Prevalence of cervical spinal injury in trauma

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Object

Diagnosis of cervical spinal injury (CSI) is an essential aspect of the trauma evaluation. This task is especially difficult in patients who are not clinically able to be evaluated (unevaluable) because of distracting painful injuries, intoxication, or concomitant head injury. For this population, the appropriate use of advanced imaging techniques for cervical spinal clearance remains undetermined. This study was undertaken to estimate the prevalence of unstable CSI, particularly among patients in whom clinical evaluation is impossible or unreliable.

Methods

Estimates of the prevalence of CSI in populations consisting of all trauma patients, alert patients only, and clinically unevaluable patients only were determined by variance-weighted pooling of data from 65 publications (281,864 patients) that met criteria for review.

Results

The overall prevalence of CSI among all trauma patients was 3.7%. The prevalence of CSI in alert patients was 2.8%, whereas unevaluable patients were at increased risk of CSI with a prevalence of 7.7% (p = 0.007). Overall, 41.9% of all CSI cases were considered to exhibit instability.

Conclusions

Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.

Abbreviations used in this paper: CSI = cervical spine injury; GCS = Glasgow Coma Scale.

Abstract

Object

Diagnosis of cervical spinal injury (CSI) is an essential aspect of the trauma evaluation. This task is especially difficult in patients who are not clinically able to be evaluated (unevaluable) because of distracting painful injuries, intoxication, or concomitant head injury. For this population, the appropriate use of advanced imaging techniques for cervical spinal clearance remains undetermined. This study was undertaken to estimate the prevalence of unstable CSI, particularly among patients in whom clinical evaluation is impossible or unreliable.

Methods

Estimates of the prevalence of CSI in populations consisting of all trauma patients, alert patients only, and clinically unevaluable patients only were determined by variance-weighted pooling of data from 65 publications (281,864 patients) that met criteria for review.

Results

The overall prevalence of CSI among all trauma patients was 3.7%. The prevalence of CSI in alert patients was 2.8%, whereas unevaluable patients were at increased risk of CSI with a prevalence of 7.7% (p = 0.007). Overall, 41.9% of all CSI cases were considered to exhibit instability.

Conclusions

Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.

Quadriplegia due to spinal cord injury is a devastating consequence of trauma to the cervical spine, involving numerous functional, psychosocial, and economic ramifications.7,12,13,24,25,27–29,45,49,61 Identification of unstable CSI is therefore an essential aspect of the trauma evaluation in preventing subsequent neurological damage.6,22,71,72,75,76 This task is especially difficult in patients who are not clinically evaluable (unevaluable group) because of intoxication or concomitant head injury, and has led to the use of advanced imaging techniques such as CT and MR imaging for radiological clearance.1,2,15,20,58,83,90,91 Continued advances in imaging quality and sensitivity now raise questions about the practice of clearing even alert, low-risk patients by clinical criteria alone,30 and have precluded the establishment of any consensus regarding the appropriate indications for the use of imaging studies.58,65,67,85,90

Although a lower threshold for the use of advanced imaging would hypothetically result in the detection and possible prevention of a greater number of CSIs, these benefits must be weighed against the associated risks and considerable costs of performing such studies and the additional treatments initiated due to false-positive results.18,19,41,77 Indeed, complications have been reported in 6–71% of critically ill patients during and after transport.94 Accurate knowledge of the prevalence of CSI in trauma patients is therefore essential for assessing the need for immobilization and/or further imaging. Scattered studies of CSI in clinical series composed of all trauma patients report CSI prevalences ranging from 1 to 14%.59,87 However, unevaluable patients require a higher index of suspicion than the general trauma population,5,46,51,64,80,96 with one patient series estimating that a GCS score ≤ 8 incurs an almost 6-fold increase in the risk of CSI.50 Numerous patient series have examined the sensitivities of various imaging modalities in the detection of CSI, and as such represent a large volume of data from which to calculate overall prevalence. However, considerable variation exists in rates of radiographic evidence of CSI, with 1 study reporting CT or MR imaging findings in 40% of obtunded patients.90 By systematically pooling data from relevant clinical series, more generalizable estimates of CSI prevalence in all trauma patients, alert patients, and unevaluable patients with trauma can be determined, along with the proportion of patients whose unstable injuries confer a risk of quadriplegia.

