Cervical Spine Clearance Protocol Research Articles

Variability of Pediatric Cervical Spine Clearance Protocols: A Systematic Review.

The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center.

Adult studies have demonstrated the efficacy of written protocols for clearance of the cervical spine. However, less than half of recently surveyed pediatric trauma centers report using a documented protocol. Little data exists on such protocols in pediatric populations, but interest remains because of potential reductions in radiation exposure, time to clearance, hospital stay, and specialist referral. However, missed injury can have devastating consequences. The purpose of this study is to examine the efficacy in detecting injury of an implemented cervical spine clearance protocol at a level-1 pediatric trauma hospital. A retrospective review was performed on pediatric patients presenting as activated traumas to the emergency department of a single level-1 pediatric trauma hospital between May 2010 and October 2018. This institution has utilized a written cervical spine clearance protocol throughout this time. Presence of cervical spine injury, documented clearance, cervical spine imaging, and follow-up documentation were reviewed for any missed injuries. There were no missed cervical spine injuries. Five-hundred sixty-three clinically significant cervical spine injuries were identified, representing 16.5% of patients. Of these, 96 were fractures, dislocations, or ligamentous injuries, representing 2.8% of all patients. Most cervical spine clearances were performed by trauma surgery. Advanced imaging of the cervical spine was ordered for 43.2% of patients overall and trended down over time. Documented cervical spine clearance protocols are effective for detection of significant injury in pediatric trauma patients. This study suggests these protocols minimize risk of missed injury and may prevent unnecessary radiation exposure, delayed clearance, prolonged hospitalization, or unnecessary specialist referral. Utilization of a standard written protocol for cervical spine clearance likely prevents missed injury and helps to minimize radiation exposure in pediatric populations. Further research is needed on evaluation and management of pediatric cervical spine trauma.

A Retrospective Pilot Study for Preoperative Screening to Prevent Iatrogenic Cervical Spinal Cord Injury.

Purpose: The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series.Methods: Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure.Results: There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman’s and Spurling’s sign, independently, were significantly associated with a positive neck extension exam (p<0.05). Fourteen patients were recommended for cervical decompression prior to planned procedure.Conclusions: Our preoperative cervical spine clearance protocol is safe and may aid in identifying patients susceptible to iatrogenic cervical spine injury.

Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination.

The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination. We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS. A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18min, p < 0.0001) and time to collar removal (median: 1042 vs. 49min, p < 0.0001) were significantly greater at the US trauma center. Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.

Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group

BACKGROUND: One recent survey of Level One Pediatric Trauma Centers shows only 46% of institutions utilize a standardized, written pediatric cervical spine clearance protocol. This study aims to create an expert, multi-disciplinary consensus statement and algorithm for pediatric cervical spine clearance by employing a modified Delphi method. METHODS: The Pediatric Cervical Spine Working Group is comprised of pediatric orthopaedic surgeons (n=15), pediatric emergency medicine physicians (n=3), pediatric trauma …

"Next Day" Examination Reduces Radiation Exposure in Cervical Spine Clearance at a Level 1 Pediatric Trauma Center: Preliminary Findings.

Safe and effective clearance of the pediatric cervical spine presents a challenging problem due to a myriad of reasons, which has often led to further imaging studies such as computed tomographic (CT) scans being performed, exposing the pediatric patient to significant radiation with a potential increased cancer risk. The goal of this study is to develop an effective algorithm for cervical spine clearance that minimizes radiation exposure. A cervical spine clearance protocol had been utilized in our institution from 2002 to 2011. In October 2012, the protocol was revised to provide indications for appropriate imaging by utilizing repeat "next day" physical examination. In 2014, the protocol was again revised with the desired goal of decreasing the use of CT scans through increased involvement of the Spine Service. A retrospective review was commenced using information from the Trauma Database from 2011 to 2014. Three groups were analyzed according to which protocol the patients were evaluated under: 2011, 2012, and 2014 protocols. During the study period, 762 patients underwent cervical spine clearance; 259 (2011 protocol), 360 (2012 protocol), and 143 (2014 protocol). The average age of all patients was 8.8 years, with 28% of patients younger than 5 years of age. There were no missed or delayed diagnoses of cervical spine injury. The use of CT scans decreased during the study period from 90% (2011 protocol) to 42% (2012 protocol) to 28.7% (2014 protocol). There was an increase in time to removal of the cervical collar at 13 to 24 hours from 8% (2011 protocol) to 22% (2012 protocol) to 19% (2014 protocol). This was not associated with an increase in hospital length of stay, which averaged 2.51 days (2011 protocol), 2.45 days (2012 protocol), and 2.27 days (2014 protocol). Repeat "next day" clinical examinations and increased involvement of the Spine Service decreased radiation exposure without compromising the diagnosis of cervical spine injury or increasing the length of stay at a Level One Pediatric Trauma Center in this pilot study. Level 4-case series.

Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol.

Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol. A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol. Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a combination of x-ray and computed tomographic imaging. Only 46% of institutions utilize a written, standardized pediatric cervical spine clearance protocol. This study demonstrates a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is our opinion that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries. Level 4-economic and decision analyses.

Diagnostic accuracy of flexion-extension radiography for the detection of ligamentous cervical spine injury following a normal cervical spine computed tomography.

Flexion-extension radiography (FER) has been utilised for the detection of ligamentous injury in patients who have been cleared of bony injury. Some studies call into question the diagnostic accuracy of FER, the high proportion of inadequate FER images and the adverse effects of prolonged cervical collar immobilisation although awaiting FER. We conducted a two-part retrospective study of trauma patients presenting to a trauma centre between January 2007 and December 2014. A cross-sectional analytic study was used to determine diagnostic accuracy and a case-control design was used to compare characteristics and complications of those having FER with similar patients not having FER. Inclusion criteria were age ≥16, blunt trauma mechanism, a normal computed tomography (CT) of the cervical spine and FER to assess for ligamentous injury. The reference standard was magnetic resonance imaging evidence of ligamentous disruption or a therapeutic intervention to treat ligamentous instability. There were 176 participants meeting inclusion criteria. Studies were considered inadequate in 168 participants (95.5%). There were zero true positives, four false positives, 168 true negatives and four false negatives: sensitivity 0% (0.0-60.2%), specificity 97.7 (94.2-99.4%), positive predictive value 0% (0.0-60.2%) and negative predictive value 97.7 (94.2-99.4%). Participants having FER remained in cervical collars and in hospital longer than control patients. Complications of cervical collar use were uncommon. FER does not contribute additional diagnostic accuracy for the detection of ligamentous injury to the cervical spine following a normal CT of the cervical spine. We recommend FER be removed from cervical spine clearance protocols.

Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review.

Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT). To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury. MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014. English-language studies that examined patients with negative CT results having confirmatory routine testing with magnetic resonance imaging (MRI), dynamic radiography, or clinical examination and that reported outcome measures of missed cervical spine injury, need for operative stabilization, or prolonged use of cervical collars. Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol. Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients). Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly. Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice. None.

Cervical spine clearance protocols in Level I, II, and III trauma centers in California

Background contextCervical spine clearance protocols were developed to standardize the clearance of the cervical spine after blunt trauma and prevent secondary neurologic injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in California is unknown. PurposeTo evaluate the cervical spine clearance protocols in all trauma centers of California. Study designAn observational cross-sectional study. Patient sampleIncluded from Level I, II, III trauma centers in California. Outcome measuresThe self-reported outcomes of each trauma center's cervical spine clearance protocols were assessed. MethodsLevel I (n=15), II (n=30), and III (n=11) trauma centers in California were contacted. Each available protocol was reviewed for four scenarios: clearing the asymptomatic patient, the initial imaging modality used in patients not amenable to clinical clearance, and the management strategies for patients with persistent neck pain with a negative computed tomography (CT) scan and those who are obtunded. Results were compared with the 2009 Eastern Association for the Surgery of Trauma (EAST) cervical spine clearance guidelines. ResultsThe response rate was 96%. Sixty-three percent of California's trauma centers (Level I, 93%; Level II, 60%; Level III, 27%) had written cervical spine clearance protocols. For asymptomatic patients, 83% of Level I and 61% of Level II centers used National Emergency X-Radiography Utilization Study criteria with/without painless range of motion. For those requiring imaging, 67% of Level I and 56% of Level II centers stated a CT scan should be the first line of imaging. For obtunded patients and patients with persistent neck pain and a negative CT scan, more than 90% of Level I and more than 70% of Level II trauma centers incorporated the 2009 EAST recommendations. No institution recommended passive flexion-extension radiographs for the obtunded patient. ConclusionsWritten cervical spine clearance protocols exist in 63% of California's trauma centers and only 51% of the centers have protocols that follow current evidence-based guidelines. Standardization and utilization of these protocols should be encouraged to prevent missed injuries and secondary neurologic injuries.

Cervical Spine Clearance Protocols in Level I, II and III Trauma Centers in California

Cervical spine clearance protocols were developed to standardize the clearance of the cervical spine following blunt trauma and prevent secondary neurological injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the California is unknown.

