1. Clearing the C Spine in the obtunded patient
Dr Colette Coyle
ICM ST7
15/11/17

2. Background C spine injury occurs in 2-4% of blunt traumas.
Neurological impairment 33-54%.
Poor functional outcome.
Devastating physical, emotional, financial, social implications.
Key is speedy identification, protection and management.
Also minimise risks of prolonged immobilisation, unnecessary imaging.
Reduce/eliminate missed injuries.

3. Practice at RLH
Conscious co-operative patients should have spinal assessment with combination of clinical exam and radiological investigation if clinical area of concern (Plain films or CT).
CT scan of whole spine is performed where clinical clearance not possible.
Spine not considered "clear" unless report finalised by radiologist holding FRCR (should be always cover 24 hours)
Any documented neurology requires discussion with spinal team/radiology +/- MRI scan.

4. PICO Question Population- Adult blunt trauma patients who are obtunded
Intervention- Should we stop spinal precautions after negative CT scan?
Comparator- Should we perform adjunctive investigation after negative CT scan before removing spinal precautions?
Outcome- Reduce/ missed unstable C spine injuries

5. Results Badhiwala et al, 2015- systematic review, 28 studies.
? role for further routine imaging or prolonged immobilisation in excluding significant C spine injury after negative CT scan in obtunded blunt trauma patients.
Interested in number of significant C spine injuries missed on CT, detected by confirmatory test.
3 groups- MRI, dynamic imaging, repeated clinical exam
MRI % instability, 0-7.3% surgery, % prolonged immobilisation (20 studies)
Clinical examination- 0% deemed as unstable needing intervention (5 studies)
Dynamic imaging % unstable/needed operation (3 studies)
Higher quality studies- (1686 pts) 0% requiring further management
CONCLUDE
C Spine clearance after negative CT from well-interpreted high quality scan is probably safe practice.
MRI detects soft tissues injuries- stable, use of collars varies following this
10 of 1555 pts had operation following MRI- poor quality scan and interpretation

6. Results EAST, 2015, systematic review 12 studies 1735 patients
no new neurologic changes after collar removal
9% incidence of stable injury with adjunctive MRI
negative predictive value of CT was 100% for an unstable C spine injury, 91% for stable injury.
Conclude
In obtunded blunt trauma patients , recommend cervical collar removal after CT based on high negative predictive value of high quality CT.
MRI increases cost, creates unnecessary treatment plans, risk of transfer, results in same conclusion - collar removal.

7. Results Raza et al, Meta-analysis 2013 10 studies, 1850 patients
negative predictive value 99.7%
no patient had an injury that required change in clinical management
Conclude
Normal CT scan is conclusive to safely rule out clinically significant injury

8. So what?
Vast majority of patients negative CT scan of high quality, reported well is sufficient to clear
but…….
MRI may have a role- High index of suspicion if significant flexion/extension injury, clinical suspicion of cord injury- unexplained shock- this is difficult, talk to neurosurgeons/spinal surgeons, highly abnormal CT scan, difficult to interpret.

9. unconscious adult trauma patients survey, level 4 27 units UK
country
Patient Group
Study type/level
Outcomes
Key Results
Badhiwala et al 2015, Canada
Obtunded blunt trauma- CT scan plus confirmatory test- MRI, dynamic imaging
systematic review, level 3
Number of missed significant injuries on CT detected on additional test
3627 patients
Jones et al 2004, London
unconscious adult trauma patients
survey, level 4
practice of imaging modality used to clear c spines
27 units UK
Patel et al, 2015, USA
obtunded blunt trauma patients
no missed unstable injuries
1735 patients
Raza et al, 2013, UK
blunt trauma, altered sensorium undergoing CT to clear C spine
Meta-analysis and cohort study
10 studies, 1850 patients