CT c-spine detects injuries – no MRI needed

September 6, 2016

Short Attention Span Summary

WEST has spoken
This was a huge prospective study that found CT c-spine, “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.”

Spoon Feed
EAST has already spoken and come to the conclusion that CT c-spine rules out injury in obtunded patients, and MRI is not routinely indicated.  WEST concurs that a negative c-spine CT rules out clinically significant injuries, with this caveat – patients with an abnormal baseline neurological exam need MRI.

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Abstract

J Trauma Acute Care Surg. 2016 Jul 20. [Epub ahead of print]

Cervical Spinal Clearance: A Prospective Western Trauma Association Multi-Institutional Trial.

Inaba K1, Byerly S, Bush LD, Martin MJ, Martin D, Peck KA, Barmparas G, Bradley MJ, Hazelton JP, Coimbra R, Choudhry AJ, Brown CV, Ball CG, Cherry-Bukowiec JR, Burlew CC, Joseph B, Dunn J, Minshall CT, Carrick MM, Berg GM, Demetriades D; and the WTA C-Spine Study Group.

Author information:

11 LAC+USC Medical Center 2 Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center 3 Oregon Health and Science University 4 Scripps Mercy Hospital 5 Cedars-Sinai Medical Center 6 R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine 7 Cooper University Hospital 8 University of California, San Diego 9 Mayo Clinic 10 University Medical Center at Brackenridge 11 University of Calgary – Foothills Medical Center 12 University of Michigan 13 Denver Health Medical Center 14 Banner University Medical Center 15 University of Colorado Health – Medical Center of the Rockies 16 Parkland Memorial Hospital, University of Texas Southwestern 17 Medical Center of Plano 18 Wesley Medical Center.

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.

PMID: 27438681 [PubMed – as supplied by publisher]