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Cervical spine collar clearance in the obtunded adult blunt trauma patient

2015; Lippincott Williams & Wilkins; Volume: 78; Issue: 2 Linguagem: Inglês

10.1097/ta.0000000000000503

2163-0763

Mayur B. Patel, Stephen S. Humble, Daniel C. Cullinane, Matthew Day, Randeep S. Jawa, Clinton J. Devin, Margaret S. Delozier, Lou M. Smith, Miya A. Smith, Jeannette Capella, Andrea Long, Joseph Cheng, Taylor C. Leath, Yngve Falck‐Ytter, Elliott R. Haut, John J. Como,

Spine and Intervertebral Disc Pathology

BACKGROUND With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question: In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? METHODS Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (Registration Number: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition. Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. RESULTS Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. CONCLUSION In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. LEVEL OF EVIDENCE Systematic review, level III.