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

Inaba, Kenji MD; Byerly, Saskya MD; Bush, Lisa D. MPAS; Martin, Matthew J. MD; Martin, David T. MD; Peck, Kimberly A. MD; Barmparas, Galinos MD; Bradley, Matthew J. MD; Hazelton, Joshua P. DO; Coimbra, Raul MD, PhD; Choudhry, Asad J. MBBS; Brown, Carlos V.R. MD; Ball, Chad G. MD, MSC; Cherry-Bukowiec, Jill R. MD, MS; Burlew, Clay Cothren MD; Joseph, Bellal MD; Dunn, Julie MD, MS; Minshall, Christian T. MD, PhD; Carrick, Matthew M. MD; Berg, Gina M. PhD, MBA; Demetriades, Demetrios MD, PhDthe WTA C-Spine Study Group

Journal of Trauma and Acute Care Surgery: December 2016 - Volume 81 - Issue 6 - p 1122–1130
doi: 10.1097/TA.0000000000001194
WTA 2016 Plenary Papers

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.

LEVEL OF EVIDENCE Diagnostic tests, level II.

From the LAC+USC Medical Center (K.I., S.B., D.D.), Los Angeles, California; Trauma and Acute Care Surgery Service (L.D.M., M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon; Oregon Health and Science University (D.M.), Portland, Oregon; Scripps Mercy Hospital (K.A.P.), San Diego, California; Cedars-Sinai Medical Center (G.B.), Los Angeles, California; R Adams Cowley Shock Trauma Center (M.J.B.), University of Maryland School of Medicine, Baltimore, Maryland; Cooper University Hospital (J.P.H.), Camden, New Jersey; University of California (R.C.), San Diego, San Diego, California; Mayo Clinic (A.J.C.), Rochester, Minnesota; University Medical Center at Brackenridge (C.V.R.B.), Austin, Texas; University of Calgary–Foothills Medical Center (C.G.B.), Calgary, Alberta, Canada; University of Michigan (J.R.C-B.), Ann Arbor, Michigan; Denver Health Medical Center (C.C.B.), Denver, Colorado; Banner University Medical Center (B.J.), Tucson, AZ; University of Colorado Health–Medical Center of the Rockies (J.D.), Loveland, Colorado; Parkland Memorial Hospital (C.T.M.), University of Texas Southwestern, Dallas, Texas; Medical Center of Plano (M.M.C.), Plano, Texas; and Wesley Medical Center (G.M.B.), Wichita, Kansas.

Submitted: February 16, 2016, Revised: May 17, 2016, Accepted: May 19, 2016, Published online: July 20, 2016.

This study was presented at the 46th annual meeting of the Western Trauma Association, February 28–March 4, 2016, in Lake Tahoe, California.

Address for reprints: Kenji Inaba, MD, Division of Trauma & Surgical Critical Care, University of Southern California, LAC+USC Medical Center, 2051 Marengo St, IPT, C5L100, Los Angeles, CA 90033; email:

© 2016 Lippincott Williams & Wilkins, Inc.