Cervical Spinal Clearance

A Prospective Western Trauma Association Multi-Institutional Trial

and the WTA C-Spine Study Group, Carlos V R Brown

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

BACKGROUND: For blunt trauma patients who have failed the NEXUS low-risk criteria, the adequacy of CT as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant C-spine injury. METHODS: Prospective multicenter observational study (09/2013-03/2015), at 18 North American Trauma Centers. All adult (≥18yo) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo or cervical-thoracic orthotic (CTO) placement using the gold standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS: 10,765 patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer). 10,276 patients [4,660 (45.3%) unevaluable/distracting injuries, 5,040 (49.0%) midline C-spine tenderness, 576 (5.6%) neurologic symptoms] were prospectively enrolled: mean age 48.1yo (range 18-110), SBP 138 (SD 26), median GCS 15 (IQR 14,15), ISS 9 (IQR 4,16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery [153 (1.5%)] or halo [25 (0.2%)] or CTO [20 (0.2%)]. The sensitivity and specificity for clinically significant injury was 98.5% and 91.0% with a NPV of 99.97%. There were 3 (0.03%) false negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome and 2 of 3 had severe degenerative disease. CONCLUSIONS: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic exam as the trigger for imaging, there is a small but clinically significant incidence of a missed injury and further imaging with MRI is warranted. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
DOIs
StateAccepted/In press - Jul 20 2016

Fingerprint

Wounds and Injuries
Spine
Central Cord Syndrome
Thorax
Nervous System Malformations
Sensitivity and Specificity
Trauma Centers
Intraoperative Complications
Neurologic Manifestations
Routine Diagnostic Tests
Nervous System
Multicenter Studies
Observational Studies
Outcome Assessment (Health Care)
Incidence

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Cervical Spinal Clearance : A Prospective Western Trauma Association Multi-Institutional Trial. / and the WTA C-Spine Study Group; Brown, Carlos V R.

In: Journal of Trauma and Acute Care Surgery, 20.07.2016.

Research output: Contribution to journalArticle

@article{56b1c1758ecf4a22a7adabfd1c23e435,
title = "Cervical Spinal Clearance: A Prospective Western Trauma Association Multi-Institutional Trial",
abstract = "BACKGROUND: For blunt trauma patients who have failed the NEXUS low-risk criteria, the adequacy of CT as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant C-spine injury. METHODS: Prospective multicenter observational study (09/2013-03/2015), at 18 North American Trauma Centers. All adult (≥18yo) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo or cervical-thoracic orthotic (CTO) placement using the gold standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS: 10,765 patients met inclusion criteria, 489 (4.5{\%}) were excluded (previous spinal instrumentation or outside hospital transfer). 10,276 patients [4,660 (45.3{\%}) unevaluable/distracting injuries, 5,040 (49.0{\%}) midline C-spine tenderness, 576 (5.6{\%}) neurologic symptoms] were prospectively enrolled: mean age 48.1yo (range 18-110), SBP 138 (SD 26), median GCS 15 (IQR 14,15), ISS 9 (IQR 4,16). Overall, 198 (1.9{\%}) had a clinically significant C-spine injury requiring surgery [153 (1.5{\%})] or halo [25 (0.2{\%})] or CTO [20 (0.2{\%})]. The sensitivity and specificity for clinically significant injury was 98.5{\%} and 91.0{\%} with a NPV of 99.97{\%}. There were 3 (0.03{\%}) false negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome and 2 of 3 had severe degenerative disease. CONCLUSIONS: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5{\%}. For patients with an abnormal neurologic exam as the trigger for imaging, there is a small but clinically significant incidence of a missed injury and further imaging with MRI is warranted. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria",
author = "{and the WTA C-Spine Study Group} and Kenji Inaba and Saskya Byerly and Bush, {Lisa D.} and Martin, {Mathew J.} and David Martin and Peck, {Kimberly A.} and Galinos Barmparas and Bradley, {Matthew J.} and Hazelton, {Joshua P.} and Raul Coimbra and Brown, {Carlos V R} and Brown, {Carlos V R} and Ball, {Chad G.} and Cherry-Bukowiec, {Jill R.} and Burlew, {Clay Cothren} and Bellal Joseph and Julie Dunn and Minshall, {Christian T} and Carrick, {Matthew M.} and Berg, {Gina M.} and Demetrios Demetriades",
year = "2016",
month = "7",
day = "20",
doi = "10.1097/TA.0000000000001194",
language = "English (US)",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
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T2 - A Prospective Western Trauma Association Multi-Institutional Trial

AU - and the WTA C-Spine Study Group

AU - Inaba, Kenji

AU - Byerly, Saskya

AU - Bush, Lisa D.

AU - Martin, Mathew J.

AU - Martin, David

AU - Peck, Kimberly A.

AU - Barmparas, Galinos

AU - Bradley, Matthew J.

AU - Hazelton, Joshua P.

AU - Coimbra, Raul

AU - Brown, Carlos V R

AU - Brown, Carlos V R

AU - Ball, Chad G.

AU - Cherry-Bukowiec, Jill R.

AU - Burlew, Clay Cothren

AU - Joseph, Bellal

AU - Dunn, Julie

AU - Minshall, Christian T

AU - Carrick, Matthew M.

AU - Berg, Gina M.

AU - Demetriades, Demetrios

PY - 2016/7/20

Y1 - 2016/7/20

N2 - BACKGROUND: For blunt trauma patients who have failed the NEXUS low-risk criteria, the adequacy of CT as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant C-spine injury. METHODS: Prospective multicenter observational study (09/2013-03/2015), at 18 North American Trauma Centers. All adult (≥18yo) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo or cervical-thoracic orthotic (CTO) placement using the gold standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS: 10,765 patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer). 10,276 patients [4,660 (45.3%) unevaluable/distracting injuries, 5,040 (49.0%) midline C-spine tenderness, 576 (5.6%) neurologic symptoms] were prospectively enrolled: mean age 48.1yo (range 18-110), SBP 138 (SD 26), median GCS 15 (IQR 14,15), ISS 9 (IQR 4,16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery [153 (1.5%)] or halo [25 (0.2%)] or CTO [20 (0.2%)]. The sensitivity and specificity for clinically significant injury was 98.5% and 91.0% with a NPV of 99.97%. There were 3 (0.03%) false negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome and 2 of 3 had severe degenerative disease. CONCLUSIONS: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic exam as the trigger for imaging, there is a small but clinically significant incidence of a missed injury and further imaging with MRI is warranted. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria

AB - BACKGROUND: For blunt trauma patients who have failed the NEXUS low-risk criteria, the adequacy of CT as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant C-spine injury. METHODS: Prospective multicenter observational study (09/2013-03/2015), at 18 North American Trauma Centers. All adult (≥18yo) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo or cervical-thoracic orthotic (CTO) placement using the gold standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS: 10,765 patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer). 10,276 patients [4,660 (45.3%) unevaluable/distracting injuries, 5,040 (49.0%) midline C-spine tenderness, 576 (5.6%) neurologic symptoms] were prospectively enrolled: mean age 48.1yo (range 18-110), SBP 138 (SD 26), median GCS 15 (IQR 14,15), ISS 9 (IQR 4,16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery [153 (1.5%)] or halo [25 (0.2%)] or CTO [20 (0.2%)]. The sensitivity and specificity for clinically significant injury was 98.5% and 91.0% with a NPV of 99.97%. There were 3 (0.03%) false negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome and 2 of 3 had severe degenerative disease. CONCLUSIONS: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic exam as the trigger for imaging, there is a small but clinically significant incidence of a missed injury and further imaging with MRI is warranted. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria

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