Clinical question / background:
- In the obtunded blunt trauma patient, can cervical collar be removed after a negative high-quality CT c-spine alone?
Definitions:
- Unstable injuries: fracture or fractures of involving contiguous columns or levels, bone misalignment (subluxations, listhesis, interspinous widening or splaying), or a single-level ligamentous injury involving all three columns.
- Obtunded: GCS<15, altered, intoxicated, intubated, unconscious, and/or unreliable exam.
Design:
- Systematic review
- 1718 subjects in 11 studies
- Inclusion criteria:
- Age 16 or older
- Blunt trauma
- Undergone CT C-spine with axial thickness less than 3mm
- Obtunded – defined as above
- Exclusion criteria:
- Excluded studies that did not specify CT axial thickness or axial thickness greater than 3mm.
Intervention
- Each patient underwent C-spine CT that was read as normal and was then retested with comparator adjunct imaging and/or physical examination.
Outcome:
- Does removal of c-collars in obtunded blunt trauma patients after evaluation by only high-quality c-spine CT change the incidence of peri-clearance events. Listed in order of importance: neurologic change after c-collar removal (paraplegia, quadriplegia), unstable c-spine injury, stable c-spine injury, post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance.
Results:
- In 11 studies, with 1,718 subjects, there were no unstable c-spine injuries missed on CT scan alone. There was a 9% incidence of stable injury: mostly ligamentous injury
- In five studies with 1,017 subjects, there were no new neurologic changes (paraplegia, quadriplegia) following cervical collar removal.
Take-home:
- In the obtunded, blunt trauma patient, C-spine CT scan alone is sufficient to clear cervical spine. There were zero unstable injuries missed and no new neurologic deficits.
Weaknesses / Critiques
- Low quality evidence in included papers. Need further study.
Further reading
