Cervical Spinal Clearance: A Prospective Western Trauma Association Multi-Institutional Trial.

Background: For blunt trauma patients who have failed the NEXUS low-risk criteria, the adequacy of 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 C-spine injury. Methods: Prospective multicenter observational study (09/2013-03/2015), at 18 North American Trauma Centers. All adult (>=18yo) 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 (CTO) placement using the gold standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. Results: 10,765 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 48.1yo (range 18-110), SBP 138 (SD 26), median GCS 15 (IQR 14,15), ISS 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 CTO [20 (0.2%)]. The sensitivity and specificity for clinically significant injury was 98.5% and 91.0% with a NPV of 99.97%. There were 3 (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 2 of 3 had severe degenerative disease. Conclusions: 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 exam as the trigger for imaging, there is a small but clinically significant incidence of a missed injury and further imaging with MRI is warranted. Level of Evidence: Level II, Diagnostic Tests or Criteria (C) 2016 Lippincott Williams & Wilkins, Inc.

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