Methods

We performed English-language searches of Medline and PubMed for articles published between 1985 and January 2008. The search used various combinations of the key words “spinal injuries,” “cervical vertebrae,” “instability,” “trauma,” “clearance,” “neck,” “diagnosis,” “epidemiology,” “prevalence,” and “incidence.” We refined the search by eliminating laboratory studies, case reports, editorials, or reviews without newly reported data, and case series with duplicated or overlapping data. These findings were supplemented by using the “Find Similar” and “Find Citing Articles” features of Medline and “Related Articles” feature of PubMed, as well as the bibliographies of selected articles. Articles were analyzed and compared with reference to the setting, study organization, definitions of clinical criteria, and data collection methods. Studies restricted to children < 15 years of age were excluded. If a study reported prevalence rates from pediatric cases separately from those in an adult population, these data were also excluded from the analysis.

Studies meeting our criteria for inclusion were organized into 3 categories: those composed of all trauma patients, alert patients, and unevaluable patients with trauma. Those studies reporting rates of instability upon detection of CSI were also placed into a fourth category, which overlapped in part with the previously listed categories. The “all trauma” category contained series in which patients were not further classified by clinical evaluability on presentation. These series were composed of patients with either unrestricted blunt and penetrating trauma or blunt trauma alone, whereas those composed solely of patients with penetrating trauma were excluded. Patients were deemed alert if they had reliable clinical examination findings, consisting minimally of being able to respond to questions regarding neck pain and cooperate with neck movement instructions. Patients were considered unevaluable if impaired consciousness, inebriation, confusion, endotracheal intubation, or distracting injuries rendered the clinical examination of the cervical spine unreliable. An unstable injury was defined as any fracture, dislocation, or purely ligamentous injury necessitating external stabilization and/or operative fixation. Data concerning unstable injuries were pooled from all series reporting their prevalence without subclassification on the basis of clinical evaluability.

Mean prevalence values for each group were obtained using variance-weighted pooling. A mixed-effects logistic regression model was used, using SAS PROC NLMIXED (SAS, Inc.). Data within each study were considered a cluster and a hierarchical model was used to calculate the average prevalence rate. The binary nature of the outcome allowed the use of summary statistics as a proxy for the entire data set. The effect across studies was assumed to vary as a normal distribution. The overall prevalence rate was calculated as the population-average estimate, together with its 95% confidence intervals. Mean prevalence values for alert and unevaluable patients were compared, using a likelihood ratio test for pooled data.60 We considered differences with a probability value < 0.05 to be statistically significant.

Results

Sixty-five studies with a total of 281,864 subjects were selected with information on the prevalence of CSI or the proportion of instability in CSI.3,4,8–11,14,16,17,21,23,26,31–40,42–44,47,48,52–57,62,63,66,68–70,73,74,78,79,81,84,86,88,92,93,95,97,98 Twentynine of these reports included 209,320 patients who sustained nonspecific trauma and were not categorized by level of consciousness (Table 1). Nine series with 21,286 cases pertained specifically to alert patients with reliable clinical examination findings (Table 2). Twenty series contained 49,938 unconscious or obtunded patients who met our criteria for unevaluable (Table 3). Twenty-one series composed of 3555 patients with known CSI reported data on the proportion of these injuries considered to be unstable (Table 4; Fig. 1). Tables 1 through 4 analyze the evidentiary characteristics of these series.

Table 1:

