CME

Cervical spine clearance

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in adult trauma patients

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Brian K. Yorkgitis, PA-C, DO; D. Michelle McCauley, DO

ABSTRACT
Up to 4% of adults with blunt trauma suffer cervical spine
injury. Clinicians who evaluate trauma patients can use
validated clinical decision tools to assess whether patients
are at risk for these injuries. Beyond these tools, imaging
(most often CT) remains the mainstay of evaluation. Further
challenges exist when patients have persistent pain or cannot
be evaluated clinically. This article reviews the evidence avail-
able to assist clinicians in evaluating adults for significant
cervical spine injury after blunt trauma.
Keywords: cervical spine, CT, MRI, obtunded, trauma, neck injury

Learning objectives

© SPL/SCIENCE SOURCE
Determine the need for spine imaging in a patient with
blunt trauma who has been placed in a cervical spine
immobilization device.
List the benefits and drawbacks to using clinical decision
tools such as the CCR and NEXUS.

C
linicians often are asked to perform cervical spine
clearance in adults after blunt trauma. Clinical
decision tools and guidelines have been developed
to help clinicians; however, challenges arise when the patient
cannot be evaluated clinically because of altered mental
status, distracting injuries, or other confounders.1,2 Clini-
cians must be able to approach each patient in an evidence-
based manner.
Initially, a cervical collar often is applied to restrict cer-
vical spine motion if the patient is at risk for spinal injury.2
However, prolonged cervical spine immobilization carries
risks and complications. Patients are at an increased risk
of developing pressure ulcers from the collar pressing on
the mandible, chin, chest, and occipital region. The collar
can interfere with airway patency and ventilation and can
increase the patient’s risk for infection. In patients with
severe traumatic brain injuries, prolonged immobilization
Brian K. Yorkgitis and D. Michelle McCauley practice in the Division
of Acute Care Surgery at the University of Florida College of Medicine-
Jacksonville. The authors have disclosed no potential conflicts of
interest, financial or otherwise.
DOI:10.1097/01.JAA.0000552718.90865.53
Copyright © 2019 American Academy of Physician Assistants
can cause increased intracranial pressure.2 Prompt identi-
fication of patients who no longer require cervical spine
motion restriction is imperative to prevent these complica-
tions. Clinicians also must be able to recognize which
patients need continued cervical spine precautions.
PREVALENCE OF CERVICAL SPINE INJURIES
The rate of cervical spine injuries (CSIs) among trauma
patients is estimated at 3.7%.3 As expected, the prevalence
among alert patients is lower (2.8%), and prevalence is
higher (7.7%) among patients who cannot be evaluated.3
Nearly 42% of patients with CSIs have cervical spine
instability.3 Speed is crucial; a delayed CSI diagnosis can
result in partial or full paralysis in up to 29% of patients.4
The incidence of CSI, particularly of the upper cervical
spine, increases in older adults, even after low-energy
mechanisms.5
ASSESSING ALERT PATIENTS
Clinical examination in alert patients who are not intoxi-
cated or do not have a distracting injury after blunt trauma
has a sensitivity of 58.8%, specificity of 62.7%, positive
predictive value of 8.1%, and negative predictive value of

