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Review
. 2015 Feb;78(2):430-41.
doi: 10.1097/TA.0000000000000503.

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma

Mayur B Patel  1 , Stephen S Humble, Daniel C Cullinane, Matthew A Day, Randeep S Jawa, Clinton J Devin, Margaret S Delozier, Lou M Smith, Miya A Smith, Jeannette M Capella, Andrea M Long, Joseph S Cheng, Taylor C Leath, Yngve Falck-Ytter, Elliott R Haut, John J Como
Affiliations
Review

Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma

Mayur B Patel et al. J Trauma Acute Care Surg. 2015 Feb.

Abstract

Background: With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance?

Methods: Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data.

Results: Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT.

Conclusion: In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone.

Level of evidence: Systematic review, level III.

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Figures

Figure 1
Figure 1
Hierarchy of outcomes for assessing C-spine collar removal in the obtunded adult blunt trauma patient after a negative C-spine CT result.
Figure 2
Figure 2
PRISMA flow diagram for systematic review phases of cervical collar clearance in the obtunded adult blunt trauma patient.
Figure 3
Figure 3
Practice management guideline.
See this image and copyright information in PMC

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