Clearing the cervical spine in trauma patients happens many times a day in every Level 1 trauma center in America, and it is potentially one of the most time and resource intensive aspects of caring for injured patients. Given the relatively low rate of subtle yet unstable cervical spine fractures and the high cost—both in terms of patient quality of life and litigation—of missed injuries, cervical spine clearance can seem like a high stakes game of finding a needle in a haystack. To help trauma centers clear the spine in the safest, most cost effective manner, the Eastern Association for the Surgery of Trauma (EAST) published clinical practice guidelines for cervical spine clearance in 2009.1 Five years have elapsed since the publication of those guidelines, and Dr. Theologis and his colleagues from San Francisco wanted to determine to what extent these guidelines were being followed across America. In order to determine this, they conducted a survey of 191 Level 1 trauma centers across the U.S., with a remarkable 87% responding. They found that only 57% of trauma centers had written protocols. Of those with cervical spine clearance protocols, 43% followed the guidelines for clinical clearance in the asymptomatic patient, 60% followed recommendations for initial imaging (i.e. CT scan), 76% complied with the guidelines for patients with neck pain and a normal CT scan, and 60% followed the guidelines for dealing with obtunded patients. Most disappointingly, 8% still had recommendations for passive flexion-extension radiographs in the obtunded patient, despite clear evidence that this technique is not effective and potentially dangerous.
The current study offers a telling snapshot on how cervical spine clearance is done in American trauma centers. While the existence of a formal written protocol at 57% of trauma centers is clearly an improvement compared to what likely existed twenty years ago, 100% of institutions should have such a protocol. Additionally, a large proportion of the protocols did not follow the most recent EAST guidelines. There are likely a variety of factors that contribute to this, including that some of the recommendations are not based on high level evidence, some institutions may have limited access to MRI scanners during off-hours, some may have wanted to reduce radiation exposure associated with CT scans, and some may simply be slow to adopt new recommendations and formally update their protocols. The two situations that tend to be most difficult to resolve in an expeditious, cost-effective manner are the patient with persistent neck pain and a normal CT scan and the obtunded patient with a normal CT scan. In the patient with persistent neck pain and a normal CT scan, the EAST guidelines suggest they can be treated in a collar with clinical follow-up, undergo flexion-extension x-rays or be evaluated with MRI. Discharging patients in a collar with re-assessment in two weeks is likely the least expensive approach, though the majority of these patients have no unstable injury and end up wearing a collar unnecessarily. Flexion-extension x-rays are relatively inexpensive, though frequently patients with neck pain cannot generate a sufficient range of motion to make the study useful, and visualizing the craniocervical and cervicothoracic junctions is difficult. While MRI allows for direct imaging of soft-tissue structures, it is expensive and also may identify ligamentous injuries of unclear clinical significance that can lead to unnecessary prolonged collar wear or even unnecessary surgery. In the obtunded patient with a normal CT scan, it is unclear if obtaining an MRI will provide any clinically important information, and transporting these ICU patients in and out of the scanner is potentially dangerous. So despite there being clinical practice guidelines, there are many common scenarios where the evidence does not provide guidance and clinicians taking care of spine patients have to rely on their judgment. However, following a well-designed institution-wide protocol likely allows the spine clearance process to go more smoothly and consistently.
Please read Dr. Theologis’s article on this Topic in the March 1 issue. Let us know if it changes your thoughts about cervical spine clearance and how you deal with these issues in your institution.
Adam Pearson, MD, MS
Associate Web Editor
1. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma 2009;67:651-9.