title: Prospective evaluation of a critical care pathway for clearance of the cervical spine using the bolster and active range-of-motion flexion/extension techniques.
abstract: BACKGROUND
  Clearance of the cervical spine after blunt trauma remains controversial in patients with normal radiologic evaluation.
  
  
  METHODS
  Blunt trauma patients with midline boney cervical tenderness and plain films that disclose no abnormalities and computed tomography (CT) scans were entered into a care pathway for spinal clearance using the Bolster or active range-of-motion (AROM) flexion/extension techniques. The quality of films between the two techniques was then compared.
  
  
  RESULTS
  In all, 159 patients entered the pathway with 14 patients (9%) unable to complete the examination secondary to pain. The Bolster was used in 129 patients (89%) and AROM was used in 16 (11%). The total range of motion was significantly better with AROM at 51.4 +/- 19.4 degrees of motion compared with 32.0 +/- 13.0 degrees with the Bolster (p < or = 0.05). The most distal level visualized was not different between groups with 6.6 +/- 0.8 cervical vertebrae visualized on average in the Bolster group and 6.8 +/- 0.7 in the AROM group. Positive findings occurred in five patients (3.4%) in the Bolster group.
  
  
  CONCLUSIONS
  The incidence of occult cervical injury in patients with boney cervical pain despite normal plain films and CT scans in this study was 3.4%. The AROM technique has better total range of motion than the Bolster, although results of the Bolster technique remain within acceptable standards. The present care pathway appears to be an effective screening tool for evaluation of this population of patients. Additional evaluation of the obtunded patient is necessary before broad implementation of this technique.
authors.affiliation: Department of Surgery, College of Medicine, University of Tennessee, Chattanooga Unit, Tennessee 37403, USA.
authors.forename: Johnathan M
authors.initials: JM
authors.lastname: Mauldin
authors.forename: Robert A
authors.initials: RA
authors.lastname: Maxwell
authors.forename: Stephen M
authors.initials: SM
authors.lastname: King
authors.forename: Robert F
authors.initials: RF
authors.lastname: Phlegar
authors.forename: Michael R
authors.initials: MR
authors.lastname: Gallagher
authors.forename: Donald E
authors.initials: DE
authors.lastname: Barker
authors.forename: R Phillip
authors.initials: RP
authors.lastname: Burns
mesh_terms: D000328:Adult; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging* / Q000293:injuries*; D005260:Female; D006801:Humans; D017846:Longitudinal Ligaments / Q000000981:diagnostic imaging* / Q000293:injuries; D008297:Male; D010146:Pain / Q000209:etiology; D017410:Practice Guidelines as Topic; D011859:Radiography; D016059:Range of Motion, Articular; D016103:Spinal Fractures / Q000000981:diagnostic imaging*; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*