Debate has forever swirled around how to clear the cervical spine. Clear clinically? CT scan plus exam? CT only? Flexion/extension views? Distracting injury?

This last one has been problematic for a long time. What is a distracting injury? Is there a difference between lower extremity wounds vs upper chest/shoulder wounds from a distraction standpoint? Is it possible to clinically clear the cervical spine if one of these injuries exist?

Finally, a multi-institutional trial was performed that strives to answer this question. Seven Level I US trauma centers participated in this 3.5 year long study. All patients with GCS > 14 underwent a standard clinical exam regardless of whether a possible distracting injury was present. Then all underwent CT evaluation of the entire cervical spine.

Here are the factoids:

• Distracting injuries were classified into three regions: head, torso, and extremities, but no further analysis was presented in the abstract
• Nearly 3,000 patients were enrolled and 70% had a potential distracting injury
• A total of 233 patients (8%) had a cervical spine injury identified by CT
• 136 patients had a cervical injury AND distracting injury, and 14 were missed by clinical exam (10%)
• 87 patients had a cervical injury BUT NO distracting injury, and 10 were missed by clinical exam (13%)
• Only one injury missed by clinical exam required operation

Bottom line: This study shows the usual prevalence of cervical spine injury after blunt trauma, but adds some interesting information regarding distracting injury. Basically, clinical examination will miss about 1% of patients with a negative exam, regardless of distracting injury status. Therefore, the study suggests that clinical clearance should be attempted on all patients first, regardless of “distracting injury.”

Reference: Clearing the cervical spine for patients with distracting injuries: an AAST multi-institutional trial. Session I Paper 3, AAST 2018.