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Cervical Spine Clearance Protocols in Level 1 Trauma Centers in the United States

Theologis, Alexander A., MD; Dionisio, Robert, BS; Mackersie, Robert, MD; McClellan, Robert Trigg, MD; Pekmezci, Murat, MD

doi: 10.1097/BRS.0000000000000147
Cervical Spine

Study Design. Observational, cross-sectional.

Objective. To evaluate cervical spine clearance protocols in level 1 trauma centers in the United States.

Summary of Background Data. Cervical spine clearance protocols were developed to prevent missed injuries that could result in neurological deficits. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the United States is unknown.

Methods. Level 1 trauma (n = 191) centers in the United States were contacted. Each available protocol was reviewed for 4 scenarios: clearing the asymptomatic patient, the imaging used in patients not amenable to clinical clearance, the management strategies for patients with persistent neck pain with a negative computed tomographic (CT) scan, and those who are obtunded.

Results. The response rate was 87%. Cervical spine clearance protocols existed in 57% of the institutions. National Emergency X-Radiography Utilization Study criteria to clear asymptomatic patients were recommended in 89% of protocols. Sixty percent of protocols used CT scans as the first line of imaging. In patients with persistent neck pain with negative CT scan flexion-extension plain radiographs were the most common (30%) next step for clearance. In patients who are obtunded, a CT scan followed by a magnetic resonance imaging was the most common method (31%) of clearance. Eight percent of the protocols recommended dynamic flexion-extension views in patients who are obtunded, which are contraindicated.

Conclusion. Written cervical spine clearance protocols exist in 57% of level 1 trauma centers in the United States. These protocols are highly variable and standardization and utilization of these protocols should be encouraged in all trauma centers to prevent missed injuries and neurological catastrophes.

Level of Evidence: 4

In an observational, survey-based study of all level 1 trauma centers in the United States, 57% of the participating institutions have written cervical spine clearance protocols. Only 60% of the centers have protocols that incorporate the most recent evidence-based recommendations provided by the 2009 Eastern Association for the Surgery of Trauma guidelines.

From the Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California-San Francisco (UCSF)/San Francisco General Hospital (SFGH), San Francisco, CA.

Address correspondence and reprint requests to Alexander Theologis, MD, Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, UCSF/SFGH, 2550 23rd St., Bldg. 9, 2nd Floor, San Francisco, CA 94110; E-mail:

Acknowledgment date: July 10, 2013. Revision date: November 21, 2013. Acceptance date: November 22, 2013.

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

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, expert testimony, consultant, royalties, patents, and stock options.

© 2014 by Lippincott Williams & Wilkins