Sanchez B, Waxman K, Jones T, Conner S, Chung R, Becerra S. The Journal of Trauma Injury, Infection, and Critical Care. 2005;59:179-183.
INTRODUCTION
Injuries to the cervical spine occurs in 2% to 6% of blunt trauma cases. These injuries continue to be difficult to identify by use of plain films. The sensitivity of plain radiographs to detect cervical spine injuries is only 85% to 90%. There is a need for prompt identification of cervical spine injuries. Computed tomography (CT) scans are being used in screening for cervical spinal injury in patients who cannot be clinically cleared.
ABSTRACT
This article utilized a prospective design to evaluate the efficacy and safety of a cervical spine protocol for blunt trauma patients. The cervical spine protocol allowed for clearing patients' cervical spine based on clinical criteria, and helical CT, instead of plain radiographs, for patients who could not be clinically cleared.
Data were collected from January 1999 to December 2002 at a Level II Trauma center. The authors selected all patients admitted for blunt trauma, including those with closed head injuries (ie, Glasgow Coma Scale <15 and loss of consciousness). All patients were evaluated in the emergency department by the Trauma team where the decision was made to clear the cervical spine either clinically or by CT scanning with sagittal reformats when clinical clearance could not be given. For any patients who had neurologic deficits, a magnetic resonance image was obtained. Patients were clinically cleared when there was no evidence of neurologic injury, alcohol, drug intoxication, altered mental status, or distracting injury, and the result of physical examination was negative.
This study evaluated 2,854 trauma patients with an average age of 37 years. The male to female ratio was 69% to 31%, respectively. Of these patients evaluated, 2,603 (91%) had blunt trauma. Of the blunt trauma patients, 1,462 (56%) had a closed head injury. Fifty-eight percent of the closed head injury patients were clinically cleared, and 36.7% required radiographic evaluation with a helical CT scan. One hundred (4%) of the total patients admitted for blunt trauma had a cervical spine and/or spinal cord injury, 20% presented with neurological deficits on arrival. Of the 100 cervical spine injury patients, 99 (99%) were identified by the protocol used in this study.
The authors concluded that the use of a cervical spine protocol that utilizes clinical findings, and helical CT scans would be appropriate to use in clearing cervical spines. The sensitivity and predictive values of this study were very high (99-100%). The authors did recognize the disadvantage of cost with a helical CT scan as opposed to plain radiographs. However, they noted that plain radiographs have a low sensitivity that leads to higher care costs for missed injuries and their consequences (19 references).
COMMENTARY
The authors of this study found a high sensitivity for detection of cervical spine injuries with the use of spiral CT scanning. This has profound implications for patients' care. The removal of a cervical collar also removes any "stigma" that may be associated with caring for patients in spinal precaution, thereby allowing caregivers to freely reposition the patient, thus decreasing complications and expediting their recovery without additional sequelae. The authors did recognize that the cost of using CT scans is initially significantly higher than using plain radiographs. However, the true cost of a cervical spine CT scan was determined to be minimal when it was performed concurrently with other CT scans required for patient management. Also, for moderate to high-risk groups, the cost of plain radiographs were suggested to be higher because of their low sensitivity, therefore creating a need to obtain further images.
The authors suggested that further study be done on comatose patients with unremarkable CT scans and no neurologic deficits who undergo magnetic resonance imaging. They hypothesize that the frequency of missed injuries in this population would remain low and that the CT scan would still have a high sensitivity of detection.
Reviewer Information: Darlene Dereczyk, BSN, RN, is the Trauma Clinical Coordinator and Patti Kunkel, BSN, RN, is the Trauma Injury Prevention Outreach Coordinator at Henry Ford Health System in Detroit, Mich.