Cervical Spine Clearance Protocols in Level 1 Trauma Centers in the United States

Observational, cross-sectional. To evaluate cervical spine clearance protocols in level 1 trauma centers in the United States. Cervical spine clearance protocols were developed to prevent missed injuries that could result in neurological deficits. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the United States is unknown. Level 1 trauma (n = 191) centers in the United States were contacted. Each available protocol was reviewed for 4 scenarios: clearing the asymptomatic patient, the imaging used in patients not amenable to clinical clearance, the management strategies for patients with persistent neck pain with a negative computed tomographic (CT) scan, and those who are obtunded. The response rate was 87%. Cervical spine clearance protocols existed in 57% of the institutions. National Emergency X-Radiography Utilization Study criteria to clear asymptomatic patients were recommended in 89% of protocols. Sixty percent of protocols used CT scans as the first line of imaging. In patients with persistent neck pain with negative CT scan flexion-extension plain radiographs were the most common (30%) next step for clearance. In patients who are obtunded, a CT scan followed by a magnetic resonance imaging was the most common method (31%) of clearance. Eight percent of the protocols recommended dynamic flexion-extension views in patients who are obtunded, which are contraindicated. Written cervical spine clearance protocols exist in 57% of level 1 trauma centers in the United States. These protocols are highly variable and standardization and utilization of these protocols should be encouraged in all trauma centers to prevent missed injuries and neurological catastrophes. 4.

Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?

BackgroundThere are variations in cervical spine (CS) clearance protocols in neurologically intact blunt trauma patients with negative radiological imaging but persistent neck pain. Current guidelines from the current Eastern Association for the Surgery of Trauma include options of maintaining the cervical collar or obtaining either magnetic resonance imaging (MRI) or flexion-extension films (FEF). We evaluated the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma. Materials and methodsAll neurologically intact, awake, nonintoxicated patients who underwent FEF for persistent neck pain after negative CT scan of the CS at our level I trauma center over a 13-mo period were identified. Their charts were reviewed and demographic data obtained. ResultsThere were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%—which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative. ConclusionsIn the current era, where cervical CT has universally supplanted initial plain films, FEF appear to be of little value in the evaluation of persistent neck pain. Their use should be excluded from cervical spine clearance protocols in neurologically intact, awake patients.

Pediatric cervical spine clearance: A review and understanding of the concepts

Spinal injuries to children account for somewhere between 1% and 10% of all spinal trauma. Evaluations of cervical spine injuries required multidisciplinary approach for definitive management. Knowing which patients are at highest risk for injuries will undoubtedly influence decisions on how aggressively to pursue a potential cervical spine injury. This can be achieved by establishing a multidisciplinary team that provides standards for cervical spine immobilization, assessment, and clearance. Implementation of such guidelines will decrease time for cervical spine clearance and incidence of missed injuries. In this article different aspect of cervical spine injuries and cervical spine clearance protocols are reviewed.

A pediatric cervical spine clearance protocol to reduce radiation exposure in children

BackgroundTo minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined. MethodsWith institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT. ResultsThere were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head–neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure. ConclusionsImplementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.

Current issues in the diagnosis of pediatric cervical spine injury

Cervical spine injury in pediatric trauma occurs rarely; however, there is significant potential for considerable morbidity when it does occur. Screening for cervical spine injuries has been shown to be most sensitive in adult trauma centers when combined with reliable physical examination findings. Because pediatric trauma patients suffer from a different range of injuries than adults, and often are not reliable due to age limitations or associated head injury, the same strategies employed in adult trauma do not always hold true in children. We look at the differences in adult and pediatric cervical spine anatomy and traumatic mechanisms, as well as the differences between cervical spine injury in infants/children and adolescents/teens. In addition, we examine the literature currently available in each population and derive consensuses on the issues that are important in managing the pediatric cervical spine. We hope to provide a framework that trauma centers can use to develop safe and effective cervical spine clearance protocols.

Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age

Cervical spine clearance after trauma in children 0-3 years of age is deceptively difficult. Young children may not be able to communicate effectively, and severe injuries may require intubation and sedation. Currently, no published guidelines are available to aid in decision-making in these complex situations. The purpose of this study was to determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age. Children 0-3 years of age, including intubated patients, who were admitted after trauma activation at Primary Children's Medical Center in Salt Lake City or the Children's Hospital of New York from 2002 to 2006 were managed according to a cervical spine clearance protocol. Data were collected in a prospective fashion. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were recorded. A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children <or= 3 years of age who were admitted to the hospital. To facilitate clearing the cervical spine in these children, plain radiographs (100%), CT studies (14%), and MR images (10%) were obtained. Nineteen ligamentous injuries (3.3%) and 9 fractures/dislocations (1.5%) were detected, with 4 patients requiring operative stabilization (0.7%). No late injuries have been detected. The protocol used has been effective in detecting cervical spine injuries in noncommunicative children after trauma. The combination of clinical information and radiographic studies is essential for safely clearing the cervical spine in these complex situations. Clearance of the cervical spine without CT or MR imaging studies is possible in the majority of cases, even in very young patients.