Prevalence of CSI in all trauma patients

Author & YearSettingCase Accrual MethodPatient PopulationNo. of PatientsInjury Incidence
Banit et al., 2000single US Level I trauma centerretrospective evaluation of clinical algorithmall trauma admissions44600.036
Bayless & Ray, 1989single US Level I trauma centerretrospective observationalblunt head trauma admissions1760.017
Borock et al., 1991single US Level I trauma centerretrospective evaluation of clinical algorithmblunt trauma admissions1790.084
Cox et al., 2001single US Level I trauma centerprospective evaluation of clinical algorithmall trauma admissions910.044
Demetriades et al., 2000single US Level I trauma centerretrospective observationalblunt trauma admissions14,7550.020
Edwards et al., 2001single Netherlands Level I trauma centerprospective evaluation of clinical algorithmhigh-energy trauma admissions17570.022
Gale et al., 2005single US Level I trauma centerretrospective evaluation of clinical algorithmblunt trauma admissions4000.048
Grossman et al., 1999106 US Level I–III trauma centersretrospective surveyall trauma admissions111,2190.043
Hanson et al., 2000single US Level I trauma centerretrospective evaluation of clinical algorithmall trauma admissions42850.020
Harris et al., 2000single US Level I trauma centerprospective evaluation of clinical algorithmtrauma patients with nonspinal injuries1450.021
Insko et al., 2002single US Level I trauma centerretrospective observationaltrauma patients undergoing flexion-extension radiography1060.085
Kreipke et al., 1989single US Level I trauma centerprospective observationalall trauma admissions8600.028
Lee et al., 2001single US Level I trauma centerretrospective observationaltrauma patients undergoing both radiography and CT6040.050
Mathen et al., 2007single US Level I trauma centerprospective observationalpatients with neck pain, neurological deficit, or intoxication6670.090
McCulloch et al., 2005single US Level I trauma centerprospective observationaltrauma patients undergoing both radiography and CT4070.143
MacDonald et al., 1990single Canadian Level I trauma centerretrospective observationalmotor vehicle crash trauma admissions7750.119
Mower et al., 200121 US university and community hospitalsprospective observationalblunt trauma admissions34,0690.024
Neifeld et al., 1988four US trauma centersretrospective evaluation of clinical algorithmblunt head or neck trauma admissions8860.030
Nguyen & Clark, 2005single US Level I trauma centerprospective observationalpatients with neck pain, neurological deficit, or intoxication2190.014
Prasad et al., 1999single Canadian Level I trauma centerretrospective observational“multitrauma” admissions65000.072
Ptak et al., 2001single US Level I trauma centerretrospective observationalall trauma admissions undergoing CT6760.089
Roberge et al., 1988single US Level I trauma centerprospective evaluation of clinical algorithmblunt trauma admissions4670.017
Roberge & Wears, 1992single US Level I trauma centerprospective evaluation of clinical algorithmblunt trauma admissions4800.035
Ross et al., 1992single US Level I trauma centerprospective observationalblunt trauma admissions4100.032
Sanchez et al., 2005single US Level II trauma centerprospective observationalall trauma admissions26030.038
Sharma et al., 2007single US university hospital emergency departmentprospective observationalall trauma admissions99030.013
Spiteri et al., 2006single UK trauma centerretrospective evaluation of clinical algorithmtrauma admissions undergoing cervical CT4340.081
Williams et al., 1992single US Level I trauma centerretrospective observationalall trauma admissions50210.045
Yanar et al., 2007Trauma registry, US countyprospective observationaladult pedestrians injured by vehicles67660.026
Table 2:

Prevalence of CSI in alert trauma patients

Author & YearSettingCase Accrual MethodPatient PopulationNo. of PatientsInjury Incidence
Barba et al., 2001single US Level I trauma centerretrospective evaluation of clinical algorithmtrauma admissions undergoing cervical CT3240.046
Ersoy et al., 1995single Turkish university hospital emergency departmentretrospective observationalconscious and oriented blunt trauma admissions3030.043
Gonzalez et al., 1999single US Level I trauma centerprospective observationalawake and alert blunt trauma admissions21760.015
McNamara et al., 1988single US Level II trauma centerprospective observationalpatients with neck pain following traumatic injury3510.020
McNamara et al., 1990single US Level II trauma centerretrospective observationalalert, nonintoxicated blunt trauma admissions2860.017
Roth et al., 1994single US military medical centerprospective cohortalert, nonintoxicated blunt trauma admissions2860.017
Stiell et al., 200110 Canadian trauma centersprospective evaluation of clinical algorithmpatients with acute blunt trauma to head or neck89240.017
Stiell et al., 20039 Canadian tertiary care hospitalsprospective evaluation of clinical algorithmpatients with acute blunt trauma to head or neck82830.026
Zabel et al., 1997single US Level I trauma centerretrospective observationalalert trauma admissions3530.025
Table 3:

