title: Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial.
abstract: For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (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 cervical spine (C-spine) injury.
  
  
  
  This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) 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 placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings.
  
  
  
  Ten thousand seven hundred sixty-five 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, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 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 cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (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 two of three scans showed severe degenerative disease.
  
  
  
  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 examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.
  
  
  
  Diagnostic tests, level II.
authors.affiliation: From the LAC+USC Medical Center (K.I., S.B., D.D.), Los Angeles, California; Trauma and Acute Care Surgery Service (L.D.M., M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon; Oregon Health and Science University (D.M.), Portland, Oregon; Scripps Mercy Hospital (K.A.P.), San Diego, California; Cedars-Sinai Medical Center (G.B.), Los Angeles, California; R Adams Cowley Shock Trauma Center (M.J.B.), University of Maryland School of Medicine, Baltimore, Maryland; Cooper University Hospital (J.P.H.), Camden, New Jersey; University of California (R.C.), San Diego, San Diego, California; Mayo Clinic (A.J.C.), Rochester, Minnesota; University Medical Center at Brackenridge (C.V.R.B.), Austin, Texas; University of Calgary-Foothills Medical Center (C.G.B.), Calgary, Alberta, Canada; University of Michigan (J.R.C-B.), Ann Arbor, Michigan; Denver Health Medical Center (C.C.B.), Denver, Colorado; Banner University Medical Center (B.J.), Tucson, AZ; University of Colorado Health-Medical Center of the Rockies (J.D.), Loveland, Colorado; Parkland Memorial Hospital (C.T.M.), University of Texas Southwestern, Dallas, Texas; Medical Center of Plano (M.M.C.), Plano, Texas; and Wesley Medical Center (G.M.B.), Wichita, Kansas.
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Saskya
authors.initials: S
authors.lastname: Byerly
authors.forename: Lisa D
authors.initials: LD
authors.lastname: Bush
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Martin
authors.forename: David T
authors.initials: DT
authors.lastname: Martin
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Peck
authors.forename: Galinos
authors.initials: G
authors.lastname: Barmparas
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bradley
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Hazelton
authors.forename: Raul
authors.initials: R
authors.lastname: Coimbra
authors.forename: Asad J
authors.initials: AJ
authors.lastname: Choudhry
authors.forename: Carlos V R
authors.initials: CV
authors.lastname: Brown
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.forename: Jill R
authors.initials: JR
authors.lastname: Cherry-Bukowiec
authors.forename: Clay Cothren
authors.initials: CC
authors.lastname: Burlew
authors.forename: Bellal
authors.initials: B
authors.lastname: Joseph
authors.forename: Julie
authors.initials: J
authors.lastname: Dunn
authors.forename: Christian T
authors.initials: CT
authors.lastname: Minshall
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Carrick
authors.forename: Gina M
authors.initials: GM
authors.lastname: Berg
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002574:Cervical Vertebrae / Q000293:injuries*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*; D055815:Young Adult