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.