Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial

Kenji Inaba, Saskya Byerly, Lisa D. Bush, Matthew J. Martin, David T. Martin, Kimberly A. Peck, Galinos Barmparas, Matthew J. Bradley, Joshua P. Hazelton, Raul Coimbra, Asad J. Choudhry, Carlos V R Brown, Chad G. Ball, Jill R. Cherry-Bukowiec, Clay Cothren Burlew, Bellal A Joseph, Julie Dunn, Christian T. Minshall, Matthew M. Carrick, Gina M. BergDemetrios Demetriades

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

BACKGROUND For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. METHODS This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. CONCLUSIONS For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.

Original languageEnglish (US)
Pages (from-to)1122-1129
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume81
Issue number6
DOIs
StatePublished - Dec 1 2016
Externally publishedYes

Fingerprint

Wounds and Injuries
Tomography
Spine
Radiography
Central Cord Syndrome
Emergencies
Thorax
Nervous System Malformations
Blood Pressure
Sensitivity and Specificity
Glasgow Coma Scale
Injury Severity Score
Trauma Centers
Intraoperative Complications
Neurologic Examination
Neurologic Manifestations
Multicenter Studies
Observational Studies
Magnetic Resonance Imaging
Outcome Assessment (Health Care)

Keywords

  • Blunt trauma
  • cervical collar
  • cervical spine
  • clearance

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Inaba, K., Byerly, S., Bush, L. D., Martin, M. J., Martin, D. T., Peck, K. A., ... Demetriades, D. (2016). Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial. Journal of Trauma and Acute Care Surgery, 81(6), 1122-1129. https://doi.org/10.1097/TA.0000000000001194

Cervical spinal clearance : A prospective Western Trauma Association Multi-institutional Trial. / Inaba, Kenji; Byerly, Saskya; Bush, Lisa D.; Martin, Matthew J.; Martin, David T.; Peck, Kimberly A.; Barmparas, Galinos; Bradley, Matthew J.; Hazelton, Joshua P.; Coimbra, Raul; Choudhry, Asad J.; Brown, Carlos V R; Ball, Chad G.; Cherry-Bukowiec, Jill R.; Burlew, Clay Cothren; Joseph, Bellal A; Dunn, Julie; Minshall, Christian T.; Carrick, Matthew M.; Berg, Gina M.; Demetriades, Demetrios.

In: Journal of Trauma and Acute Care Surgery, Vol. 81, No. 6, 01.12.2016, p. 1122-1129.

Research output: Contribution to journalArticle

Inaba, K, Byerly, S, Bush, LD, Martin, MJ, Martin, DT, Peck, KA, Barmparas, G, Bradley, MJ, Hazelton, JP, Coimbra, R, Choudhry, AJ, Brown, CVR, Ball, CG, Cherry-Bukowiec, JR, Burlew, CC, Joseph, BA, Dunn, J, Minshall, CT, Carrick, MM, Berg, GM & Demetriades, D 2016, 'Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial', Journal of Trauma and Acute Care Surgery, vol. 81, no. 6, pp. 1122-1129. https://doi.org/10.1097/TA.0000000000001194
Inaba, Kenji ; Byerly, Saskya ; Bush, Lisa D. ; Martin, Matthew J. ; Martin, David T. ; Peck, Kimberly A. ; Barmparas, Galinos ; Bradley, Matthew J. ; Hazelton, Joshua P. ; Coimbra, Raul ; Choudhry, Asad J. ; Brown, Carlos V R ; Ball, Chad G. ; Cherry-Bukowiec, Jill R. ; Burlew, Clay Cothren ; Joseph, Bellal A ; Dunn, Julie ; Minshall, Christian T. ; Carrick, Matthew M. ; Berg, Gina M. ; Demetriades, Demetrios. / Cervical spinal clearance : A prospective Western Trauma Association Multi-institutional Trial. In: Journal of Trauma and Acute Care Surgery. 2016 ; Vol. 81, No. 6. pp. 1122-1129.
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abstract = "BACKGROUND For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. METHODS This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5{\%}) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3{\%}] unevaluable/distracting injuries, 5,040 [49.0{\%}] midline C-spine tenderness, 576 [5.6{\%}] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9{\%}) had a clinically significant C-spine injury requiring surgery (153 [1.5{\%}]) or halo (25 [0.2{\%}]) or cervical-thoracic orthotic placement (20 [0.2{\%}]). The sensitivity and specificity for clinically significant injury were 98.5{\%} and 91.0{\%} with a negative predictive value of 99.97{\%}. There were three (0.03{\%}) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. CONCLUSIONS For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5{\%}. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.",
keywords = "Blunt trauma, cervical collar, cervical spine, clearance",
author = "Kenji Inaba and Saskya Byerly and Bush, {Lisa D.} and Martin, {Matthew J.} and Martin, {David T.} and Peck, {Kimberly A.} and Galinos Barmparas and Bradley, {Matthew J.} and Hazelton, {Joshua P.} and Raul Coimbra and Choudhry, {Asad J.} and Brown, {Carlos V R} and Ball, {Chad G.} and Cherry-Bukowiec, {Jill R.} and Burlew, {Clay Cothren} and Joseph, {Bellal A} and Julie Dunn and Minshall, {Christian T.} and Carrick, {Matthew M.} and Berg, {Gina M.} and Demetrios Demetriades",
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T1 - Cervical spinal clearance

T2 - A prospective Western Trauma Association Multi-institutional Trial

AU - Inaba, Kenji

AU - Byerly, Saskya

AU - Bush, Lisa D.

AU - Martin, Matthew J.

AU - Martin, David T.

AU - Peck, Kimberly A.

AU - Barmparas, Galinos

AU - Bradley, Matthew J.

AU - Hazelton, Joshua P.

AU - Coimbra, Raul

AU - Choudhry, Asad J.

AU - Brown, Carlos V R

AU - Ball, Chad G.

AU - Cherry-Bukowiec, Jill R.

AU - Burlew, Clay Cothren

AU - Joseph, Bellal A

AU - Dunn, Julie

AU - Minshall, Christian T.

AU - Carrick, Matthew M.

AU - Berg, Gina M.

AU - Demetriades, Demetrios

PY - 2016/12/1

Y1 - 2016/12/1

N2 - BACKGROUND For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. METHODS This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. CONCLUSIONS For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.

AB - BACKGROUND For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. METHODS This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. CONCLUSIONS For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.

KW - Blunt trauma

KW - cervical collar

KW - cervical spine

KW - clearance

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