Cervical Spine Clearance: A Review and Understanding of the Concepts

Cervical spine injury is relatively rare, occurring in only 2% to 3% of patients with blunt trauma who undergo imaging studies. However, timely and accurate recognition of cervical spine injury is essential for the optimal management of patients with blunt trauma as subsequent morbidity includes prolonged immobilization. Evaluation of cervical spine injuries should begin in the emergency department and involves a combination of pediatric, trauma, orthopedic, and neurosurgeons for definitive management. Knowing which patients are at highest risk for injuries will undoubtedly influence decisions on how aggressively to pursue a potential cervical spine injury and can be achieved by establishing a multidisciplinary team approach that provides cervical spine immobilization, assessment, and clearance. Implementation of such guidelines will decrease time for cervical spine clearance and incidence of missed injuries. In this article different aspects of cervical spine injuries and cervical spine clearance protocols are reviewed.

Magnetic Resonance Imaging (MRI) in the Clearance of the Cervical Spine in Blunt Trauma: A Meta-Analysis

There is a subset of blunt trauma patients that present with symptoms suspicious for cervical spine injury or with unreliable clinical exams whose initial plain radiographs or cervical computed tomography (CT) scan are negative. Uncertainty remains, however, because no gold standard has been established for definitively clearing the cervical spine of injury in this patient cohort. Individual studies have detailed the use of magnetic resonance imaging (MRI) in this patient population without conclusive results. Comprehensive database searches were conducted for prospective or retrospective diagnostic studies of blunt trauma patients who were entered into a cervical spine clearance protocol that included MRI. Inclusion criteria were minimum 30 patients with clinically suspicious or unevaluatable cervical spines, clinical follow-up as the gold standard, data reported to allow the collection of true positives, true negatives, false positives, and false negatives, MRI obtained within 72 hours of injury, and plain radiographs that disclosed nothing abnormal of the cervical spine with or without a CT scan that disclosed nothing abnormal. Log odds meta-analysis of the sensitivity, specificity, positive, and negative predictive value of MRI was performed. Five Level I diagnostic protocols, enrolling 464 patients receiving MRI, were included. There were zero false negatives in the five studies resulting in a negative predictive value of 100%. Log odds meta-analysis produced a 94.2% positive predictive value (95% confidence interval [CI] 75.0, 989), 97.2% sensitivity (95% CI 89.5, 99.3), and 98.5% specificity (95% CI 91.8, 99.7). Ninety-seven (97 of 464, 20.9%) patients had abnormalities identified by MRI that were not identified by plain radiographs with or without CT. A magnetic resonance image that did not disclose anything abnormal can conclusively exclude cervical spine injury and is established as a gold standard for clearing the cervical spine in a clinically suspicious or unevaluatable blunt trauma patient. An accurate number of false positive MRI scans cannot be determined.

LITIGATION OF MISSED CERVICAL SPINE INJURIES IN PATIENTS PRESENTING WITH BLUNT TRAUMATIC INJURY

Approximately 800,000 cervical spines are cleared in emergency departments each year. Errors in diagnosis of cervical spine injury are a potentially huge medicolegal liability, but no established protocol for clearance of the cervical spine is known to reduce errors or delays in diagnosis. The Lexis-Nexis, Westlaw, and Medline databases were queried for cases of missed cervical injury. Errors were categorized according to a novel system of classification. Type I errors occurred when inadequate or improper tests were ordered. Type II errors occurred when adequate tests were ordered, but were either misread or not read. Type III errors occurred when adequate tests were ordered and read accurately, but the ordered test was not sensitive enough to detect the injury. Twenty cases of missed or delayed diagnosis of cervical spine injury were found in 10 jurisdictions. Awards averaged 2.9 million dollars (inflation adjusted to 2002 dollars). Eight cases resulted in verdicts in favor of the defendant, but none of these cases involved an alleged Type II error. Fear of lawsuits encourages defensive medicine and complicates the process of clearing a patient's cervical spine. This analysis adds medicolegal support for the judicious use of imaging studies in current cervical spine clearance protocols. However, exposure to significant liability suggests that a low threshold for computed tomography is a reasonable alternative.