Computed tomography alone for cervical spine clearance in the unreliable patient - Are we there yet?

Background: Injuries to the cervical spine (CS) occur in 2% to 6.6% of blunt trauma patients. Studies have suggested that computed tomography (CT) alone is sufficient for CS clearance in unreliable patients based on follow-up magnetic resonance (MR) imaging not altering management. We hypothesized that an admission cervical spine CT with no acute injury-using new CT technology-is not sufficient for CS clearance in an unreliable patient. Methods: The trauma registry was used to identify all patients with blunt trauma who had CS imaging with a CT and MR between August 2004 and December 2005. During this time period, a clinical guideline was in place whereby patients who had persistently unreliable examinations had MR despite a normal admission CT. Medical records were reviewed for demographics, Glasgow Coma Scale (GCS) score at time of MR, and injury specific data. Results: Seven hundred thirty-four patients in total were identified. Two hundred three patients without obvious neurologic deficits but unreliable clinical examination, defined by a GCS score of <= 14, had an initial cervical spine CT read by an attending trauma radiologist as having no acute injury. Mean age was 42.3 years (+/- 20.4 years) and mean Injury Severity Score was 29.1 (+/- 11.8). There were 135 (66.5%) men. Mechanism of injury included motor vehicle or motorcycle collision (48.8%), falls (25.4%), pedestrians struck (10.2%), assault (7.8%), and other (7.8%). One hundred eighty-four (90.6%) patients had a negative MR and collars were subsequently removed. After collar removal, no patient developed new neurologic deficit. Eighteen (8.9%) patients had an abnormal MR, 2 of which required operative repair and 14 required extended cervical collar use. Two patients had collars removed at the discretion of the attending surgeon. One patient had a suboptimal MR and was discharged in a collar with scheduled follow-up. Conclusion: Newer generation CT continues to miss CS injuries in unreliable patients. MR changed the management in 7.9% of patients having had an admission CT with no acute injury. Thus, we recommend continued use of MR for CS clearance in the unreliable patient and ongoing evaluation as the quality of CT imaging continues to evolve.