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

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.

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.

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

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- 0-1.5% instability, 0-7.3% surgery, 0-29.5% prolonged immobilisation (20 studies) Clinical examination- 0% deemed as unstable needing intervention (5 studies) Dynamic imaging- 0-0.2% 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

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.

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

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.

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