CT for Cervical Spine Clearance in the Obtunded Adult Blunt Trauma Patient is Appropriate in a Resource‐Constrained Environment

Abstract

PURPOSE: Cervical spinal injury (CSI) following blunt trauma to the neck can have devastating consequences. There is a current controversy surrounding how CSIs are excluded in obtunded patients. This study aimed to evaluate the utility of CT in cervical spine clearance in a high-volume trauma center in a developing world setting. METHODS: Longitudinal 11-year data (2012-2022) were collected from the Hybrid Electronic Medical Registry (HEMR), based at the Pietermaritzburg Metropolitan Trauma Service, to identify all obtunded patients (GCS < 15) who underwent a cervical CT scan. The accuracy of CT imaging in identifying CSI was evaluated by calculating the diagnostic sensitivity, specificity, negative predictive value, and positive predictive value against the final admission diagnosis. RESULTS: In total, 1039 obtunded blunt trauma patients underwent CT of the C-spine. 121 (12%) of these patients had a CSI demonstrated on CT or MRI. Six (5%) required surgery, and 115 (95%) were treated nonoperatively. In total, 113 (93%) of these patients had a positive CT, and 8 (7%) patients had a false-negative CT but went on to have a positive MRI for CSI; none of these patients with an injury identified on MRI required surgery. CT demonstrated a sensitivity and specificity of 93.4% and 96.2%, with a negative predictive value of 99.1% for identifying CSI. CONCLUSION: In the obtunded trauma patient, CT correctly identifies all patients with a bony fracture of the cervical spine who will require intervention. In a small subset of patients, CT will miss non-bony injuries. MRI may be necessary for further investigation in the context of persisting clinical concern for CSI (e.g., neurological deficit, polytrauma, unstable vital signs (especially hypotension), and intubation). Most of these non-bony injuries do not require surgery.