12 www.JAAPA.com Volume 32 • Number 2 • February 2019

Copyright © 2019 American Academy of Physician Assistants


Key points
Up to 4% of adults with blunt trauma suffer CSI.
Validated clinical decision tools such as the CCR and
NEXUS can help clinicians determine whether patients
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are at risk for CSI.
Imaging, typically CT, is the mainstay of evaluating
patients for CSI.
Appropriate management is controversial for patients who
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have a negative CT scan and altered mental status or
decreased consciousness.
96.4%.4 As an adjunct to clinical examination of the patient
after blunt trauma, various clinical decision tools have
been validated and can help clinicians with bedside evalu-
ation of the cervical spine. The most common are the
Canadian C-Spine Rule (CCR) and the National Emergency
X-Radiography Utilization Study (NEXUS) Low-Risk
Criteria (Tables 1 and 2). These tools each have a high
sensitivity and specificity. Although NEXUS has been more
widely adopted because of its simplicity and ability to be
easily memorized, studies have demonstrated CCR to be
a more superior tool for helping clinicians with clinical
clearance. The CCR has a higher sensitivity than NEXUS
(99.4% versus 90.7% with 95% CI) for clinically impor-
tant CSIs.6,7 Clinically significant CSIs include any fracture,
dislocation, or ligamentous instability seen on imaging.7
Judicious use of CCR in place of NEXUS has the ability
to lower unnecessary use of radiography and the need for
immobilization in alert patients.6-8
The efficacy of clinical clearance in the presence of
distracting injuries in alert patients has raised some
concern. However, a study by Rose and colleagues found
that the severity of distracting injuries did not affect the
efficacy and sensitivity of clinical examination.1 Sixty-
one percent of patients with distracting injuries were
clinically cleared with a negative predictive value greater
than 99% and a sensitivity of 99%, reducing the use of
CT imaging.1
Although NEXUS does not take patient age into account,
the CCR considers age 65 years or older a high-risk factor
and recommends cervical spine imaging for these patients.
Several studies have demonstrated that imaging detected
a cervical spine fracture in between 34% and 55% of older
adults who did not have cervical spine tenderness.5,9 Con-
sidering patients age 65 years and older as higher risk was
challenged in a study by Healey and colleagues, who
examined patients ages 55 years and older with asymp-
tomatic cervical spine fractures.10 They found that nearly
20% of patients without tenderness or pain on initial
presentation had a cervical spine fracture.10 Many of these
patients would have been deemed low-risk by CCR and
NEXUS. Clinicians evaluating the cervical spine for injury
should take patient age into account when deciding whether
to order cervical spine imaging.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2019 American Academy of Physician Assistants
Cervical spine clearance in adult trauma patients
ASSESSING CLINICALLY UNEVALUABLE PATIENTS
In some patients, clinical examination alone cannot rule
out CSI. For example, patients may have a negative CT
scan but altered mental status or decreased consciousness.
Appropriate management for these patients is controver-
sial. Multiple imaging modalities can be used, including
radiography, CT, MRI, and flexion/extension (F/E) radio-
graphic views.11 Some clinicians support using only a
multidetector CT scan (MDCT) to rule out injury in
patients who cannot be clinically cleared. Although oth-
ers argue that this single modality is inadequate, MDCT
allows for better detection of fractures and misalignment.
MRI allows better visualization of soft-tissue disks and
ligamentous structures.12
How to evaluate obtunded patients also is controver-
sial. The clinical decision tools listed above are widely
accepted for screening alert patients for CSI. However,
evidence for their use in obtunded patients with blunt
trauma is less robust. Guidelines from the Eastern Asso-
ciation for the Surgery of Trauma (EAST) were developed
based on a systematic review of literature to guide clini-
cians in managing the trauma patients who could not
TABLE 1. Canadian C-Spine Rule 8
High-risk factors—if any are present, imaging is required
• Age 65 years or older
• Dangerous mechanism of injury
° Fall of 1 m or greater or 5 or more stairs
° Axial load to head
° Motor vehicle accident with rollover, ejection, or at
high speed (more than 62 mph)
° Bicycle collision
° Motorized recreational vehicle crash
• Paresthesia in extremities
Low-risk factor that allows safe assessment of range of
motion—if the answer to any of these is no, imaging is required
• Simple rear-end motor vehicle accident
° Excludes being pushed into oncoming traffic, hit by
large bus/truck, hit by high-speed vehicle, rollover
• Sitting position in ED
• Ambulatory at any time
• Delayed onset of neck pain
• Absence of midline cervical spine tenderness (not
immediate onset)
Range of motion assessment—If no imaging is required for the
above risk factors, assess the patient’s ability to actively rotate the
neck 45 degrees to the left and to the right—if unable, imaging is
required
www.JAAPA.com 13
 CME
be evaluated clinically. EAST concluded that cervical
collars could be removed from obtunded patients only
after a negative high-quality CT of the cervical spine
