Clinical Clearance of the Cervical Spine in the Presence of a Distracting Injury

Abstract

Introduction: Clearance of cervical spine injuries is essential in blunt trauma patients. Commonly used screening guidelines (NEXUS and Canadian C-spine rules) consider a negative physical examination unreliable in patients with distracting injuries (DI) and require further radiographic imaging to rule out cervical spine injury. Recent literature advocates for more judicious radiographic criteria in patients with DI, citing resource utilization concerns and new data showing improved safety. We aim to review the current evidence for recommendations when clearing the cervical spine in blunt trauma patients who are alert, awake, have no neurologic deficits but do have distracting injuries.Methods: We performed a literature review of PubMed, Cochrane Evidence-Based Medicine, and guidelines from Eastern Association for the Surgery of Trauma (EAST), Western Trauma Association (WTA) and Advanced Trauma Life Support (ATLS) to include five relevant studies from 2001 to 2019.Results: There are few studies, with no randomized controlled trials, evaluating clearance of the cervical spine in blunt trauma patients with DI. The missed rate of cervical spine injuries in DI patients ranged from 0.2% to 13%. The definition of DI had varied definitions without consistency throughout the studies. Multiple studies showed an association with a higher miss rate in upper torso DI compared to lower torso. The EAST, WTA, and ATLS guidelines adhere closely to the NEXUS and Canadian C-Spine rules and include additional imaging for patients with DI.Recommendation: Blunt trauma patients who are alert, awake, without neurologic deficits but do have distracting injuries require additional imaging to clear the cervical spine. However, omission of additional imaging may be considered in patients with isolated lower torso distracting injuries.KeywordsCervical spine injuryDistracting injurySpine clearance