Prevalence of CSI in clinically unevaluable trauma patients*

Author & YearSettingCase Accrual MethodPatient PopulationNo. of PatientsInjury Incidence
Bolinger et al., 2004single US Level I trauma centerprospective evaluation of clinical algorithmpatients with TBI and GCS scores < 844600.036
Brooks & Willett, 2001single UK trauma centerretrospective observationalunconscious trauma patients1760.017
Chiu et al., 2001single US Level I trauma centerretrospective observationalpatients with GCS scores < 15 on admission1790.084
D'Alise et al., 19992 US Level I trauma centersretrospective observationalintubated for head or severe multisystem injuries910.044
Davis et al., 2001single US Level I trauma centerprospective evaluation of clinical algorithmhead-injured ICU admissions14,7550.020
Diaz et al., 2003single US Level I trauma centerprospective observationalaltered mental status or distracting injuries17570.022
Freedman et al., 2005single Australian trauma centerretrospective observationalunconscious trauma patients admitted to ICU4000.048
Geck et al., 2001single US Level I trauma centerretrospective observationalpatients with high-energy mechanisms of injury111,2190.043
Griffen et al., 2003single US Level I trauma centerretrospective observationalaltered mental status or neurological deficit42850.020
Griffiths et al., 2002single US Level I trauma centerretrospective observationalunconscious or semiconscious trauma patients1450.021
Hogan et al., 2005single US Level I trauma centerretrospective observationalobtunded trauma patients1060.085
Holly et al., 20022 US Level I trauma centersretrospective observationalhead injury with GCS scores 3–12, or GCS score >12 with CT abnormality8600.028
Jelly et al., 2000single UK trauma centerprospective observationalpatients intubated for polytrauma6040.050
Kihiczak et al., 2001single US Level I trauma centerretrospective observationalunevaluable patients undergoing MR imaging after negative CT6670.090
Padayachee et al., 2006single UK trauma centerprospective observationalunconscious with TBI in ICU4070.143
Piatt et al., 2006all Pennsylvania trauma centersretrospective observationalTBI w/ GCS scores < 87750.119
Schenarts et al., 2001single US Level I trauma centerprospective evaluation of clinical algorithmaltered mental status after blunt traumatic injury34,0690.024
Sees et al., 1998single US military medical centerretrospective observationalunresponsive or obtunded with GCS scores 108860.030
Stassen et al., 2006single US Level I trauma centerretrospective evaluation of clinical algorithmobtunded blunt trauma patients2190.014
Widder et al., 2004single Canadian Level I trauma centerprospective observationalobtunded blunt trauma patients65000.072

* ICU = intensive care unit; TBI = traumatic brain injury.

Table 4:

Prevalence of unstable CSIs in all trauma patients

Author & YearSettingCase Accrual MethodPatient PopulationNo. of PatientsInjury Incidence
Banit et al., 2000single US Level I trauma centerretrospective evaluation of clinical algorithmall trauma admissions1510.291
Berne et al., 1999single US Level I trauma centerprospective observationalblunt trauma with intoxication or paralytics200.400
Chiu et al., 2001single US Level I trauma centerretrospective observationalpatients with GCS scores < 15 on admission4710.556
Davis et al., 19936 US trauma centersretrospective observationalall trauma admissions7400.181
Demetriades et al., 2000single US Level I trauma centerretrospective observationalblunt trauma admissions2920.219
Freedman et al., 2005single Australian trauma centerretrospective observationalunconscious trauma patients admitted to ICU70.714
Geck et al., 2001single US Level I trauma centerretrospective observationalpatients with high-energy mechanisms of injury30.333
Gerrelts et al., 1991single US Level I trauma centerretrospective observationalblunt trauma admissions500.400
Goldberg et al., 200121 US university and community hospitalsretrospective observationalblunt trauma admissions8180.707
Griffiths et al., 2002single US Level I trauma centerretrospective observationalunconscious or semiconscious trauma patients21.000
Harris et al., 2000single US Level I trauma centerprospective evaluation of clinical algo rithmtrauma patients with nonspinal injuries31.000
Holly et al., 20022 US Level I trauma centersretrospective observationalhead injury with GCS scores 3 12, or GCS scores > 12 with CT abnormality240.583
MacDonald et al., 1990single Canadian Level I trauma centerretrospective observationalmotor vehicle accident trauma admissions920.174
Mathen et al., 2007single US Level I trauma centerprospective observationalpatients with neck pain, neurological deficit, or intoxica tion600.250
Reid et al., 1987single Canadian Level I trauma centerretrospective observationalcohort of patients with known CSIs2530.348
Ross et al., 1992single US Level I trauma centerprospective observationalblunt trauma admissions430.302
Schenarts et al., 2001single US Level I trauma centerprospective evaluation of clinical algorithmaltered mental status after blunt traumatic injury700.171
Sliker et al., 2005multiple Level I trauma centersretrospective literature reviewobtunded blunt trauma patients1650.612
Spiteri et al., 2006single UK trauma centerretrospective evaluation of clinical algorithmtrauma admissions undergoing cervical CT950.916
Widder et al., 2004single Canadian Level I trauma centerprospective observationalobtunded blunt trauma patients180.000
Yanar et al., 20072 US Level I trauma centersretrospective observationalpedestrians injured by automobiles1780.242
Fig. 1.
Fig. 1.