alone failed to detect an injury.13 This is part of EAST’s
latest recommendations that no longer advocate for F/E
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radiographs. Emphasis is placed on the high negative
predictive value of high-quality CT in eliminating clini-
cally significant unstable injuries. High-quality was
defined as an axial CT from the occiput to T1 with
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coronal and sagittal reconstructions.3,13
A retrospective study by Hogan and colleagues concluded
that MRI findings did not change the management of
obtunded patients when a CT scan was negative.14 Chew
and colleagues found that, compared with MDCT, MRI
provided no additional information when trying to iden-
tify unstable CSIs after blunt trauma in patients who did
not show signs of motor deficits on examination.12 A
meta-analysis performed by Panczykowski and colleagues
showed that out of 14,327 obtunded or intubated patients,
a negative CT scan was sufficient to rule out unstable
cervical spine fractures, so the cervical collar could be
removed.14 Hogan and colleagues similarly concluded that
a negative MDCT in an obtunded patient did not need to
be followed by an MRI.15 Tomycz and colleagues found
TABLE 2. NEXUS low-risk criteria8
Cervical-spine radiography is indicated for patients with
trauma unless they meet all of the following criteria:
• No posterior midline cervical-spine tenderness, defined
as pain on palpation of the midline neck from nuchal
ridge to prominence of the first thoracic vertebra or
pain with direct palpation of any cervical spine spinous
process
• No evidence of intoxication, in which intoxication is
defined as a recent history provided by the patient or an
observer of intoxication or intoxicating ingestion; or evi-
dence of intoxication on physical examination such as
an odor of alcohol, slurred speech, ataxia, dysmetria, or
other cerebellar findings; or any behavior consistent with
intoxication; or tests of bodily secretions that are posi-
tive for alcohol or drugs that affect the level of alertness
• Normal level of alertness, defined as a Glasgow Coma
Scale score of 14 or less; disorientation to person,
place, time, or events; an inability to remember three
objects at 5 minutes; a delayed or inappropriate re-
sponse to external stimuli; or other findings
• No focal neurologic deficit on motor or sensory
examination
• No painful distracting injuries that could be producing
pain sufficient to distract the patient from a second (neck)
injury
14 www.JAAPA.com
Copyright © 2019 American Academy of Physician Assistants
that out of 180 patients with a normal CT, MRI identified
38 patients with acute findings, none of whom were found
to have instability or required operative intervention.16
This suggests that MRI is unlikely to reveal unstable inju-
ries after a normal CT in obtunded patients.16 In contrast,
Menaker and colleagues recommended that MRI still be
used in this patient population because late MRI findings
may occur.17 In their study of 203 patients, 8.9% (18) had
an abnormal MRI after no injury was identified on CT
scan of the cervical spine.17 Two of these patients required
operative fixation and 14 required extended use of cervi-
cal collar. Most patients (10) were diagnosed with liga-
mentous injury of only one ligament at only one level and
5 had a cord contusion alone.17
PATIENTS WITH PERSISTENT NECK PAIN
Patients with persistent pain who undergo an MDCT that
does not identify an acute injury remain a challenge for
clinicians.18 The possibility of a missed CSI remains a feared
complication in these patients. A body of literature sup-
ports removing the cervical collar if no CSIs are identified
by high-quality MDCT. However, research supports further
imaging to discern injuries that may not be detected on
MDCT.
F/E radiographs Many institutions continue to obtain
F/E radiographs routinely in patients with persistent neck
pain despite a negative CT scan. An adequate F/E radio-
graph is defined by the ability to visualize the base of the
occiput down to the top of T1 and when it shows at least
30 degrees of movement in both flexion and extension.
Studies have shown that F/E radiographs were only able
to detect significant injuries when the radiograph showed
at least 30 degrees of movement of the cervical spine from
the neutral position.19
The usefulness of these radiographs is questionable. In
a study by McCracken and colleagues, 70% to 80% of
F/E radiographs were inadequate by criteria previously
described.11 In additional related studies, inadequacy ranged
from 30% to 95%.20
In addition to their limited value, F/E radiographs are
expensive. Tran and colleagues reported that nearly
$172,000 was spent in 1 year on F/E radiographs.21 Of
patients who were found to have ligamentous injury on
F/E radiographs, none had a significant injury or subse-
quent neurologic deterioration.21 The researchers recom-
mended that for awake, alert, and neurologically intact
patients, F/E radiographs should be eliminated after a
negative CT scan.21
Oh and colleagues reported that of the four patients
who had negative F/E radiographs with a ligamentous
injury found on subsequent MRI, none required any
intervention.20 This suggests that MRI can be overly
sensitive. They concluded that F/E radiographs do not
contribute to diagnostic accuracy for the detection of
ligamentous injury in the cervical spine following a
Volume 32 • Number 2 • February 2019

