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Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth

Rose, Melanie K. MD; Rosal, Lindy M. BS; Gonzalez, Richard P. MD; Rostas, Jack W. MD; Baker, Jeremy A. BS; Simmons, Jon D. MD; Frotan, Mohammed A. MD; Brevard, Sydney B. MD

Journal of Trauma and Acute Care Surgery: August 2012 - Volume 73 - Issue 2 - p 498–502
doi: 10.1097/TA.0b013e3182587634
EAST 2012 POSTER PAPERS
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OBJECTIVE The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant “distracting injuries.”

METHODS During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of “distracting injuries.” Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with “distracting injuries,” including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. “Distracting injuries” were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a “distracting injury.”

RESULTS During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one “distracting injury” had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with “distracting injuries” had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with “distracting injuries” were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with “distracting injuries.”

CONCLUSIONS In the awake and alert blunt trauma patient with “distracting injuries,” clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with “distracting injuries.” These findings suggest the concept of “distracting injury” in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with “distracting injuries” allows for significant reduction of both healthcare cost and radiation exposure.

LEVEL OF EVIDENCE Diagnostic study, level I.

From the Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of South Alabama, Mobile Alabama.

Submitted: December 21, 2011, Revised: March 28, 2012, Accepted: April 2, 2012.

This study was presented as a poster at the 25th annual meeting of the Eastern Association for the Surgery of Trauma, January 10–14, 2012, in Lake Buena Vista, Florida.

Address for reprints: Richard P. Gonzalez, MD, Division of Trauma, Critical Care, Burn and Acute Care Surgery, Department of Surgery, University of South Alabama, 2451 Fillingim St., Mobile, Alabama 36617; email: rgonzalez@usouthal.edu.

© 2012 Lippincott Williams & Wilkins, Inc.