Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis

Pierre-Marc Dion; Marjorie Lapierre; Hussein Said; Sophie Tremblay; Khadeeja Tariq; Tyler Lamb; Shane W English; Michael Kingstone; Alexandra Stratton; Sylvain Boet; Risa Shorr; Jacinthe Lampron

doi:10.1016/j.injury.2023.111308

Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis

Injury. 2024 Mar;55(3):111308. doi: 10.1016/j.injury.2023.111308. Epub 2023 Dec 31.

Authors

Affiliations

¹ Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
² Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
³ Division of General Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
⁴ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine (Critical Care), The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
⁵ Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Orthopedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
⁷ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Department of Innovation in Medical Education, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada.
⁸ Library Services, The Ottawa Hospital, Ottawa, ON, Canada.
⁹ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of General Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada. Electronic address: Jlampron@toh.ca.

PMID: 38266326
DOI: 10.1016/j.injury.2023.111308

Abstract

Background: Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma.

Methods: A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology.

Results: 744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity.

Conclusions: Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma.

Implications of key findings: Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.

Keywords: Blunt trauma; Cervical spine injuries; Diagnostic imaging; Meta-analysis; Obtunded patients; Systematic review.

Publication types

Meta-Analysis
Systematic Review
Review

MeSH terms

Adult
Cervical Vertebrae / diagnostic imaging
Cervical Vertebrae / injuries
Humans
Magnetic Resonance Imaging
Neck Injuries*
Prospective Studies
Retrospective Studies
Spinal Injuries* / diagnostic imaging
Tomography, X-Ray Computed
Wounds, Nonpenetrating* / diagnostic imaging
Wounds, Nonpenetrating* / therapy