normal CT scan.20 Similarly, after 69% of patient radio-
graphs were deemed inadequate by radiologists, Khan
and colleagues concluded that F/E radiographs do not
appear to be clinically useful in assessing cervical spine
instability.18 They recommended that patients be reassessed
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in 7 to 10 days for neck pain and if pain was still present,
clinicians should reassess the need for F/E imaging. In
patients with persistent neck pain, muscle spasms may
prevent adequate F/E imaging; after 7 to 10 days, the
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muscles will have relaxed, allowing improved adequacy
of F/E if one is deemed clinically necessary.18
MRI In addition to F/E imaging in patients with per-
sistent neck pain, researchers have investigated the use-
fulness and appropriateness of MRI in patients with a
normal CT scan. Chew and colleagues reported that
ligamentous injury was found in 34% of all abnormali-
ties on MRI following a normal CT.12 However, none of
these patients required surgical intervention or a halo
for cervical instability.12
CT scan Several studies support the adequacy of CT
scan alone to rule out CSI.12,22-25 Schuster and colleagues
found that no patient with a negative CT scan and the
absence of neurologic deficits had an MRI that revealed
clinically significant injuries.26 Resnick and colleagues
found that of 2.2% of patients with a normal CT scan
and persistent neck pain and/or sensory deficits had a new
finding on MRI; none of these patients required surgical
intervention.25 No clinically significant injury was missed
on CT scan. Researchers concluded that MRI did not alter
management in alert patients with a normal CT.25 Malhotra
and colleagues found that CT has a negative predictive
value (NPV) of 79.1% for CSI in patients who are clini-
cally suspicious for injury or who cannot be evaluated;
for unstable injury, the NPV for CT was 98.5%.27 MRI
may be useful in patients with persistent abnormal neu-
rologic examinations.27 Ackland and colleagues compared
patients with a positive finding on early MRI following a
negative CT with those with negative findings on early
MRI.28 At 1 year, no associated adverse long-term outcomes
were found in patients with MRI-detected injuries com-
pared with patients without MRI-detected injuries. Delay
in return to work was associated with the presence of
other injuries to the limbs.28
CONCLUSION
Cervical spine evaluation for adults with blunt trauma
continues to be a challenge for clinicians. Clinical deci-
sion tools are a foundation to begin the evaluation, and
the CCR appears to be a more sensitive tool than
NEXUS. Age and mechanism of injury is important
when evaluating patients after blunt trauma; asymp-
tomatic patients ages 55 years and older who would be
deemed low-risk using clinical decision tools have been
found to have cervical spine fractures. The available
literature does not support the use of F/E radiographs
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2019 American Academy of Physician Assistants
Cervical spine clearance in adult trauma patients
when evaluating patients with persistent neck pain. In
addition, significant evidence concludes that MRIs have
not been of added benefit in patients who have normal
CT scans but have persistent pain or altered mental
status. Selective use of additional imaging tests beyond
CT appears to be more appropriate than broad-based
use in these populations. JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.org.
Successful completion is defined as a cumulative score of at least 70%
correct. This material has been reviewed and is approved for 1 hour of
clinical Category I (Preapproved) CME credit by the AAPA. The term of
approval is for 1 year from the publication date of February 2019.
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Volume 32 • Number 2 • February 2019