Cervical Spine Collar Clearance in the obtunded adult blunt trauma patient: A systematic review and
Patel et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for Surgery of Trauma. J Trauma Acute Care Surg 2015 Feb;78(2):430-41. DOI:10.1097/TA.0000000000000503
Cervical Spine Collar Clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for Surgery of Trauma
To find an evidence-based response to the question: in the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high quality cervical spine CT scan alone, or after a negative high quality C-spine CT result combined with adjunct imaging to reduce peri-clearance events such as new neurologic change, unstable C-spine injury, stable C–spine injury, need for post-clearance imaging, false negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance.
The authors performed a literature review for blunt trauma patients age 16 or older who underwent CT C-spine with axial thickness of less than 3mm and who were obtunded. The definition if obtunded was broad in this study and included GCS <15, use of words intubated, unreliable exam, altered, intoxicated, unconscious. The primary outcome was critical outcomes that were graded on a scale of 1-9, with a score of 9 being the most serious. For example, scores of 1-2 were the outcomes time to C-collar removal and C-collar pressure ulcers, whereas scores of 8-9 were neurologic change after C-collar removal including paraplegia and quadriplegia or unstable injury. All studies were pre-post or partial cohort and were composed of retrospective and prospective studies. Adjunct study modalities to CT C-spine included MRI, flex-ex neck radiographs, and in-hospital clinical follow up. As there were no RCTs or cohort studies included, a meta-analysis could not be performed.
All of the data was biased or bias was unable to be assessed, had serious study limitations, and had very low to moderate overall quality of evidence. Overall there was a 9% incidence of stable injuries after combined CT C-spine with adjunct study modality in a population of 1718 patients in 11 studies. There were no unstable injuries reported. The negative predictive value for C-spine CT was 100% for unstable C-spine injury and 91% for any stable C-spine injury.
The Take Away
The authors of the study recommended conditional C-collar removal of the obtunded trauma patient with a negative high quality CT C-spine alone. They state that additional testing would unnecessarily increase costs, put patients at risk for false positive reads, and risk further injury of critical patients in moving them for further imaging. As any missed injury is most likely to be a stable injury, further diagnostics would not change a patient’s immediate treatment plan, as the treatment of stable C–spine injuries is controversial (immobilization vs early mobilization). Overall, it is reasonable to consider C-collar removal in the obtunded patient with a negative CT C-spine, although it should be noted that this recommendation is based on a study comprised of very low quality data and further studies are necessary to fully assess a true risk of injury with this clinical decision.