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Clearance of the Cervical Spine in Clinically Unevaluable Trauma Patients

Halpern, Casey H. MD*; Milby, Andrew H. MD†; Guo, Wensheng PhD‡; Schuster, James M. MD, PhD*; Gracias, Vicente H. MD§; Stein, Sherman C. MD*

doi: 10.1097/BRS.0b013e3181e9acb2
Health Services Research

Study Design. Meta-analytic costeffectiveness analysis.

Objective. Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries.

Summary of Background Data. We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use.

Methods. Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies.

Results. Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%–60%). Sensitivities for CT and MRI alone were 83% (82%–84%) and 87% (84%–89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low.

Conclusion. As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.

We performed a structured review and cost-effectiveness analysis to compare cervical spine management strategies in clinically unevaluable patients. Commonly used clearance tests lack sufficient sensitivity to compete with empiric collar application until responsiveness is regained. Even theoretical tests with perfect sensitivity are unlikely to be more cost-effective than collar application.

From the *Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, PA; †Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA; ‡Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; and §Division of Trauma and Surgical Critical Care, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA.

Acknowledgment date: March 27, 2009. Revision date: May 9, 2009. Acceptance date: May 15, 2009.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Sherman C. Stein, MD, Department of Neurosurgery, University of Pennsylvania Medical Center, 3rd Floor, Silverstein Pavilion, Philadelphia, PA 19104; E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.