Clearing the Cervical Spine In The Obtunded Patient

In the alert asymptomatic trauma patient who meets the NEXUS or Canadian C-spine Rule criteria, the cervical collar can be safely removed without imaging (1). The obtunded patient who is not examinable poses a difficult clinical situation. What is required to safely remove the cervical collar? Emergency Physicians routinely face this issue. It might be instructive to review the current recommendations from the Trauma Societies and the practice at large trauma centers.

The Eastern Association for the Surgery of Trauma conditionally recommends cervical collar removal after a “negative high-quality C-spine CT scan result alone” (1,2). Although MRI had been advocated for these patients in the past, new literature has concluded MRI “had a lower health benefit and a higher cost compared with no follow-up after a normal CT finding in patients with obtunded blunt trauma to the cervical spine, a finding that does not support the use of MRI in this group of patients” (3).

The Western Trauma Association conducted a multi-institutional study with more than 10,000 patients and concluded “if the CT is adequate and negative, the collar may be removed with a low risk of clinically significant injury” (4). In this large study, there were 3 false-negative CTs (0.03%) that missed a clinically significant injury, but all had exams consistent with central cord syndrome. The conclusion is that that MRI remains valuable only for “the patient who arrives with motor or sensory neurologic deficits or without witnessed movement of all extremities.”

At Bellevue Hospital in New York City, for example, policy now exists to clear the obtunded patient with a negative cervical spine CT alone (1).

References:
(1) Bernstein MP, et al. Radiol Clin North Am. 2019 Jul;57(4):767-785.
(2) Patel MB, et al. J Trauma. 2015;78: 430-441.
(3) Wu X, et al. JAMA Surg. 2018; 153: pp. 625-632.
(4) Inaba K, et al. J Trauma Acute Care Surg. 2016;81:1122-1130.