Cost-effectiveness of cervical spine clearance interventions with litigation and long-term care implications in obtunded adult patients following blunt injury.

Background: Recent guidelines from EAST conditionally recommend cervical collar removal after a negative cervical CT in obtunded adult blunt trauma patients. Though the rates of missed injury are extremely low, the impact of chronic care costs and litigation upon decision-making remains unclear. We hypothesize that the cost-effectiveness of strategies that include additional imaging may contradict current guidelines. Methods: A cost-effectiveness analysis was performed for a base-case 40 year-old, obtunded, male with a negative CT. Strategies compared included: adjunct imaging with cervical MRI, collar maintenance for 6 weeks, or removal. The probability for long-term collar complications, spine injury, imaging costs, complications associated with MRI, acute and chronic care, and litigation were obtained from published and Medicare data. Outcomes were expressed as 2014 US dollars and quality-adjusted life-years (QALYs). Results: Collar removal was more effective and less costly than collar use or MRI (19.99 vs. 19.35 vs. 18.70 QALYs; $675,359 vs. $685,546 vs. $685,848) in the base case analysis. When the probability of missed cervical injury was greater than 0.04 adjunct imaging with MRI dominated, however, collar removal remained cost effective until the probability of missed injury exceeded 0.113 at which point collar removal exceeded the $50,000 threshold. Collar removal remained the most cost-effective approach until the probability of complications from collar use was reduced to below 0.009, at which point collar maintenance became the most cost-effective strategy. Early collar removal dominates all strategies until the risk of complications from MRI positioning is reduced to 0.03 and remained cost-effective even when the probability of complication was reduced to 0. Conclusion: Early collar removal in obtunded adult blunt trauma patients appears to be the most effective and least costly strategy for cervical clearance based upon the current literature available. Level of Evidence: Level IV- Cost-effective analysis (C) 2016 Lippincott Williams & Wilkins, Inc.

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