Clearing the Cervical Spine in Patients with Distracting Injuries: An AAST Multi-Institutional Trial
Bottom line: Negative clinical exam may be sufficient to clear c-spine in awake, alert adult blunt trauma patients, even distracting injury present.
The Article: Khan AD, Liebscher SC, Reiser HC, et al. Clearing the Cervical Spine in Patients with Distracting Injuries: An AAST Multi-Institutional Trial. Journal of Trauma and Acute Care Surgery. September 2018. doi:10.1097/TA.0000000000002063.
The Idea: Judicious use of CT to assess for C-spine injury improves resource utilization; however, missed C-spine injuries could be catastrophic. EAST and NEXUS guidelines suggest the need for imaging if distracting injury (DI) is present. Recent single center trials suggest that negative physical exam may be sufficient to clear C-spine, even in the presence of DI.
The Study: This was a prospective trial from 2014-2017 at 8 trauma centers which enrolled 2929 patients. Inclusion criteria: 18+ yo, blunt trauma, GCS >or= 14. All patients underwent a standardized clinical evaluation to assess for C-spine injury, then underwent CT C-spine regardless of clinical evaluation result.
Standardized clinical evaluation:
Questioning and physical exam to assess for neurological deficits. It none identified, C-collar removed and manual in-line stabilization initiated
Asked about neck pain. If none, neck examined
Palpation of posterior neck to assess for midline and lateral tenderness. If none, ROM assessed.
Flexion and extension to assess for pain with ROM. If negative, additional ROM assessed.
45 degree rotation to both directions to assess for pain with ROM. If negative, evaluation considered negative.
Cervical collar replaced or removed depending on institutional protocol.
Distracting injuries were noted after full trauma evaluation, and included: skull fx, >2 facial bone fx, mandible fx, ICH, >2 rib fx, clavicle fx, sternal fx, pelvic fx, intra-abd injury, thoracolumbar spine fx, femur fx, tib fib fx, humerus fx, rad/ulna fx, hip or shoulder dislocation
Primary endpoint: injury missed by physical exam but subsequently detected by CT. They also looked at the effect of DI on miss rate.
Results: Twenty-five of 222 (11.3%) of C-spine injuries detected on CT were missed by clinical evaluation. There was no difference in rate of clinically missed injury when comparing patients with distracting injury vs without (10.4% vs 12.6%). One of 25 clinically missed C-spine injuries required surgical intervention (ORIF), but there were no complications from clinically missed injury.
Sensitivity of physical exam in detecting C-spine injury: 89.6% (+DI), 87.4% (-DI). Specificity of physical exam in detecting C-spine injury: 88.7% (+DI), 78.0% (-DI)
The Takeaway: Guidelines suggest that DI limits the sensitivity of clinical evaluation for C-spine injury. However, in this study, they found no difference in rate of clinically missed injury with or without DI (10.4% vs 12.6%), with sensitivities of 89.6% (+DI) vs 87.4% (-DI).
However, the rate of clinical missed C-spine injury was unacceptably high (11.3%), which suggests that a different clinical assessment protocol should be used. Authors suggest that this may be due to the fact that all patients underwent CT C-spine, so the risk of incomplete assessment was low. They also note that the level of training of trauma team member was unrestricted, so less experienced providers may have missed more injuries.
Limitations: There is no consensus definition of “distracting injury.” The authors attempted to standardize this, though they chose their definition simply to remain consistent with previous studies. Furthermore, no a priori power analysis was performed, so the study was possibly underpowered.