective screening tool. comes normal and distracting in- neurologic deficits as indicators for
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graphic evaluation. Such patients initially evaluated by CT or plain ra- dislocations of the cervical spine: An
should be expeditiously evaluated so diographs. A consensus on how to analysis of three hundred hospitalized
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moved and restrictions eliminated. J Bone Joint Surg Am 1979;61:1119-
1142.

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6. Eubanks JD, Gilmore A, Bess S,
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Clearing the Cervical Spine in the Blunt Trauma Patient

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