title: Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma.
abstract: BACKGROUND
  With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance?
  
  
  METHODS
  Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data.
  
  
  RESULTS
  Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT.
  
  
  CONCLUSIONS
  In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone.
  
  
  METHODS
  Systematic review, level III.
authors.affiliation: From the Veterans Affairs (VA) Tennessee Valley Healthcare System (M.B.P.), Nashville VA Medical Center; Division of Trauma and Surgical Critical Care (M.B.P., S.S.H., M.A.S., T.C.L.), Department of Surgery, and Department of Neurosurgery (M.B.P., J.S.C.), Section of Surgical Sciences, Department of Radiology and Radiological Sciences (M.A.D.), and Department of Orthopedic Surgery and Rehabilitation (C.J.D.), Vanderbilt University School of Medicine, Nashville; University of Tennessee Health Science Center (M.S.D.), College of Medicine, Memphis; and University General Surgeons (L.M.S.), University of Tennessee Medical Center, Knoxville, Tennessee; Trauma Surgery Section (D.C.C.), Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin; Division of Trauma, Emergency Surgery, and Surgical Critical Care (R.S.J.), Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York; Trauma Service (J.M.C.), University of Pittsburgh Medical Center-Altoona, Altoona, Pennsylvania; Department of Surgery (A.M.L.), Medical Center of Central Georgia, Macon, Georgia; VA Healthcare System of Ohio (Y.F.-Y.), Cleveland VA Medical Center; Division of Gastroenterology (Y.F.-Y.), Department of Medicine, Case Western Reserve University School of Medicine; and Division of Trauma, Critical Care, and Burns (J.J.C.), Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Departments of Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Mayur B
authors.initials: MB
authors.lastname: Patel
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Humble
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Cullinane
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Day
authors.forename: Randeep S
authors.initials: RS
authors.lastname: Jawa
authors.forename: Clinton J
authors.initials: CJ
authors.lastname: Devin
authors.forename: Margaret S
authors.initials: MS
authors.lastname: Delozier
authors.forename: Lou M
authors.initials: LM
authors.lastname: Smith
authors.forename: Miya A
authors.initials: MA
authors.lastname: Smith
authors.forename: Jeannette M
authors.initials: JM
authors.lastname: Capella
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Long
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Cheng
authors.forename: Taylor C
authors.initials: TC
authors.lastname: Leath
authors.forename: Yngve
authors.initials: Y
authors.lastname: Falck-Ytter
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: John J
authors.initials: JJ
authors.lastname: Como
mesh_terms: D001915:Braces; D020878:Device Removal; D019317:Evidence-Based Medicine; D006801:Humans; D019838:Neck Injuries / Q000000981:diagnostic imaging* / Q000628:therapy*; D017410:Practice Guidelines as Topic; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000628:therapy*