Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma

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  • Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Object

The current standard of practice for clearance of the cervical spine in obtunded patients suffering blunt trauma is to use CT and an adjuvant imaging modality (such as MR imaging). The objective of this study was to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable cervical spine injury following blunt trauma.

Methods

The authors performed a meta-analysis of studies comparing modern CT with adjunctive imaging modalities and required that studies present acute traumatic findings as well as treatment for unstable injuries. Study quality, population characteristics, diagnostic protocols, and outcome data were extracted. Positive disease status included all injuries necessitating surgical or orthotic stabilization identified on imaging and/or clinical follow-up.

Results

Seventeen studies encompassing 14,327 patients met the inclusion criteria. Overall, the sensitivity and specificity for modern CT were both > 99.9% (95% CI 0.99–1.00 and 0.99–1.00, respectively). The negative likelihood ratio of an unstable cervical injury after a CT scan negative for acute injury was < 0.001 (95% CI 0.00–0.01), while the negative predictive value of a normal CT scan was 100% (95% CI 0.96–1.00). Global severity of injury, CT slice thickness, and study quality did not significantly affect accuracy estimates.

Conclusions

Modern CT alone is sufficient to detect unstable cervical spine injuries in trauma patients. Adjuvant imaging is unnecessary when the CT scan is negative for acute injury. Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury.

Abbreviations used in this paper: GCS = Glasgow Coma Scale; ISS = Injury Severity Score; NEXUS = National Emergency X-Radiography Utilization Study; QUADAS = Quality Assessment of Diagnostic Accuracy Studies.

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Contributor Notes

Address correspondence to: David O. Okonkwo, M.D., Ph.D., Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, Pennsylvania 15213. email: okonkwodo@upmc.edu.

Please include this information when citing this paper: published online May 27, 2011; DOI: 10.3171/2011.4.JNS101672.

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