Session VI - Spine

Fri., 10/6/06 Pediatrics & Spine, Paper #30, 11:44 am

Clearance of the Asymptomatic Cervical Spine: A Meta-Analysis

Paul Anderson, MD1 (n); William Tontz, MD1 (n); Daniel Resnick, MD2 (n);
1University of Wisconsin, Department of Orthopaedics, Madison, Wisconsin, USA;
2University of Wisconsin, Department of Neurosurgery, Madison, Wisconsin, USA

Background: Approximately 13 million blunt trauma patients are treated annually in the United States and Canada; 1% to 3% of these have a cervical spine injury. Despite this low prevalence, radiographic evaluation of the cervical spine utilizing radiographs is often performed. A central question is who needs radiographs in the clearance process?

Methods: A computerized literature search of the National Library of Medicine from 1966 to December 2004 was performed using keywords "spinal injury", "spinal fractures" or "spinal injuries." This resulted in 7994 matches. Combination with keywords "cervical", "human studies" and "English language" resulted in 2038 matches. Combination with the keywords "clearance", "diagnosis" or "radiography" yielded 1433 matches that were reviewed. All papers focusing on the clinical decisions of radiographic use with regard to the diagnosis of cervical spine injury in adult victims of trauma were included. In addition, references were obtained from the bibliographies of the included papers. The practice parameters and reference list developed by the Eastern Association for the Surgery of Trauma practice parameter workgroup for cervical spine clearance was reviewed, as was the reference list developed by the NEXUS (National Emergency X-radiography Utilization Study) group. 14 level I or level II protocols were identified that met the above inclusion criteria. Overall, 61,989 patients were evaluated in the 14 studies. There were two large protocols encounteredThe NEXUS (44,450 patients) and the Canadian C-spine Study (8924 patients). Both were studied in more than one prospective investigation. There were nine protocols that were developed at institutions and tested locally; these were designated as "institutional" protocols.

Results: Overall, the protocols correctly recommended radiographic evaluation in 3.2% of patients who were found to have a cervical spine injury (PPV 3.1%, CI 3.1-3.4). The protocols failed to recommend radiographs in 0.2% of patients who subsequently were identified as having a cervical spine fractures (NPV 99.8%, CI 99.6-99.8). A total of 28 "occult" cervical spine injuries were identified in the 14 studies (Table II). In all patients, there were no cases of occult cervical spine injury resulting in a neurologic deficit. The protocols correctly recommended radiographs in 97.6% of patients who had cervical spine injury (sensitivity 97.6%, CI 96.9-98.3). In symptomatic patients, 25.9% had a cervical spine injury (specificity 25.9%, CI 25.7-26.3).

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.