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

Ann Intern Med. 2015 Mar 17;162(6):429-37. doi: 10.7326/M14-2351.


Background: Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT).

Purpose: 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.

Data sources: MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014.

Study selection: 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.

Data extraction: Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol.

Data synthesis: 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).

Limitations: Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly.

Conclusion: 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.

Primary funding source: None.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Cervical Vertebrae / diagnostic imaging*
  • Cervical Vertebrae / injuries*
  • Cervical Vertebrae / pathology
  • Humans
  • Immobilization
  • Magnetic Resonance Imaging
  • Tomography, X-Ray Computed
  • Unconsciousness / complications*
  • Wounds, Nonpenetrating / complications*