Flow chart showing the evidentiary value with regard to prevalence of CSI in publications fulfilling the initial search criteria. Bold numbers represent the number of publications in each category.

The overall prevalence of CSI in all trauma patients was 3.7% (Tables 1 and 5). In alert patients only, the prevalence of CSI was 2.8% (Tables 2 and 5). Clinically unevaluable patients were found to be at increased risk of CSI with a prevalence of 7.7% (Tables 3 and 5). Once detected, 41.9% of all CSI were subsequently determined to be unstable (Tables 4 and 5). The difference in prevalence of CSI between the alert and unevaluable groups was statistically significant, with unevaluable patients at a significantly greater risk for CSI than alert patients (p = 0.0072).

Table 5:

Pooled prevalences of CSIs*

Patient PopulationNo. of PatientsPooled Mean (%)95% CI
all trauma209,3203.683.64–3.72
alert patients21,2862.782.74–2.81
unevaluable patients49,9387.667.59–7.81
proportion of unstable injuries3,55541.8741.46–42.28

* CI = confidence interval.

Discussion

Our findings demonstrate a higher prevalence of CSI in clinically unevaluable patients with trauma compared with alert patients with trauma. Hence, this high-risk patient population may be subject to increased occult unstable injuries. The potential for quadriplegia following CSI that is undiagnosed underscores the importance of detecting such injuries, but it is unknown whether the use of advanced imaging techniques for cervical spinal clearance is cost effective when compared with prolonged semirigid collar immobilization. A more precise quantification of the prevalence of CSI in these populations allows us for the first time to make evidence-based decisions in guiding large-scale resource utilization. It is our expectation that these prevalence figures will aid in the calculations needed for indicated cost-effectiveness studies.

There are several important limitations to this study. Many of these limitations are inherent to the technique of meta-analysis, and are the result of variations in the definition of certain clinical terms used by articles that met our inclusion criteria. Most notable of these is the distinction between alert and unevaluable trauma patient populations. Every attempt was made to categorize the included studies systematically, although the existence of minor disparities between study populations is acknowledged. Authors also differed as to whether the overall trauma populations included patients with penetrating trauma or were restricted to those with blunt trauma. The regional variability in rates of penetrating trauma limits the generalizability of these data to all trauma centers, although these rates were invariably quite low.

Conclusions

Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Detection of CSI in this population is especially challenging, and places these patients at increased risk for cervical instability and quadriplegia. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.

Disclaimer

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

References

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Article Information

Address correspondence to: Sherman C. Stein, M.D., Hospital of the University of Pennsylvania, Department of Neurosurgery, 3 Silverstein, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. email: sherman.stein@uphs.upenn.edu

© AANS, except where prohibited by US copyright law.

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    Flow chart showing the evidentiary value with regard to prevalence of CSI in publications fulfilling the initial search criteria. Bold numbers represent the number of publications in each category.

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